Advanced Laparoscopic Surgeries

Laparoscopic Colorectal Surgery

What is laparoscopic colorectal surgery?

Traditional surgery involves a large cut in the abdomen and is associated with lot of morbidity and very slow and painful recovery.
Laparoscopic colorectal surgery is a highly advanced, safe and effective alternative to both conventional and laparoscopic-assisted surgery. It offers greater vision, control and accuracy for surgeons.

In laparoscopic colorectal surgery 3-5 small tiny incisions are placed. Through these incisions or holes, the entire surgery is carried out with the help of telescope attached to camera and long thin instruments. It is associated with minimal pain and faster recovery.

The bowel or colorectal conditions treated by us are:

Types of colorectal surgeries done by our team
Achalasia cardia

The esophagus is a tube that carries food from the mouth into the stomach. Between esophagus and the stomach lies lower esophageal sphincter which acts as a valve. It allows entry of food from food pipe or esophagus into the stomach but not the other way around. It therefore prevents acidic secretions of stomach entering into the food pipe.

In achalasia cardia there is degeneration of nerves controlling the function of lower esophageal sphincter. As a result, the sphincter fails to relax resulting in backup of food into the food pipe. It usually affects people between the age of 25 to 60 years and it can have both genetic and autoimmune component.

Symptoms
  • Difficulty in swallowing food and sensation of food sticking into the lower part of chest.
  • Weight loss
  • Heart burn due to fermentation of retained food
  • Chest pain due to muscle spasm.
  • Chronic cough and lung problems due to food entering into the wind pipe (regurgitation)
Diagnosis

Manometry studies used to assess the pressures in lower part of esophagus demonstrates inactivity of sphincter and loss of motility or peristalsis.
Radiographic studies demonstrate dilated food pipe and tight lower sphincter.
Endoscopic studies demonstrate residual food particles in food pipe, sometimes erosions and retained saliva.

Treatment of achalasia cardia

Medications:
There are certain medicines which can provide temporary relief from this condition. These include amyl nitrate, nifedipine, isosorbide dinitrate etc.

Botulin injection:
Botox injection given directly into the sphincter may provide symptomatic relief for a few weeks and is usually indicated in patients unfit for surgery.

Pneumatic dilatation:
Forceful dilatation of the esophagus with the help of long cylindrical non-compliant balloon may provide relief from this condition in 60% of the patients. The forceful dilatation actually stretches to almost tear the sphincter allowing esophagus to function in a better manner.

Surgical management:
The best treatment till date for achalasia cardia with success rate of more than 95%. Our team carries the surgery laparoscopically involving 4 tiny cuts in the abdomen. Ensuring extremely fast recovery, the procedure involves partially cutting of sphincter under direct vision. The patient is usually discharged within 48 hours and can resume normal activities within 3-4 days.

Pancreatic Pseudocyst

Pancreas is a very vital organ situated just below the stomach and in close proximity to liver. The main function of pancreas is to secrete juices for digestion of food and insulin for the maintenance of glucose levels.
When pancreas get severely infected because of slippage of gall stones into the pancreatic duct or excessive alcohol intake, it is called pancreatitis.

Pseudocyst Symptoms

The main symptoms of Pseudocyst are abdominal pain which is dull aching and in upper part of abdomen along with bloating of abdomen. the patients can also present with nausea, vomiting, loss of appetite, weight loss and swelling or a mass in the abdomen.
Sometimes, if not properly managed or treated in time, the cyst can rupture which is a life-threatening condition. The patient usually complains of severe pain in abdomen, vomiting of blood, weak and rapid heartbeat and fainting.

Management of Pseudocyst

If the pancreatic cyst is small and asymptomatic, it can be watched and managed conservatively by doing periodic scans. Most of the pancreatic cyst eventually disappears.

Non-surgical treatment
Endoscopic drainage of the pseudocyst – this procedure involves removal of contents or infected fluid present in the cyst with the help of endoscope. An endoscope is inserted through mouth into the stomach and then into pancreas. With the help of endoscope, the cyst is punctured and the fluid is drained. This procedure has its own limitations and the position and size of cyst determines the success rate.
External Percutaneous drainage – this procedure involves draining the contents of cyst through a tube which is placed through the skin into the pancreatic pseudocyst under USG or CT guided imaging. This procedure also has its own indications and limitations and associated with a bit higher recurrence rate..

Laparoscopic surgical management of pseudocyst
The purpose of surgery is to create a connection between the pseudocyst and surrounding organ such as stomach and bowel. The results of surgery are excellent in experienced hands as it is a permanent procedure with negligible recurrence rates.
Our team is performing the surgery laparoscopically ensuring faster recovery and excellent results. it involves placing 3-4 tiny incisions over the abdomen to carry out the surgery. the patient is usually discharged within 48 hours of surgery and can return back to work within 6-7 days. The types of surgery carried out by our team include:

Laparoscopic Cystogastrostomy
TThe most common surgical procedure for the management of pseudo pancreatic cyst. It involves creation of connection between the stomach and pancreatic cyst through laparoscopic approach.

Laparoscopic Cystojejunostomy
In this procedure a connection is established between the cyst and the small bowel so that the cyst contents are directly drained directly into the bowel.

Laparoscopic Cystoduodenostomy
In this procedure a connection is created between the duodenum (the first part of the intestine) and the cyst to allow drainage of the cyst content into duodenum.
The type of surgical procedure depends upon the location and size of cyst. Depending upon the location, the organ which is in immediate vicinity is chosen to establish connection with cyst.

GERD

Gerd is a condition in which acid produced into the stomach often come back into the food pipe or esophagus. It occurs due to improper functioning of the valve present at the junction of food pipe and stomach. A weak or malfunctioning sphincter causes reflux of acid into food pipe causing heart burn and several other symptoms.

Causes of gastro esophageal disease or acid reflux:
  • Obesity
  • Pregnancy
  • Smoking and alcohol
  • Certain medicines
  • High fatty diet
  • Hiatus hernia
Symptoms

Heart burn is the most common symptom and patient usually complains of burning sensation in the chest.
Some patients present with bitter taste of mouth due to acid reflux into mouth.
Some patients experience difficulty in swallowing or sticking of food into the food pipe.
Sometimes this acid can reflux into breathing pipe causing asthma, sore throat, chronic cough or even pneumonia.

When to consult a doctor

If your heart burn occurs more than 2 times in a week, if the symptoms are gradually increasing in intensity or if the symptoms start affecting your day to day activities, you must consult us without any delay.

GERD that is left unchecked may give to serious health problems like formation of stomach ulcers, or burning of food pipe leading to narrowing down of food pipe or even development of a condition called as Barret’s esophagus. It is a precancerous condition which might give rise to cancer of food pipe in later stages.

Treatment of GERD

Life Style modifications: Majority of the patients respond with simple conservative methods. These include some dietary and life style modifications and medicines. Our excellent team of gastroenterologists and nutritionists work in tandem to identify factors responsible for causing acid reflux, helping you to develop some life style modifications and promoting certain food items which will help you providing long lasting relief from this condition.

Medications: Along with lifestyle modifications, we also prescribe certain medicines in the form of PPIs and prokinetics which will further help to alleviate the symptoms of acid reflux in majority of the patients.

Anti-reflux surgery: : Surgical treatment of GERD is also an option especially for patients who are unresponsive to lifestyle modifications and medicines, started experiencing side effects of medicines or want to get rid of medicines.

Some special tests need to be carried out to establish the diagnosis of GERD, rule out other co-existing medical conditions and to corelate acid reflux symptoms.

These tests include:
  • Upper GI endoscopy
  • 24-hour pH test
  • Esophageal impedance pH study
  • Esophageal manometry

The surgery for GERD is known as anti-reflux surgery and involves a procedure called fundoplication. The purpose of this procedure is to augment the function of lower esophageal sphincter and recreate a barrier to stop reflux.

This is done by wrapping upper portion of the stomach entirely around the lower end of esophagus which acts as a mechanical barrier to prevent acid reflux. Our team performs Nissen fundoplication laparoscopically. The entire surgery is carried out with the help of 4 tiny incisions.

The patients are discharged within 48 hours of surgery. Because of laparoscopic surgery, patient experiences minimal pain, faster recovery, less chances of wound infection or hernia.

Our results of the surgery are generally excellent and the vast majority of patients report effective symptom reduction, a high level of satisfaction, and an improved quality of life after having the surgery. Nearly all patients are taken off of reflux medication after surgery.

Traditional surgery involves a large cut in the abdomen and is associated with lot of morbidity and very slow and painful recovery.
Laparoscopic colorectal surgery is a highly advanced, safe and effective alternative to both conventional and laparoscopic-assisted surgery. It offers greater vision, control and accuracy for surgeons.

In laparoscopic colorectal surgery 3-5 small tiny incisions are placed. Through these incisions or holes, the entire surgery is carried out with the help of telescope attached to camera and long thin instruments. It is associated with minimal pain and faster recovery.

The bowel or colorectal conditions treated by us are:

  • Diverticular disease (little pockets or outpouchings in the lining ofthe bowel)
  • Crohn’s disease and ulcerative colitis (inflammatory bowel disease)
  • Removal of large colonic polyps
  • Appendicitis
Diverticulitis of the colon
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Diverticulosis is a benign condition characterized by multiple out pouches or tiny pockets in the lining of colon especially sigmoid colon. It usually occurs in old age due to severe constipation.

They are usually unharmful but complications can occur in 20% of people with diverticulosis. One of these complications is rectal bleeding, called diverticular bleeding, and another is diverticular infection, called diverticulitis.

The majority of patients can be managed without surgery but some patients might require surgery like severe diverticulitis that does not respond to medical treatment, patients with impaired immune systems, diverticulitis that recurs despite a high-fiber diet, peritonitis, fistula formation, or obstruction of bowel.

Depending upon the type of complication, we perform various types of laparoscopic surgeries like excision of fistula, Hartmann procedure (removal of sigmoid colon with colostomy) and sometimes, left hemicolectomy in non- infected cases.

Hartmann procedure is indicated for the treatment of diverticulitis of colon or gangrene or death of bowel due to volvulus of sigmoid colon.

It is usually done as an emergency surgery when the colon is infected, perforated and unprepared. As a result, it becomes extremely unsafe to join the two ends of bowel.

Our team has the experience and expertise to perform these surgeries either laparoscopically or robotically. However, in certain circumstances the surgery is not feasible to carry out by latest modalities. It might require conventional open surgery for the best management of the condition.

Inflammatory bowel disease

Crohn’s disease is an inflammatory bowel disease which affects terminal part of small intestine or beginning of large intestine along with other body parts like eye, mouth, anus.

The inflammation involves the deeper layers of bowel with no definitive cause and no permanent cure.

When the disease is active, patients may present with diarrhea, fever, fatigue, abdominal pain and cramping, blood in your stool, mouth sores, reduced appetite and weight loss, pain or drainage near or around the anus due to inflammation from a tunnel into the skin (fistula).

The management of Crohn’s disease is usually conservative along with life style modification. However, patient suffering from this condition are prone to develop complications like intestinal obstruction, narrowing down of bowel(stricture), formation of fistula and sometimes even cancer.

Although surgery does not offer permanent cure, it becomes a necessity for proper management of complications. The most commonly performed surgeries by our team include:

  • Subtotal Colectomy: which is also called large bowel resection and done to cure the intestinal obstruction, fistula, or severe Crohn’s disease in your large intestine.
  • Proctocolectomy: - It is done to remove entire colon and rectum
  • Small Bowel Resection: it is done to recover the intestinal obstruction or severe Crohn’s disease in your small intestine

We are performing these surgeries both laparoscopically or robotically with excellent results.

Ulcerative Colitis:

Ulcerative Colitis is another form of inflammatory bowel disease. The disease develops and progresses gradually involving only the innermost lining of large bowel and rectum.

Exact cause is unknown but stress, malfunctioning of immune system, high fat diets are some of the factors associated with ulcerative colitis.

Patients usually develop diarrhea mixed with blood and pus, abdominal cramps, rectal bleeding, urgency to defecate, weight loss and loss of appetite.

The management of this condition is usually conservative along with life style modifications. The drugs usually prescribed are anti-inflammatory, immuno suppressants and symptomatic management of the disease.

Some patients usually do not respond to medical management or may develop complications resistant to conservative therapy. In such patients, surgery is the only option.

Rectal Prolapse

Rectum is last part of the intestine where feces is stored before being passed. When the rectum lining becomes weak or detached from the body, rectum starts protruding from the anus, a condition called as rectal prolapse.

Cause of Rectal Prolapse
  • Multiple pregnancies
  • Chronic constipation
  • Diarrhea
  • Chronic cough
  • Neurological conditions like multiple sclerosis, spinal cord tumors
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Symptoms of rectal prolapse

Patient complain of some lump coming out of anus while passing stool which can be pushed back into the anus after defecation.
Over a period of time, prolapse may become permanent and patient describe it as like "sitting on a ball.
Some patients complain of passing bright red blood while passing stool.

What happens if patient of rectal prolapse defers treatment

If a patient has been diagnosed as having rectal prolapse, it is highly recommended that a permanent cure in the form of surgery should be sought as early as possible.

It is because that repeated stretching of anal sphincter which happens during prolapse may cause permanent damage to sphincter resulting in fecal incontinence (no control over bowel movement) even after surgery.

Treatment for Rectal Prolapse

There are two general approaches for management of rectal prolapse

Abdominal approach:

in this approach, we enter through the belly and repair of rectal prolapse is done either robot assisted or using advanced laparoscopic techniques. Both the methods involve making 3-4 tiny incisions into the belly and is associated with fast recovery.
If the patient is medically fit, abdominal repair always has better outcomes and higher success rates in the long term.

Perineal approach:
Perineal approach involves repair through the bottom. It is usually indicated for patients who are medically unfit for long duration surgeries or are having lot of co-morbidities.
The success rate associated with perineal approach is usually inferior when compared to abdominal approach.