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Institute of Laparoscopic Surgery

Leparoscopic Surgery Training

FAQs

  • Morbid obesity is a disease which is chronic and lifelong
  • Causative factor of the disease is due to excessive fat storage
  • BMI or Body Mass Index is a measure of calculating a person’s excess weight
  • It is calculated by the following formula:

 

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  • Being overweight and obese are reversible conditions that can be treated by medical management whereas morbid obesity requires surgical intervention.
  • The body mechanisms that control a person’s weight are set in such a manner in morbidly obese patients that they gain weight easily.
  • These patients find it difficult to lose weight and even more difficult to sustain it.

Morbid obesity is an extreme health hazard with medical, psychological, social, physical and economic co-morbidities.

  • There is increased risk of developing high blood pressure, diabetes (type2), heart disease, stroke, gallstone disease, cancer of breast, prostate and colon.
  • Morbidly obese persons are victims of prejudice and public ridicule due to their size. This repeated mental trauma leads to psychological illnesses such as depression.
  • Discrimination at work results in poor socio-economic conditions.
  • Morbid obesity is a treatable cause of early preventable deaths.
  • Morbid obesity is a disease like any other disease.
  • It has become necessary to recognize this entity as a cause of severe mental and physical morbidity which shows significant improvement following weight loss. It is more important for the patients themselves to understand this disease, its morbid implications and their inability to control it on their own.

Bariatric surgery is a treatment option for patients with morbid obesity.

  • This surgery helps you lose weight by altering your body’s food digestion and absorption.
  • There are several surgical options, each having their benefits and risks.
  • Gastric Bypass, Sleeve Gastrectomy and Gastric Banding are some of the procedures. The choice of procedure should be made after a thorough discussion with your Surgeon.

You will qualify for morbid obesity surgery if:

 

  • You are classified as ‘Morbidly obese’ (BMI MORE THAN 37.5)
  • Your BMI is 32.5 - 37.5 with severe obesity related medical conditions e.g. diabetes, heart disease, high blood pressure, arthritis, etc.
  • Other methods of weight loss (dietary/medicines) have been unsuccessful.
  • You are unable to perform routine activities or daily chores due to the weight problem.
  • You have understood the surgical procedure for weight loss; the risks and after effects involved and are committed to making lifelong behavioral changes pertaining to dietary and physical activities.
  • Patient must learn to eat food in small amounts and to chew it well and slowly.
  • Follow-up is necessary in the first year after surgery and then as advised by your surgeon for dietary / nutritional counseling.
  • Weight loss starts soon after surgery and continues for 2 years.
  • Improvements occur in obesity related medical conditions, with almost 60% patients not requiring medication.
  • There is enhanced quality of life with improved stamina, mood, self esteem and body image.
  • Obesity surgery is not a cosmetic surgery, in fact plastic surgery may be required following weight loss after obesity surgery.

 

Care for the morbidly obese requires a comprehensive set-up. The management team comprises the Surgeon, Dietician, Endocrinologist, Physician, Cardiologist, Physiotherapist and Psychologist.

It is the protrusion (bulge) of abdominal viscera through a weakened part of abdominal wall. A hernia does not get better over time, nor will it go away by itself (except very small congenital navel hernia). It always becomes bigger with time.

The common types of hernia are present in the groin (inguinal), belly button (umbilical) and the site of a previous operation (incisional). There are many more types but are rare.

Hernia is easy to recognize. It appears as a bulge under the skin. This bulge may appear on standing or straining and disappear on lying down. It may or may not be painful. Discomfort may worsen at the end of the day and also while coughing and sneezing.

Surgery is the only cure for majority of hernias. There is no medical treatment for it.

Once detected, for best results, the hernia should be treated as early as possible. Also, early operation will prevent complications like obstruction and strangulation. When compared with large hernias, the surgical results with smaller hernias are much more satisfying.

Strangulation of hernia is a surgical emergency.

The hernia becomes very painful, does not reduce and the overlying skin becomes red. The patient will require hospitalization and immediate surgery.

The types of surgery available for treating hernias are:

  • Laparoscopic surgery (also known as Minimal Access Surgery / Minimally Invasive Surgery / Endoscopic Surgery).
  • Conventional (Open) Surgery.

Three (5-5-10 mm sized) incisions are made and cannulas placed in them. A laparoscope (a long narrow telescope) connected to a special camera is inserted through a cannula (a small hollow tube), allowing the surgeon to view the hernia and surrounding area on a video screen. Other cannulas are inserted which allow the surgeon to work ‘inside’. A piece of surgical mesh is fixed over the hernia defect and held in place with small surgical staples.

Endoscopic surgery causes much less pain and patients are mobile within hours after surgery. They are also allowed to resume all activities much earlier and can go back to work within 5-7 days. Another advantage is that both sides can be operated in the same sitting without any extra pain or stay. The cosmetic results are excellent.

Yes. Now world over, there is consensus that the use of mesh is desirable in majority of patients to strengthen the wall whether surgery is done conventionally or endoscopically. Only the childhood hernias are repaired without using mesh.

Yes. Done by a properly trained surgeon in a well equipped centre, it is a safe surgery with excellent results.

Yes. Day care surgery is being performed on young and fit patients. The patient is called to the operation theatre in the morning in a fasting state of more than eight hours. After the operation, patient is observed for 4-6 hours post operatively in the day care facility before getting discharged. In case the need arises, there is a provision for overnight admission as well.

Gallbladder is a pear shaped organ present close to the liver. Its function is to store and concentrate bile juice which is produced in the liver. It does not produce bile as many people think.

Bile is a liquid produced by the liver which helps the body to digest fat. On eating a meal, the gallbladder pushes this bile into the common bile duct which carries it to the intestine.

Gallstones are stones which form within the gallbladder. They may vary in number and size. For management of these stones, size/ shape and number is not relevant.

The exact cause for their formation is not known, however, risk factors include:

  • Gender: Women between 20 and 60 years of age are twice as likely to develop gallstones as compared to men.
  • Age: Practically all age groups but more common in the 30s and 40s.
  • Obesity
  • Excess estrogen (women on oral contraceptive pills, etc)
  • Cholesterol lowering drugs
  • Diabetes
  • Rapid weight loss
  • Prolonged fasting
  • Hereditary blood disorders
  • Unknown geological factors, such as gallstones are much more common in northern and eastern parts of India.

Yes, day care surgery may be performed in young and selected patients. The patient is supposed to be fasting and would be called to the operating theatre in the morning. The operation would be performed and the patient would be observed for 4-6 hours post operatively in our day care facility. The patient would normally be discharged the same afternoon. However, if the need arises, he/she could be admitted overnight as well.

Women are more prone as compared to men.

People in their 30s and 40s

Overweight men and women

People who fast frequently or lose a lot of weight quickly

Pregnant women, women on hormone therapy and women who use birth control pills for a prolonged period

Symptoms of gallstones are severe abdominal pain often called a gallstone ‘attack’ (colic) because they occur suddenly. Gallstone attacks often follow fatty meals, and they may occur during the night. A typical attack can cause the following:

  • Severe pain in the right upper abdomen that increases rapidly and lasts from few minutes to several hours
  • Pain in the back between the shoulder blades
  • Pain under the right shoulder
  • Nausea or vomiting

 

Other symptoms of gallstones include:

  • Abdominal bloating (gas formation)
  • Recurring intolerance to fatty foods
  • Belching
  • Indigestion

 

People who also have the following symptoms should see a doctor right away:

  • Sweating
  • Chills (shivering)
  • Low-grade fever
  • Yellowish color of the skin or whites of the eyes
  • Clay-colored stools

Many people with gallstones have no symptoms. These patients are said to be asymptomatic and these stones rae called ‘silent stones’.

  • Recurrent severe abdominal pain or vomiting
  • Pus formation in the gallbladder (Empyema)
  • Cholangitis (life threatening infection of biliary system)
  • Gangrene and perforation of the gallbladder
  • Acute pancreatitis (swelling of pancreas) which can have a catastrophic sequel of multi organ failure and other serious complications
  • Jaundice due to blockage of the common bile duct due to stones
  • Associated with cancer of gallbladder in the long term

Slippage of the stone(s) in CBD may cause pain or jaundice or both. This situation requires an endoscopy (ERCP) for removing the stone(s). This should preferably be done before surgery. However it may also be done after the operation.

Sometimes a stone in the CBD may not show on ultrasound, however patient may have symptoms which are indicative of the same. In this event the patient requires magnetic resonance cholangiopancreatography (MRCP – an MRI scan) which shows the presence of stones in the common bile duct.

The surgeon may use endoscopy for removing CBD stones before gallbladder surgery. Once the endoscopy is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP and EPT.

Fortunately, the gallbladder is an organ that people can live without. Losing it won’t even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder.

It is a narrow hollow muscular tube present near the junction of the small and large intestine. It has no significant function in human beings.

It means inflammation of appendix (infection or swelling). The term acute means sudden development of the inflammatory process.

It is most commonly seen in the second decade of life (adolescence), though it can occur in any age group.

80% of cases of acute appendicitis are caused due to obstruction of lumen of appendix. The reason of obstruction could be a faecolith (i.e. hard faecal matter), worms if present in the intestines and rarely a foreign body like seeds.

Severe pain around the navel which shifts after a few hours to the right lower abdomen.Coughing and straining cause an increase in the pain. Pain is accompanied by nausea and vomiting. Less common complaints include burning on passing urine and loose stools.

The clinical signs and symptoms as mentioned above, are the most important indications for reaching a diagnosis. In addition, raised total blood count confirms the diagnosis. Acute appendicitis is the most common abdominal emergency and requires surgery.

An abdomen ultrasound may help in reaching the diagnosis in case the clinical examination and other investigations are inconclusive.

Gangrene and rupture of appendix causing generalized abdominal infection, Intra Abdominal Abscess (collection of pus) and Septicaemia (generalized, severe infection in blood) leading to catastrophic life threatening consequences.

The treatment of acute appendicitis is removal of the appendix (i.e. Appendicectomy). This can be done by an open technique or laparoscopically. Laparoscopic appendicectomy is performed by making three tiny (3-5-10 mm) incisions through which the telescope and instruments are introduced and the appendix is removed. The advantage of laparoscopy over open technique is less pain, early recovery and excellent cosmetic results. Also, laparoscopically the entire abdomen and pelvis can be inspected to rule out any other pathology.

Appendix is a vestigial organ (something which has no well defined function) in humans and thus can be removed without any consequence.

There are no side-effects as it has no definite function in the human body. It is a useful organ for animals where it helps in digestion.

Laparoscopy has the advantage of lesser post operative pain, early recovery, good cosmetic results as well as the chance to rule out any other pathology present in the same surgical sitting. This is a method of choice in well equipped institutes having a trained surgical team.

Anal fistula, or fistula-in-ano, is a common anorectal problem in which an abnormal connection develops between the inner surface of the anal canal and the skin around the anal verge.

Anal glands located between the two layers of the anal sphincters (muscle which open and close the anal orifice) and draining into the anal canal are the site where these fistulae originate. It is the blockage of the outlet of these glands which cause secretions to accumulate inside and an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula.

Yes! The fistula tract can branch into the fascial layers of the perianal region. Abscesses can also recur if the fistula seals, allowing the accumulation of pus. It may then point to the surface at the same site or a different site, and the process repeats. This way more than one fistula opening can develop. Patients suffering from Crohn’s disease are more likely to have multiple fistulous tracts and complex fistulas.

The recurrence rate after surgical treatment of anal fistulae is possible due to various reasons. Most recurrences develop within a year following surgery. Factors associated with recurrence include complex type of fistula, horseshoe extension, lack of identification or lateral location of the internal fistulous opening and previous fistula surgery.

Specific complications of anal fistula operation are uncommon, but can include:

  • Infection – this can result in an anal abscess and further surgery may be needed
  • Damage to the sphincter muscles – this may affect your bowel control and can lead to faecal incontinence ( incontinence is associated with female sex, high anal fistula, type of surgery and previous fistula surgery)
  • Prolonged period of painful dressing which may be needed for weeks or months
  • Narrowing of the anal canal (the short, muscular tube that connects the rectum with the anus)
  • Re-occurrence – there is a chance that the fistula may come back in quite significant number of patients.

The video-assisted anal fistula treatment (VAAFT) in India is described as Minimally-Invasive Anal Fistula Treatment (MAFT). This technique is performed for the surgical treatment of complex anal fistulas and their recurrences. This is a major breakthrough treatment option for complex fistulas.

 

In this technique, we first examine the fistula path with an endoscope and determine the point of the internal opening of the fistula. In the second step, the internal opening of the fistula is closed, with the help of stapler and the entire part of the fistula is destroyed by electrocautery under direct telescopic vision.

 

There is no surgical wound in the perianal region hence no dressing is needed. The risk of faecal incontinence is not there because no sphincter damages occur. The procedure is done under spinal anesthesia / general anesthesia. There is minimal post-operative discomfort.

Piles or hemorrhoids are swollen blood vessels in the anal passage. There are two circular bunches of veins, one inside the anal canal and the second at the anal verge. Accordingly they are called internal and external hemorrhoids.

There are certain conditions which predispose to formation of piles. These are –

  1. Excessive straining while passing stools e.g. chronic constipation, low fibre diet, poor bowel habits.
  2. Increased backward pressure on pelvic blood vessels e.g. pregnancy, pelvic tumors.

Yes! Piles tend to worsen with time and may result in severe bleeding which requires blood transfusions. They may protrude outside the anal opening and become very painful causing significant morbidity. They are often associated with discharge soiling the undergarments and causing irritation. Complications of piles include anemia due to frequent blood loss, thrombosis ( bleeding into the pile mass), strangulation, ulceration and infection spreading into the liver system.

An anal fissure is a small tear or cut in the skin at the anal opening. Fissures typically cause pain and often bleed. Fissures are quite common, but are often confused with other causes of pain and bleeding, such as hemorrhoids. Most fissures occur along the mid-line: the top or bottom - of the anus.

The typical symptoms of an anal fissure are pain during or after defecation and fresh bleeding. The pain may be severe enough to cause the patients to avoid defecation.

Injury: Most commonly due to a hard, dry bowel movement. Many women during childbirth develop an anal fissure. Other causes of the anal fissure are: digital insertion (during examination), foreign body insertion, or anal intercourse. A fissure may also develop following diarrhea or inflammatory conditions of the anal area.

 

Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). Chronic fissures often have a small external lump associated with the tear called a sentinel pile or skin tag.

The principle of treating an anal fissure is relieving the anal spasm and correcting the constipation. At least 50% of anal fissures heal by medical management alone.

  1. Drinking more fluids.
  2. Eating a high fibre diet to avoid constipation.
  3. Using stool softeners.
  4. Allowing enough time for a bowel movement.
  5. Sitz baths (soaking anal area in plain warm water).
  6. Avoid foods that may not be well digested (i.e. nuts, popcorn, tortilla chips).
  7. Topical ointments.

 

Medical treatment of an acute anal fissure may take a few days or weeks, while healing of a chronic anal fissure may take more than 6 weeks.

In case a fissure does not heal it should be reexamined to determine if an underlying problem exists that prevents healing.

Fissures can recur in some after a hard bowel movement. Even after the pain and bleeding has disappeared one should continue to aim for good bowel habits and adhere to a high fibre diet or fibre supplement regimen. If the problem returns without an obvious cause, further assessment may be needed.

A fissure not responding to non surgical management will require some intervention to relieve muscle spasm. This may be by chemical internal sphincterotomy (CIS) or lateral internal sphincterotomy (LIS).

This procedure is a minimally invasive approach to relax the anal muscle by partially paralyzing it by injecting chemicals into the anal sphincter muscle. The relief occurs within a few days and complete healing occurs in a few weeks time.

Surgery is a highly effective treatment for a fissure and recurrence rates after surgery are low. Surgery usually consists of a small operation to divide a portion of the internal anal sphincter muscle ( a lateral internal sphincterotomy). This helps the fissure heal and decreases pain and spasm.

 

If a sentinel pile is present, it too may be removed to promote healing of the fissure. A sphincterotomy rarely interferes with one’s ability to control bowel movements and is most commonly performed as a short outpatient procedure.

Complete healing occurs in a few days/ weeks, although pain often disappears after a few days.

No! However if symptoms persist despite healing of the fissure, a careful evaluation is needed to rule out other conditions that can cause similar symptoms. You may require additional testing even if your fissure has successfully healed. A colonoscopy may be required to exclude other causes of bleeding.

A condition wherein the rectum (distal most part of large intestine just above the anal canal) protrudes out of the anal opening due to stretching or disruption of its attachments to the posterior abdominal wall.

The primary cause of rectal prolapse remains unclear. Predisposing factors include prolonged straining while passing stools (chronic constipation), multiple pregnancies, neurological illnesses causing muscular weakness or connective tissue disorders (genetic predisposition).

 

It is often seen in the elderly as aging causes the supporting ligaments to stretch the anal sphincter muscle to weaken.

 

The most popular concept is due to a functional disturbance of the pelvic floor. Weakness of the anal sphincter muscle is often associated with rectal prolapse, resulting in leakage of stool or mucus.

The presence of a large pink mass protruding out of the anal opening is embarrassing. The mass may protrude only on bowel movements or sneezing, or chronically protrude from the body at all times.

 

Extreme pain and difficulties with bowel movements may also be noticed, especially if the rectum undergoes any torsion (twisting) during its collapse. Bleeding or mucus discharge from the damaged tissue, loss of urge to defecate and fecal incontinence may also occur.