Laparoscopic / Hysteroscopic procedures
In the last two decades, minimally invasive surgery has changed the way most gynecological problems are treated. Diagnostic hysteroscopy and laparoscopy have become the mainstay for diagnosing endometrial, uterine and adnexal pathology.
Majority of common gynecological problems such as endometriosis, pelvic inflammatory diseases, peritubal pathology, pelvic adhesions, benign ovarian cysts, hydrosalpinx, selected leiomyomas et cetera are now treated with operative Laparoscopic procedures very successfully.
Operative hysteroscopy has become the procedure of choice for dealing with intra-uterine septum, intra-uterine adhesions, sub mucous leiomyomas and endometrial polyps.
Dr Padmavathi prides herself as one of the pioneers in minimally invasive procedures, having introduced them as early as 2001in Padmapriya Hospital. Hospital offers the entire range of operative Laparoscopic and Hysteroscopic procedures including laparoscope assisted vaginal hysterectomies and Laparoscopic hysterectomies.
Infertility management is yet another area where both diagnostic and Laparoscopic surgery have contributed tremendously and resulted in numerous couples achieving their dreams.
Menopause is the time in a women’s life when her menstrual function ceases. This usually happens around age 45-55. However her hormonal functions start declining a good ten years before this event. These phases in her life are referred to as pre menopause and peri menopausal years.
These declining hormonal levels bring about many changes to the body, mind and sense of well being. Several life style diseases such as hypertension, Diabetes, Obesity, metabolic syndrome, depression also tend to manifest on women of this age group.
Indian women tend to suffer in silence rather than seek solutions for these problems. Padmavathi Hospital has started the menopause clinic specially dedicated to addressing these specific issues. Complete screening, investigations and management options will be offered to these women. Emotional support and counseling will also play a key role in the management.
Padmapriya is dedicated to serving families through excellence in individualized care. We believe the birth of your baby is one of the most important events in your lifetime. As each individual is unique, so is each pregnancy and birthing experience. Your first visit On your first visit to our center, we will
As each pregnancy is unique you will be called back for antenatal visits according to when your Obstretician thinks it is required. The recommended routine is as early as possible and then every 4 to 6 weeks until 7 months of pregnancy, then every 2 weeks until 9 months, and then weekly until the baby arrives What will be done during your subsequent visits?
An ultrasound scan has been proven to be an easy,painless and safe way of assessing your baby.It is routinely offered to all mothers at 3 months and at 5-6 months to make sure that the baby is structurally normal.
In addition to the ultrasound ,other blood tests are now available which can increase the chance of detecting certain abnormalities in the baby. Pregnancy Classes
Sign up for our pregnancy classes which will help you understand the changes that you may experience during pregnancy, deal with the various facets of pregnancy and to prepare you adequately for the arrival of your bundle of joy.
The process of conceiving is no less than a miracle. An intricate sequence of events must be carefully orchestrated in both the man and the woman.
Fertilisation occurs when a woman's egg and a man's sperm fuse to form a single cell. This occurs in one of the fallopian tubes. For this to happen, the egg and the sperm have to perform certain functions beforehand and once fused, the merged cells must find their way to the uterus and embed into the lining of the womb, in order for the fertilisation to become a pregnancy. Here is a brief overview of the roles played by the female egg and the male sperm.
The exact time of the month for ovulation depends on your menstrual cycle. Taking an average menstrual cycle of 28 days, ovulation occurs on days 12-15. Day one is the first day of your period.At ovulation, an egg is released from the ovaries. It is picked up by and travels down one of the fallopian tubes towards the uterus where , if intercourse has taken place within the last four days, it may meet sperm.
Eggs live and can be fertilised for 12-24 hours after being released. Sperm can live and stay active in your body for up to 48 hours. Hormones prompt an increase in blood supply to the womb, in preparation for implantation. It takes up to five days for the fertilised egg to reach the womb and embed itself in the lining.
If the egg is not fertilised, or if the fertilised egg cannot attach to the womb lining, then a period begins.
At the point of ejaculation during intercourse, a man can release up to 300 million partner’s vagina.
Only a small proportion of those make it through the neck of the womb and on to the fallopian tubes. The sperm must be actively moving, of normal appearance and of sufficient quantities to be considered normal. It must also be capable of moving through the female genital tract to reach the fallopian tube, where the egg is fertilised.
The quality of the cervical mucus in the woman’s body at the time of ovulation must be such that it allows free passage of the sperm into the uterus. Finally, only one sperm will find its way in to fertilise an egg.
Once the sperm penetrates the egg, the chromosomes carried by the sperm and the egg come together and the egg is fertilised. Within hours, the microscopic zygote divides over and over to produce multiple cells. Over the period of about 5 days, the fertilised egg or blastocyst now made up of about 150 cells, makes its way to the uterus or womb.
At this point, if conditions are favourable, the fertilised egg embeds itself in the lining of the womb and the female becomes pregnant
Ovulatory problems are the most common cause of female infertility and occur due to hormonal imbalance. This imbalance may arise either within the hypothalamus, the pituitary gland or in the ovaries. Common causes of these problems include stress, excess weight loss or weight gain, excessive production of prolactin (the hormone that stimulates milk production in the breasts) and polycystic ovarian disease
About 20% of women have polycystic ovaries (PCO). Many women with PCO have normal menstrual cycles and actually do not have a problem conceiving. However, some women have follicles on their ovaries which get stuck at a certain stage of development before they can get to the stage of producing an egg. This condition is known as polycystic ovarian syndrome (PCOS). PCOS is due to a hormonal imbalance, especially a raised LH, with irregular or absent periods. PCOS can very often be caused by a high glycaemic diet as many PCOS patients are also insulin resistant. It can also cause increased hair growth on the face and body inevitably-difficulty conceiving.
Symptoms of PCOS in women include irregular or no periods, often heavy and prolonged when they do arrive. The patient may be prone to being overweight and often craves mid-meal snacks, is often tired and may also complain of pelvic pain.
Treatment usually involves a practical diet and if required, the use of drugs to correct the hormonal imbalance and to stimulate ovulation. If a woman is overweight then losing excess weight, exercising and changing to a low glycaemic diet may help to improve the hormone imbalance. Medication is used to increase sensitivity to insulin and the most widely used is Metformin.
Alternatively, a laparoscopic polycystic ovarian drill, which involves putting a telescope into the tummy and inserting a needle into the ovary to disrupt it and trigger ovulation, may be performed.
Patients with PCOS are often successfully treated, though there can be the complication of either over or under stimulation of the ovaries, which has to be carefully managed by an experienced and reputable consultant.
Endometriosis is a condition that commonly affects women during their reproductive years. It occurs when endometrial cells, which are normally found only inside the womb, are found outside the uterine cavity. Some women with Endometriosis are without symptoms, but others suffer painful periods and pain during intercourse.
Endometriosis can appear as spots or patches called implants or as cysts on the ovaries and in severe cases can affect surrounding tissue causing adhesions or scar tissue. Unlike the lining of the uterus, endometrial tissue located outside the womb is trapped and does not have a way to leave the body. This can cause inflammation near the implants and if nerve tissue is affected, pelvic pain may result.
The diagnosis of Endometriosis cannot be made from symptoms alone as some women have no symptoms as there may be other reasons for pelvic pain.
Surgery or Laparoscopy is the only definitive way to diagnose endometriosis. Laparoscopy allows direct visualisation and ideally biopsy of areas suspected of being endometriosis. It is carried out by inserting a small telescope through an incision close to the naval.
Endometriosis can be managed quite simply and IVF is an appropriate treatment for associated infertility where other methods have failed.
During laparoscopy, the surgeon can also clarify if the tubes are open. This is where liquid is flushed through the neck of the womb. This flushing with liquid is similar to Saline Infusion Hysterosonography which is carried out on all female patients pre-IVF at Womens Center.
Many women who have Endometriosis can conceive without any difficulty however some women do have difficulty getting pregnant.
IVF is an appropriate treatment for infertility associated with Endometriosis where other methods have failed.
Tubal factor infertility accounts for up to one quarter of all cases of infertility. This includes cases where both the fallopian tubes are blocked, or one is blocked, or one (or both) are scarred. It is usually caused by pelvic infection (e.g. pelvic inflammatory disease (PID) or appendicitis), by pelvic endometriosis, or by scar tissue that forms after pelvic surgery.
In cases of relatively minor tubal damage it can be difficult to be certain if it is solely responsible for the infertility – or simply an additional factor in addition to other significant contributing causes. From a practical point of view, the presumptive diagnosis is of tubal factor unless the degree of scarring is very minimal. In this event, and if no other cause of infertility is found, then a diagnosis of unexplained infertility may be warranted.
The diagnosis can be made in a number of ways. Your doctor may suggest a laparoscopy and hydrotubation. A camera is placed through your belly button (usually) to inspect the pelvis. This is especially useful if other features are present e.g. pain which might suggest endometriosis (often treated at the same time). Dye is passed through the tubes and patency (or blockage or swelling) confirmed. The most common cause of blocked tubes is infection (PID) of which the most common infection is chlamydia. About 70% of women who have blocked tubes have had a chlamydia infection although it is often silent and they will not have even been aware of it.
A less invasive test still carried out in some hospitals is called a hysterosalpingogram. It is a useful test but is being superseded in many parts of the world by HyCoSy or saline sonography. These do not require X-Ray technology but rather vaginal ultrasound (like you may have when being monitored for fertility treatment). HyCoSy uses a special contrast dye while the saline test uses sterile salty water (saline). These are much less invasive than the older tests and may themselves be overtaken by three-dimensional ultrasound in years to come.
Knowledge of how you will respond to hormone injections during an IVF treatment cycle is a very important part of fertility treatment.Depending on your own individual characteristics, you may fall into the extremes of response – an excessive response or and inadequate response. A recently developed test allows us to modify our approach, resulting in a reduced incidence of both of these extremes.
It has now been established that the hormone AMH, which is made by the ovarian follicle containing the egg, can accurately predict how your ovaries will respond to fertility drugs. This is sometimes called the ovarian reserve. Armed with this information, our consultant can make better decisions from the outset as to how to best proceed with your assisted reproduction cycle.
AMH involves a single blood test which can be performed at any stage in the menstrual cycle. At Womens Center , we can analyse your AMH levels in our own dedicated laboratory. Other relevant hormones may be measured in parallel with AMH, these are thyroid stimulation hormone (TSH) and Prolactin. Together these are known as the AMH profile.
Male infertility occurs when a man does not produce enough sperm, known as a low sperm count, or the sperm are not of a sufficiently high quality to fertilise the egg.
It is also possible that there are problems with the tubes that carry sperm resulting in no sperm in the ejaculate (azoospermia). A man may also find it difficult to get an rection, or have trouble ejaculating, therefore, sperm may not reach his partner's vagina.
Abnormalities in semen production can cause male fertility problems. The initial screening for men is a semen analysis. A normal assessment should show a sperm count of more than 20 million sperm per ml with at least 50% of the sperm actively motile and more than 35% of the sperm with a normal shape.
The sperm should be able to survive in the female genital tract for a period of 24-48 hours so that they are able to reach the site of fertilisation in the fallopian tubes.
Abnormalities in the semen are primarily due to a defect in sperm production by the testicles. The cause of this is usually unknown but may be associated with previous infections or surgery including undescended testis or hernia. Abnormalities may also be caused by excessive drinking.
Certain drugs, radiation and radiotherapy may have a detrimental effect on the production of the sperm. The presence of a varicocele, a condition where there is an increase in the blood flow around the testicles due to dilated veins, may lead to a rise in the temperature around the testicles, which may adversely affect sperm production and motility.
Absence of sperm in the ejaculate (azoospermia) may due to an obstruction at the level of the vas deferens, epididymis, or even at the level of the testes. It may also be due to bilateral congenital absence of the vas. Some men may have testicular failure which is failure of production of the spermatozoa. This may be the result of a chromosomal disorder or previous infections such as mumps. It may also be associated with the history of failure of descent of the testes into the scrotum.
On rare occasions there may be anti-sperm antibodies in the sperm which impair their motility. This may occur following a reversal of a vasectomy or other surgery on the male genitals and may also be related to previous infections or injury. Your semen sample will be tested for sperm antibodies during the analysis.
Until recently, there has been no effective treatment for male infertility. Drugs have rarely improved sperm counts. However, since the introduction of micro manipulative techniques, in particular Intracytoplasmic Sperm Injection (ICSI), the success rates for couples with male problems have markedly improved.
ICSI bypasses the natural process involved in a sperm penetrating an egg and is therefore used when there are problems that make it difficult to achieve fertilisation naturally or with conventional IVF
Sperm DNA is packaged by nature in a different way compared to that of other cells in the body. In sperm cells, DNA is arranged in very tight organised loops so that it can be carried safely to its final destination – the egg.
Semen protects sperm from several hazards along the journey. DNA fragmentation occurs when particular reactive oxygen species damage the sperm DNA. If damaged sperm is accepted into an egg for fertilisation, poor quality embryos or miscarriage can result.
There is a test that can assess this problem. The sperm chromatin structure assasy (SCSA) can measure a DNA fragmentation index (DFI). This test may reveal high susceptibility toward DNA damage or actual DNA fragmentation already present in the sperm.
Treatment includes maintaining appropriate temperature for the scrotum, giving up smoking, reducing your weight and ensuring that any medication that you are on does not cause DNA fragmentation.
There are a number of factors that inhibit conception. It is important to clearly understand those possible factors, so that you take appropriate action
Statistics show that female factors account for approximately 40% of all infertility cases and male factors account for a further 40%. In the remaining 20% cases, fertility is unexplained.
Sometimes a minor problem with both partners can impair fertility. At times, there may be no scientific explanation for infertility.
Under normal circumstances, a couple has a 25% chance of conceiving a child each month, if they have unprotected intercourse during the fertile part of the menstrual cycle. About 80% of couples do conceive a child within a year.
When considering infertility treatment, time is never on your side and age is an important factor. Every six months makes a significant difference in terms of your infertility, so don’t wait to seek treatment. Broadly, the guidelines are that if you are under 35 and have not conceived within one year, then talk to your doctor and get expert advice.
If you are over 35, then time is critical and you should seek medical advice much more quickly- after six months at the most.
Women are most fertile between the ages of 20 and 24.
At 35 you are half as fertile as you were at 25.
At 40 you are half as fertile as you were 35.
This means that it can much longer to get pregnant when you reach your late thirties or early forties.
A woman’s ovaries age in the same way that normal aging affects all of her organs and tissues. Most women have about 300,000 eggs in their ovaries at puberty. For each egg that matures and is released or ovulated during the menstrual cycle, at least 500 eggs do not mature and are absorbed by the body.
As a woman ages, the remaining egg in her ovaries also age, making them less capable of fertilisation and their embryos less capable of implanting.
Fertilisation ia also associated with a higher risk of genetic abnormalities such as chromosomal abnormalities. The risk of a chromosomal abnormality in a woman age 20 years is one in 500 while the risk in a woman age 45 is one in 20.
Gynaecological problems such as pelvic infection, tubal damage, Endometriosis and fibroids also tend to increase with age. Aging does not just affect women; it also affects men, although to a lesser degree. Aging affects DNA sperm.
Laparoscopic surgery is also called minimally invasive surgery (MIS), bandaid surgery and keyhole surgery. It is a specialized surgical technique in which operations in the abdomen are performed through small incisions or ports usually 0.5–1.5 cm. A large single incision is carried out in traditional open surgery procedures. Keyhole surgery uses images displayed on TV monitors for magnification of the surgical elements. Laparoscopic surgery can also be used for operations within the abdominal or pelvic cavities. Keyhole surgeries performed on the thoracic or chest cavity are called thoracoscopic surgery. Laparoscopic surgeries are popularly performed for Crohn’s disease, ulcerative colitis, rectal prolapse, cancer, diverticulitis and chronic constipation.
The laparoscope is a long, thin, fiber optic cable like a telescope which illuminates and magnifies the structures inside the abdomen. There are two types of laparoscopes:
The telescopic rod lens system is a device which uses a single chip or three chip video camera connected to it.
In the digital laparoscope the charge-coupled device is placed at the end of the laparoscope instead of the telescopic rod lens system.
A fiber optic cable system is attached which is connected to a ‘cold’ light source such as halogen or xenon. These are inserted through a 5mm or 10mm cannula or trocar to view the operative field. After prepping, the abdomen is insufflated with carbon dioxide gas. This elevates the abdominal wall above the internal organs like a dome creating a working and viewing space. CO2 is used because it is common to the human body and can be absorbed by tissue and removed by the respiratory system. It is also non-flammable, which is important because electrosurgical devices are commonly used in laparoscopic procedures.
A vast majority of the abdominal operations can be done by laparoscopy with excellent results, minimum pain and quick recovery.
Surgery of the esophagus is conducted for perforation, cancer, reflux and other conditions.
GERD Esophageal surgery can be conducted for gastroesophageal reflux disease or acid reflux. This is a condition in which the acidic juices in the stomach leak into the esophagus. Surgical intervention tightens and restructures the area using laparoscopy. Several small incisions are made in the abdomen and the upper portion of the stomach is wrapped up around the base of the esophagus.
Surgery for corrosive esophageal injury: Intentional or accidental ingestion of corrosive acid or alkali can lead to severe injury of the esophagus and or stomach. A good number of these patients respond well to endoscopic dilatation while some of them will require surgery. A transhiatal esophageal resection is performed for corrosive injury. A gastric pull-up or colon pull-up is performed to replace damaged esophagus.
Esophageal Cancer Surgery: Cancer of the esophagus commonly seen in chronic smokers presents with dysphagia (inability to swallow) and progressive weight loss. The cancer along with the surrounding normal tissue can be removed surgically. Lower third and middle third cancers of the esophagus are amenable to surgical treatment in the form of removal of the esophagus called esophagectomy. Esophagectomy are of two types open esophagectomy and minimally invasive esophagectomy.
Open esophagectomy can be approached as transthoracic esophagectomy where the part of the esophagus is removed through small incisions in the chest and abdomen. It can also be approached as transhiatal esophagectomy where incisions are made in the abdomen and neck. In some procedures incisions are made through all three avenues, the abdomen, chest and neck.
Minimally invasive esophagectomy is a procedure that is performed for small cancers, where surgical instruments are inserted through small incisions and a scope is inserted to view inside the organs during the operation.
Surgery for cancer of GE junction Cancer of the gastro-esophageal junction requires removal of the esophagus and part of the stomach. This procedure is called esophago-gastrectomy. The remaining stomach is then pulled up through the chest and anastomosed to the esophagus in the neck.
Achalasia cardia – Achalasia cardia is functional and motor disorder of the esophagus. The lower sphincter of the esophagus fails to relax and there is high body peristalsis. It is a benign condition where there is an obstruction at the lower end of the esophagus quite often treated by balloon dilatation. Failure of balloon treatment will require surgery in the form of – Laparoscopic / open cardiomyotomy.
Individuals suffering from morbid obesity undergo gastric bypass surgery. When a person has been unable to sustain weight loss with appropriate diet and is affected by comorbid conditions, it leads to obesity. It can be life threatening and even affect the quality of life of the individual. Surgical procedure first involves division of stomach into a small pouch and large pouch and then positioning the small intestine to connect to both. The general term used for surgeries for morbid obesity is bariatric surgery. The surgery is usually painless since it is done under general anesthesia. There are at least three types of gastric bypass surgeries:
In this technique the small intestine is divided 45 cm below the lower stomach. It is then arranged in a Y intersection in the proximal end of the small intestine, enabling food outflow through a Roux limb.
In this technique the Y intersection is at the distal end of the small intestine. There is reduced absorption of fats and starches which are passed on to the large intestine.
MGB is a relatively new procedure and less invasive. The stomach is divided and detached from the esophagus. The detached portion of the stomach is stapled and stitched. About 2 to 7 feet of intestine is also bypassed and the new, smaller portion of the stomach attached to it. Food is now received by this small stomach and continues its digestive process through the rest of the intestines.
The gastric band operation reduces the capacity of the stomach with the help of a band. A small pouch is created in the upper stomach which can hold very little food. It is an adjustable gastric band, containing a circular balloon which is inflated. As you eat, the pouch fills up and the band restricts the passage of food to the lower part of the stomach.
Gastric sleeve surgery can be accomplished as an open surgery or a laparoscopic surgery. A large part of the stomach is removed leaving only a tube shaped gastric sleeve for a stomach. The detached stomach is closed with surgical staples.
Peptic ulcers are caused by Helicobacter Pylori. A large gastric ulcer in the lining of the stomach presents with severe upper abdominal pain and vomiting. Quite often these ulcers heal by medication. These ulcers can bleed massively requiring transfusion of blood and sometimes surgery. Surgery for ulcers will be in the form of partial gastrectomy
Duodenal ulcers can cause bleeding or sometimes gastric outlet obstruction causing persistent vomiting. An anastomosis between the stomach and the proximal loop is created for draining the contents of the stomach. Surgery for this ailment will be in the form of gastro-jejunostomy and truncal vagotomy
Cancer of the stomach is a very common ailment in southern India. Cancer of the stomach is in the form of a malignant tumor developing in the stomach. Stomach cancer is also called gastric cancer. These patients present with a varied presentation which includes weight loss, pain abdomen, vomiting or sometimes with no symptoms at all. An upper GI endoscopy is usually diagnostic. Cancer of the stomach will primarily require surgery in the form of partial,total gastrectomy or bypass followed by chemotherapy if necessary.
Acid injury to the stomach due to accidental or suicidal ingestion of bathroom acid causes severe damage to the stomach, which will require emergency or elective surgery on the stomach like Bypass Gastric Surgery.
Fundoplication for hiatus hernia Severe heartburn due to hiatus hernia will at times require surgical treatment in the form of a fundoplication to reconstruct a new valve at the junction between the food pipe and stomach
Collection of pus in the liver is a common occurrence especially in alcoholics needing antibiotics and anti-amoebics and repeated aspiration by pushing a needle into it under ultrasound guidance. Some large abscesses located in inaccessible areas of the liver, multiple abscesses and those threatening to rupture will require surgical intervention.
There are three major types of liver abscesses namely pyogenic liver abscess, amoebic liver abscess and fungal abscess. Procedures for drainage of liver abscesses include needle aspiration, percutaneous catheter drainage, open and laparoscopic surgical drainage.
Percutaneous needle aspiration: Material for microbiologic and pathologic evaluation can be done recovered with needle aspiration. Aspiration of the cavity material is done under CT scan and ultrasound guidance.
Percutaneous catheter drainage: Percutaneous catheter drainage is usually performed for small cysts. Cysts greater than 5 mm, multiloculated cysts and ruptured cysts surgical drainage is preferred. A catheter is placed under Seldinger or trocar techniques under CT and ultrasound guidance. This method is used to drain multiple abscesses.
Laparoscopic liver abscess drainage: A small cut below the umbilicus is made under general anesthesia. A laparoscope is then inserted into the peritoneal cavity after establishing the pneumoperitoneum. Pus is aspirated from the liver through paracentesis.
Open surgical drainage: The area is explored for abdominal lesions after making a right subcostal or a superior median abdominal incision. Once the position of the liver is established, hemostatic forceps are used to enter the cavity and remove the pus with a paracentric needle.
Cysts of the liver are well encapsulated fluid collections. Most simple cysts are congenital and a symptomatic. They can usually be treated without surgery. But when they become large and cause symptoms, simple liver cysts are unroofed. The portion of the wall extending to the surface of the liver is excised. Large symptomatic cysts require laparoscopic puncture from time to time but cyst unroofing is also conducted laparoscopically.
The cystic liver is decompressed with a combination of unroofing, fenestration or resection of the liver. This procedure is considered only for patients displaying chronic and disabling pain.
Cystadenoma and cystadenocarcinoma are treated with complete ablation of the tumor. Enucleation, fenestration, formal resection and complete fulguration are also implemented.
Common liver affliction in India, hydatid cyst is a parasitic disease caused by a certain tape worm carried by domestic dogs. Unlike Hydatid cysts can be life-threatening if untreated. Majority of these cysts require surgical treatment with either a marsupialization or a cysto-pericystectomy. Spillage of cyst contents can sometimes cause anaphylactic reaction and dissemination of hydatid disease.
A slit is cut into the abscess and the edges are stitched to form a continuous layer from the exterior to the interior surface. The site can then drain easily.
Laparoscopic cystopericystectomy is almost the same as open surgery. It is a very difficult procedure where initially the cyst is punctured and the fluid aspirated so as to prevent spillage. This part of the surgery is very well controlled in an open surgery rather than a laparoscopic surgery
Cancer of the liver is a dreaded condition affecting both young and the old. Primary liver cancer is called hepatocellular carcinoma and can be a congenital defect or even due to scarring of the liver due to alcohol abuse. Most cancers from different digestive organs in the abdomen spread to the liver causing secondary deposits. Secondary cancer deposits from colon cancer are amenable to liver resection. Surgeries for liver cancer include partial hepatectomy, liver resection and lobectomy and liver transplant. In partial hepatectomy part of the cancer affected liver is removed. In liver resection and lobectomy the lobe of the liver is removed or an attempt is made to remove the cancer surrounding the tissues of the liver.
Patients with injury to the liver often benefit from laparoscopy to evaluate the extent of the injury and decide on opening the abdomen for a definitive surgery.
Gallbladder stones are an extremely common disorder and are usually asymptomatic. Some patients experience biliary colic, an intermittent and often severe pain in the epigastrium or right upper quadrant, and at times between the scapula because of temporary obstruction of the cystic duct with a gallstone. If the cystic duct obstruction persists, the gallbladder becomes inflamed and the patient develops cholecystitis, an acute inflammation and infection of the gallbladder. The vast majority of patients with gallstones are asymptomatic.
Some common ailments of gallbladder and bile duct are as follows: Gallstones are formed when bile salts become hard particles and create blockage.
Cholecystitis is an acute and chronic inflammation.
Acute cholecystitis could be the result of tumors and other illnesses. Chronic cholecystitis is caused due to shrinkage of the gallbladder due to repeated acute cholecystitis and loses its functionality.
Choledocholithiasis occurs when the gallstones are lodged in the bile ducts or the neck of the gallbladder. Acalculous gallbladder disease is also called biliary kinesia which occurs due to the absence of gallstones. Primary Sclerosing cholangitis is scarring, inflammation and damage to the bile ducts. Gallbladder cancer spreads from the inner walls of the gallbladder to other organs.
Gallbladder polyps are harmless growths or lesions on the gallbladder. Gangrene of the gallbladder occurs when there is improper or inadequate blood flow and the gallbladder does not function. Abscess of the gallbladder occurs when the area has pus formation and is inflamed. Bile duct obstruction is blockage of bile ducts due to gallstones.
Bile reflux when fluid in the liver called bile backs up into the stomach and esophagus. Primary biliary cirrhosis occurs when small bile ducts in the liver are damaged.
Laparoscopic cholecystectomy In this procedure the gallbladder is removed by minimally invasive surgical techniques. The procedure is done under general anesthesia. Four small incisions are made in and around the umbilicus, which are called laparoscopic ports. Thin, long tubes or laparoscopes are inserted through these incisions which magnifies the view of the area. Surgical instruments are used to carefully separate the gallbladder from the liver and the bile duct and extract it through one of the ports.
Laparoscopic common bile duct exploration This procedure is commonly used in the treatment of choledocholithiasis and can be done percutaneously, laparoscopically or endoscopically. The approach is the same as laparoscopic cholecystectomy. Four ports are opened and a very small opening is made in the cystic duct where the gallbladder connects to the bile duct. Cholangiography is performed with the insertion of a thin tube. A balloon or a tiny basket is used to retrieve the stones from the duct. Laparoscopic bile duct bypass The drainage of bile into the intestine is blocked due to stricture of the bile duct. The bile then accumulates in the blood and causes jaundice. Bile duct surgeries are very complex and difficult. Since the bile duct is located deep into the abdomen, the procedure carries longer incisions into the abdomen.
Laparoscopy is used to remove the stones in the bile duct. Resection of choledochal cysts There are five types of choledochal cysts that can be managed through different techniques.
Type 1: They are saccular or fusiform dilatations of the extrahepatic duct and a complete excision of the extrahepatic duct is performed. Biliary-enteric continuity is restored through a Roux-en-Y hepaticojujenostomy.
Type 2: This is an isolated diverticulum protruding from the wall of the common bile duct and the dilated diverticulum is entirely excised and the common bile duct defect is closed over a T-tube.
Type 3: Called the choledochocele it develops from the intraduodenal portion of the common bile duct and therapeutic choice generally depends on the size of the cyst. Endoscopic sphinterectomy is used for choledochoceles < 3 cm and lesions > 3 cm are extracted via a transduodenal approach.
Type 4: Multiple dilations both intrahepatic and extrahepatic bile ducts, exist in the cyst. A Roux-en-Y hepaticojujenostomy is done to completely excise the extrahepatic duct. For intrahepatic ductal diseases, the affected lobe of the liver is resected.
Type 5: This is called Caroli’s disease and contains multiple dilations of the intrahepatic duct and the left lobe. This may require a liver transplantation if there is evidence of liver dysfunction.
Pancreaticoduodenectomy is also called Whipple or Kausch-Whipple procedure. This procedure is performed for cancer of the pancreatic head, tumors of the common bile duct, duodenal papilla and ampulla. The procedure involves surgical removal of head of the pancreas, part of the duodenum, the gallbladder, pylorus which is a portion of the stomach and the lymph nodes located near the head of the pancreas. The end of a patient’s bile duct and the remaining pancreas are then connected to the small bowel to ensure flow of bile and enzymes into the intestines
Indicated for tumors in the body and tail of the pancreas, a distal pancreatectomy involves the removal of neoplasms either laparoscopically or with open surgery. With both laparoscopic and open distal pancreatectomy procedures, surgeons attempt to preserve the spleen. Distal pancreatectomy attempts to remove the bottom half of the pancreas due to the presence of a tumor in the tail of the pancreas. Once removed the edge of the pancreas is sutured to avoid leakage of pancreatic juices. There are at least three different techniques for distal pancreatectomy which are open distal pancreatectomy and splenectomy, spleen preserving distal pancreatectomy and laparoscopic distal pancreatectomy.
Open distal pancreatectomy and splenectomy The blood supply of the spleen is closely associated with the pancreas. Open distal pancreatectomy and splenectomy involves complete removal of the spleen along with the tail of the pancreas.
Spleen preserving distal pancreatectomy The blood vessels in the spleen are responsible for supplying blood to the pancreas. In an attempt to preserve this process, the blood vessels are carefully separated from the pancreas and the tail of the pancreas is then removed.
Laparoscopuc distal pancreatectomy This procedure is recommended for people suffering from pseudocysts or chronic pancreatitis, islet cell tumors of the pancreas or cystic tumors in the pancreas. A laparoscopic hand access device is utilized with an incision of about just 2.5 inches. The specialty of the device enables the surgeon to insert their hand into the abdomen during the surgery.
With chronic pancreatitis, a dilated pancreatic duct usually reflects obstruction. Quite often these patients present with stones in the pancreas. In chronic pancreatitis, there is progressive pancreatic fibrosis and subsequent loss of exocrine and endocrine functions. Surgical intervention is warranted for patients with intractable pain that does not respond to non-surgical therapy. Otherwise considered benign, chronic pancreatitis can affect the quality of life in an individual causing significant distress..
Longitudinal Pancreaticojejunostomy (Puestow Procedure) A longitudinal incision is made in the pancreas. The pancreatic duct is opened from the tail to the head of the pancreas and attached to the small bowel. The duct and the pancreas are then sewn together to the pancreatic duct to allow drainage. Distal Pancreaticojejunostomy (Du Val Procedure)
The pancreas is divided transversely at the neck, and the body and tail are drained via attachment to the small bowel. A termino-lateral Pancreaticojejunostomy will enable resection of the pancreatic tail and retrograde drainage of the pancreatic duct. The pancreatic duct is then decompressed.
When endoscopic sphincterotomy is unsuccessful, surgical transduodenal sphincteroplasty may be required of the minor or major papilla. It is an open surgery under general anesthesia.
Surgery on the small intestine is one of the most frequently done procedures in our surgical practice which include Small Bowel Obstruction Surgery and Small Bowel Resection Surgery. Where most of the conditions could be treated with medicines small bowel obstruction and adenocarcinoma of the small bowel essentially require surgery.
Some of the conditions that cause disruptions in the small bowel and require surgical intervention are outlined below.
Small intestine is one of the common sites of tuberculosis in India and even associated with HIV. The small intestinal involvement is in the region of distal small bowel and proximal colon called ‘ileo-caecal tuberculosis’ This condition usually presents with progressive obstruction to the lumen of the bowel leading on to constipation and diarrhea. This requires surgical treatment in the form of limited resection of the ileo-caecal region. A tuberculous intestine is usually an emergency procedure.
Small bowel perforation: Typhoid ulcers leading onto perforation and peritonitis requiring emergency laparotomy and closure of perforation is not uncommon in our practice. This is an absolute emergency and should be tackled right away without delay. The surgery aims at correcting the anatomical problem and removes any foreign material that might have been lodged in the peritoneal cavity. The distended bowel is decompressed through a nasogastric tube.
Bleeding from the small bowel: Small bowel bleeding is uncommon and is difficult to diagnose. It occurs predominantly due to abnormal blood vessels or arteriovenous malformations in the wall of the bowel. Often labeled as ‘obscure GI bleeding’ it can be slow chronic ooze or massive bleeding all of a sudden. This entity will require a variety of investigations like capsule endoscopy; enteroscopy and a nuclear scan to exactly localize the site of bleed which then has to be removed surgically. If the cause is identified as AVMs, then they are cauterized with a small amount of electric current is passed through the endoscope.
Crohn’s disease is yet another condition of the small intestine seen more often these days than before, usually seen in young individuals with chronic diarrhea and weight loss. There are specific investigations available now to diagnose this condition with accuracy. Most of these patients will require long-term medical treatment. Some of them develop bowel obstruction, internal fistulae requiring repeated operations. The operative options for Crohn’s disease include internal bypass, external bypass, resection of the small bowel, anastomotic technique, laparoscopy and laparoscopic assisted procedure and strictureplasty.
Tumors of the small bowel are either adenocarcinoma or lymphoma presenting with bleeding and or obstruction. These need to be excised with a wide margin. Gastro-intestinal stromal tumors are seen quite often in the small intestine requiring excising a segment of the involved bowel. Small bowel adenocarcinomas are essentially treated with resection – removal of the affected portion and rejoining of the small bowel, chemotherapy and radiotherapy.
A gangrenous bowel can be a life-threatening condition. This usually affects people above the age of 50. Sudden occlusion of the blood supply to the small intestine leading on to gangrene of the small bowel causes severe abdominal pain and distension. Emergency surgical resection of the gangrenous tissue is conducted along with antibiotic therapy. A new opening in the abdomen is created to allow waste to empty into a bag outside the body.
Incarceration in a hernia and trauma to the intestine are some of the other common conditions requiring surgery on the small intestine. Bowel obstruction can be functional or mechanical. The repair is conducted under general anesthesia. The area of blockage is identified and unblocked and damaged parts of the bowel are removed. The healthy ends are then reconnected and stapled.
Colorectal surgery is required for disorders of the colon, rectum and anus. Common surgical treatments include colectomy, polypectomy, ileo/colostomy, strictureplasty, anoplasty, and hemorrhoidectomy. A new surgical method called Compression Anastomotic Ring-locking Procedure (CARP) is also a preferred choice.
Surgery for Familial polyposis coli:Familial polyposis coli or familial adenomatous polyposis is an uncommon hereditary disease of the colon presenting with multiple polyps all over the colon. This condition has a high malignant potential hence will require complete removal of the colon and rectum. Bowel continuity is restored by performing an ileo-anal pouch. This surgery is prophylactic and is performed when the polyps are diagnosed usually in teenagers. There are four types of surgical options total abdominal colectomy with ileo-rectal anastomosis, total proctocolectomy with end ileostomy, total proctocolectomy with ileal pouch anal anastomosis and total proctocolectomy with continent ileostomy.
Surgery for ulcerative colitis: Ulcerative colitis is an inflammatory disease of the large bowel, which can vary in severity. It usually starts from the rectum and ascends towards the caecum. Most patients in India have a milder form of ulcerative colitis localized to the left colon and subsiding with oral medication. Some of these patients present to the emergency ward with severe symptoms requiring hospitalization and sometimes surgery for conditions like ‘toxic megacolon’ ,massive lower GI bleeding etc. Surgery will involve total colectomy with ileostomy. Elective surgery for extensive ulcerartive colitis or pancolitis or cancer in a setting of ulcerative colitis will include removal of the entire colon and rectum called “ total procto-colectomy” and the normal continuity is restored by creating an ‘ileo-anal pouch’. This procedure generally requires creation of Brooke ileostomy or continent ileostom.
Diverticulitis is a condition usually seen in the old where areas of weakness develop in the sigmoid and ascending colon resulting in localized ballooning of colonic mucosa called diverticulosis. Infection and inflammation of these diverticuli result in diverticulitis. This condition might require surgery if it presents with colonic obstruction, colo-vesical fistula or uncontrollable bleeding. Surgery includes partial colectomy and anastomosis. Surgery of diverticulitis is recommended if the patient faces repeated attacks of diverticulitis, an abnormal fistula formed between the colon and the adjacent organ and people who have an impaired immune system susceptible to repeated attacks of diverticulitis.
Surgery for Cancer of Colon and rectum: One of the commonest diseases of the colon and rectum, cancer can affect any part of the large bowel. Surgical removal of the cancer is the primary treatment modality. Rectal cancers will require complete removal of the rectal apparatus with a permanent end colostomy. In some of the rectal cancers the anal sphincter mechanism can be preserved by using surgical staplers. Cancers of the colon will require removal of a part of the colon called right or left hemi-colectomy. Early stage rectal cancers use a local resection or transanal resection. Rectal tumors can also be resected using the APPEAR technique – Anterior Perineal PlanE for Ultra-low Anterior Resection. Other surgical treatments for rectal cancer include transanal endoscopic mircrosurgery and total mesorectal excision.
GI Bleeding is an emergency. Patients present with massive vomiting of blood or hematemsis. Some of the most common causes of GI bleed are cirrhosis of liver and ulcer disease. Bleeding stops on its own in 90% of the patients. The rest will either require endoscopic treatment or sometimes surgery to effectively stop the bleeding. GI bleeding can be life threatening if not treated on time. It is predominantly characterized by hemorrhage in the GI tract starting from the pharynx down to the rectum.
GI bleed can be broadly classified as upper GI and lower GI bleed. Upper GI bleed originates from the pharynx and ligament of Treitz. Lower GI bleed originates from the colon, rectum or anus. Where the causes are confirmed as peptic ulcer, gastric erosions due to alcohol and NSAIDs, gastric varices, Mallory-Weiss tear, angiodysplasia and gastric cancer the following surgeries are recommended: Under-running the ulcer : Peptic ulcers usually stop bleeding spontaneously. But when non-operative methods fail, surgery becomes the only option for a life-threatening situation. The simplest way to stop an ulcer from bleeding is to by underrunning it. The surgery is done under general anesthesia. The laparoscopic procedure involves making a 11mm port just under the xiphisternum. 2 to 3 stitches are passed deep into the ulcer and the sutures are tied tight to stop the bleeding. A major part of the procedure involves just looking for the peptic ulcer which is an extremely tedious and meticulous process.
A pyloroplasty is done to open the lower part of the stomach, a thick, muscular area called the pylorus. Under general anesthesia, a laparoscopic surgery requires three small incisions in the area that connect the stomach and the duodenum. Some of the thickened muscle of the pylorus is divided laterally and cut through to widen it making the connection larger. There are at least three types of pyloroplasty: Jaboulay pyloroplasty Without pylorus incision – side to side gastroduodenostomy Heineke Mikulicz pyloroplasty longitudinal incision transversely across the pylorus – common procedure
Finney pyloroplasty With pylorus incision – side to side gastroduodenostomy
This procedure involves removal of part of the stomach. The procedures are performed under general anesthesia. A midline incision from the xiphoid process to the umbilicus and self-retaining subcostal retractors the upper abdomen is explored for metastasis. The part of the stomach is resected and gastroduodenal anastomosis is achieved after duodenal and omental mobilizations.
This procedure aims at cutting into the abdomen to resect all of the stomach. A midline incision or a bilateral subcostal incision inferior to the umbilicus is made exposing the stomach and distal esophagus. Self-retaining retractors provide a wider exposure. The stomach is retracted and the esophagus is directly connected to the small intestine.
Vagotomy : The vagus nerve which is also called the pneumogastric nerve is resected. There are many types of vagotomy such as: Truncal vagotomy First the pylorus is drained and then divides the main trunk of the vagus.
Selective vagotomy In this procedure too, the pylorus is first drained and then the anterior and posterior nerves of Latarjet are divided.
Highly selective vagotomy This is also called proximal gastric vagotomy and involves denervation of the fundus and body of the stomach.
For patients who present with bleeding from esophageal varices (swollen veins in the food pipe), endoscopic variceal ligation is the treatment of choice and surgery is usually done as a last resort if all other measures fail. The procedure is done endoscopically where an enlarged vein or varix in the esophagus ligated with a rubber band. In view of the poor liver condition these patients are not good candidates for surgery.Non-cirrhotics are the ones with portal vein thrombosis or non-cirrhotic portal fibrosis also form a large component of GI bleeding. These patients do very well after surgery because of their preserved liver condition.
Some patients presenting with intermittent vomiting of blood or passing melena will require surgical treatment as a permanent cure for bleeding. Surgery is either in the form of a spleno-renal shunt in non-cirrhotic patients or splenectomy with devascularisation in cirrhotic patients.
Splenorenal shunt : In a splenorenal shunt procedure, the vein from the spleen is detached from the portal vein and attached to the renal vein, thereby reducing the varices.
Splenectomy and devascularization : New procedures for splenectomy and devascularization require that a splenectomy is done first. The distal esophagus is then devascularized through the diaphragm hiatus.
The portal venous system comprises of the portal vein and the veins that start from the stomach, intestine, spleen and pancreas and merge into the portal vein. This portal vein branches out into smaller tributaries to pass through the liver. Increased resistance from the systemic venous system forces the blood to flow through alternate channels causing hepatic venous pressure which is elevated. When does not flow properly through the liver, the vessels in the liver are blocked. There is high blood pressure in the veins of the liver the result is swollen veins or varices in the esophagus, stomach, rectum and umbilical area. These varices rupture and cause internal bleeding which can be life threatening. When there is obstruction in the liver the pressure in the portal vein increases. The obstructions are classified as Prehepatic, intrahepatic and posthepatic portal hypertensions.
Intrahepatic hypertension Cirrhosis and hepatic fibrosis scarring are primary intrahepatic causes of portal hypertension. Other illnesses that could lead to portal hypertension are fatty liver, alcohol abuse, hepatitis B and C infections, Wilson’s disease, cystic fibrosis, hemochromatosis, primary sclerosing cholangitis, biliary atresia and schistosomiasis.
Prehepatic hypertension The prehepatic causes are portal vein thrombosis and congenital portal vein atresia.
Posthepatic hypertension The posthepatic causes of portal hypertension are hepatic vein thrombosis, inferior vena cava thrombosis and restrictive pericarditis.
Some common symptoms of portal hypertension are:
Varices Blood gets redirected and gathers into other veins making its way to the heart. The veins are swollen and enlarged.
Esophageal gastric varices This can be life threatening with symptoms of hematemesis, tarry and bloody stools. Hepatic encephalopathy The liver is unable to filter waste products and these get accumulated, causing lethargy and confusion.
Ascites Due to decrease of protein in the body, there is abnormal fluid collection within the peritoneum. Splenomegaly Blood and blood components are trapped in the spleen causing enlargement of spleen.
Surgical intervention for portal hypertension is considered only when methods to control varices such as sclerotherapy, latex banding and balloon tamponade fail to control the bleeding. There are at least two decompression procedures that can be considered:
Proximal Spleno-renal shunt In a majority of Indians spleen needs to be removed because of hyprsplenism and a splenic vein end to renal vein side can be done especially in the non-cirrhotic variety of portal hypertension
This is a standard procedure used for decompression of gastroesophageal varices. A subcostal incision is made and a fixed retractor is used for improved intra-abdominal access. The splenic vein is identified and detached from the portal vein. This is then anastomosed to the left renal vein.
A tubular connection is placed within the liver using x-ray guidance, joining two veins in the liver. This is commonly called a stent. The procedure is usually done under general anesthesia. After an incision is made in the area, the internal jugular vein is first identified. With the help of x-ray guidance a catheter is passed into the liver into the hepatic vein. A contrast material is then injected into the hepatic vein to plan placement of TIPS stent. Under fluoroscopy, a stent is placed connecting the portal vein into the hepatic vein. A balloon is inflated and the stent is expanded in place.
A bilateral subcostal incision or a J incision is made for exposure of the liver. The hepatic hilum is dissected to prepare for native liver removal. The common area of anastomoses is the hepatic artery and the gastroduodenal artery. Preserving the longitudinal vessels supplying the common bile duct, the portal vein is transected. Once the native liver is removed, the graft liver is implanted.
Liver donations have their own criteria such as:
Age of donor between 18 and 60 years old
- Donor should be in good health
- Donor should have a matching blood type
- Donor should undergo several tests before being considered fit for the transplant.