Laparoscopic Surgery

Laparoscopic Hernia Repair – TEP and TAPP

A hernia is a sac-like structure that protrudes from a weak area or opening in the wall of the abdominal cavity. It is seen as a bulge over the skin, and often characterized with pain and discomfort. The most commonly used laparoscopic surgical techniques for hernia repair are transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) repair.

TAPP repair — this minimally invasive surgical procedure is performed under general anaesthesia. Your surgeon makes a small incision beneath the navel. A needle is inserted through the incision and the abdomen is filled with gas. This allows your surgeon to view the internal organs clearly. The needle is removed and a camera is inserted through the incision. Further, 2 more incisions are made near the navel to introduce the surgical instruments. The peritoneum (a membrane that lines the abdominal cavity) is cut and the hernia sac is removed carefully. A synthetic mesh is placed over the peritoneal opening and then closed with sutures. The disadvantage of the TAPP procedure is it can cause injury to adjacent abdominal organs. The advantage of the TAPP procedure is that it can be performed on patients who have undergone previous lower midline surgery.

TEP repair — this procedure is also performed under general anaesthesia. Your surgeon makes small incisions below the navel. A balloon is placed in the preperitoneal space (space between the peritoneum and anterior abdominal wall) and filled with gas to separate the layers. The camera and the surgical instruments are passed through the incisions. Your surgeon exposes the hernial sac, repositions it and seals the hernia with a synthetic mesh. The incisions are then closed with sutures. The mesh slowly gets incorporated with the tissues of the abdominal wall. The advantage of TEP procedure is that it prevents the risk associated with damage to the internal organs as it is performed outside of the peritoneum.

As with all surgical procedures, TEP and TAPP hernia repair may be associated with certain complications, which include infection, bleeding, swelling and damage to the adjacent organs.

Laparoscopic Cholecystectomy

Of all surgical procedures, for which laparoscopy is an option, cholecystectomy (gallbladder removal) is the most widely recognized and accepted. Where there is inflammation and infection in the gallbladder (Cholecystitis) early removal of the gallbladder may be indicated. Using advanced laparoscopic technology, it is now possible to remove the gallbladder through tiny incisions in the front of the abdomen.

Indications for laparoscopic gallbladder removal (cholecystectomy) may include:

  • Cholecystitis
  • Complications such as jaundice, pancreatitis
  • Recurrent pain or vomiting
  • If the patient suffers from cholangitis

What are the benefits?

The main benefit of this procedure is that it is minimally invasive surgery. Minimally invasive surgery generally means less pain and faster recovery. There is relatively little incision pain compared to standard abdominal surgery. As a result, the recovery time is much quicker.

Is laparoscopy always advised?

There are a few instances when laparoscopic surgery is not preferable to conventional surgery for cholecystectomy but the majority of patients are suitable for a laparoscopic procedure.

Risks & complications

Like any abdominal surgery, laparoscopic cholecystectomy carries some risks however these are relatively infrequent.

Complications are rare and may include:
  • Bleeding & infection may occur but is rare with experienced surgeons.
  • In a few cases, the gallbladder cannot be safely removed by laparoscopy. Standard open abdominal surgery is then immediately performed.
  • Nausea and vomiting may occur after the surgery.
  • Injury to the bile ducts, blood vessels, or intestine can occur, requiring corrective surgery.

Summary

Laparoscopic cholecystectomy is one of the most common surgical procedures performed in Australia. With experienced surgical teams, complications are uncommon and most patients will return to relatively normal activities within one to two weeks.

Appendectomy

Appendectomy is the surgical removal of appendix, a small finger-shaped organ attached to the cecum (first part of the colon). Appendectomy is indicated in appendicitis, the inflammation of appendix and can be done two ways.

The older method, laparotomy, removes the appendix through a single incision in the lower right area of the abdomen. The newer method, laparoscopic surgery, uses several smaller incisions and special surgical tools fed through the incisions to remove the appendix.

The surgeon makes an incision over the abdomen and inserts a harmless gas into the abdominal cavity to expand the viewing area of the abdomen. Surgeon inserts trocar into an incision through which the laparoscope is introduced into the abdomen. Additional small incisions may be used for inserting surgical instruments to be used during the procedure. With the images from the laparoscope as a guide, the surgeon can look at the appendix and determine the extent of the problem and removes the appendix. Once the appendix is removed the area is washed with sterile fluid to minimize the risk of infection. The tiny incisions are closed and covered with small bandages. Laparoscopic surgery leads to fewer complications, such as hospital-related infections, and has a shorter recovery time.

Surgery occasionally reveals a normal appendix. In such cases, many surgeons will remove the healthy appendix to eliminate the future possibility of appendicitis. Occasionally, surgery reveals a different problem, which may also be corrected during surgery. Sometimes an abscess forms around a burst appendix called an appendiceal abscess. An abscess is a pus-filled mass that results from the body’s attempt to keep an infection from spreading. An abscess may be addressed during surgery or, more commonly, drained before surgery. To drain an abscess, a tube is placed in the abscess through the abdominal wall. CT is used to help find the abscess. The drainage tube is left in place for about 2 weeks while antibiotics are given to treat infection. Six to eight weeks later, when infection and inflammation are under control, surgery is performed to remove what remains of the burst appendix.

Laparoscopic Varicocelectomy

Laparoscopic varicocelectomy is a surgical procedure indicated for the treatment of infertility in men. Varicocele, enlargement of the veins in the scrotum, is the most common cause of infertility in men. The surgery is performed under general anaesthesia. A catheter is placed to drain urine and empty the bladder. You doctor inserts a needle into the abdominal cavity and inflates it with carbon dioxide gas. This helps your surgeon view the surgical site more clearly. The needle is removed and 3 to 4 small incisions are made on your abdomen, through which a laparoscope (tube with a light and a small camera) and other surgical instruments are inserted. The varicocele is isolated and cut. The arteries are kept intact. The remaining veins are sutured securely and incisions are closed firmly with stitches.

Like all surgical procedures, laparoscopic varicocelectomy may be associated with certain complications, which include:

  • Testicular artery injury
  • Reoccurrence of varicocele
  • Hydrocele (sac filled with fluid that forms around testicles)

The advantages of laparoscopic varicocelectomy include:

  • Reduced hospital stay
  • Smaller incisions and less scarring
  • Faster recovery
  • Less post-operative pain

Laparoscopic Bowel Resection

Laparoscopic Bowel Resection is the surgical resection of all or part of the large intestine. It the most common procedure performed to remove the cancer cells. It is usually performed as an outpatient procedure and under general anaesthesia.

Colon cancer is the growth of rapidly dividing cells in the large intestine. It is also referred as colorectal cancer. Cancers of colon develop from polyps, the small and non-cancerous growths of tissues. Colon cancer usually begins in glands lining the colon and rectum. Colon cancer initially begins as noncancerous tumours and gradually develops into cancer which spreads to other tissues.

Surgical Procedure:

It is a minimally invasive technique where several small incisions are made rather than one large incision. Three to five small incisions are made on the lower abdomen. A laparoscope, a telescopic video camera is used to see the inside of the abdomen, is inserted through an incision. Small surgical instruments are passed through other 2 incisions and colon is removed. Carbon dioxide (CO2) gas is filled in the lower abdomen and expanded for easy access and the diseased part of the colon is removed. At the end of surgery, the healthy ends are reattached, the incisions are closed with the sutures, and a dressing pad is applied.

The advantages of laparoscopic bowel resection are smaller incisions, minimal soft tissue trauma, less pain, faster recovery time, less scarring, and shorter hospital stay.

Following the surgery, your surgeon may recommend you follow certain measures for a successful outcome:

  • Do not remove the dressing over the incision for the first two days and keep the area clean and dry. No showering or bathing during this time. The incision usually heals in about 5 days.
  • Your surgeon may give you activity restrictions such as no heavy lifting. It is very important that you follow your surgeon’s instructions for a successful recovery.
  • You may feel soreness around the incision area. Your surgeon may give you a prescription pain medicine or recommend NSAID’s (non-steroidal anti-inflammatory drugs) for the first few days to keep you comfortable.
  • If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple days while the excess gas is being absorbed.

Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, shortness of breath, leg pain, and or dizziness.

Complications:

Complications of laparoscopic bowel resection include infection at the site of operation, bleeding, and damage to nearby organs.

Splenectomy-Laparoscopic

Splenectomy is the surgical removal of the spleen, a large organ located in the upper left part of the stomach that contains macrophages which are specialized cells that fight against foreign bodies. Splenectomy is indicated in splenomegaly, a condition of enlarged spleen. Patients with splenomegaly may or may not exhibit the symptoms and will be diagnosed by physicians by physical examination or radiological diagnosis. The most common symptoms include abdominal pain, hiccups, weakness, fatigue, frequent infections severe bleeding and difficulty eating large meals.

Laparoscopic splenectomy: Is performed under general anaesthesia. It uses a laparoscope, an instrument with a tiny camera and a light at the end. Three to four incisions are made on the abdomen, and the laparoscope is inserted through one of the incisions. The laparoscope allows viewing the area on a bigger screen. Other surgical instruments are inserted through the other incisions. Gas is pumped to expand the abdomen to give more space to work. The spleen is removed using the laparoscope and other instruments. The small incisions are stitched.

Some of the complications include bleeding, wound infection, pneumonia, injury to surrounding structures and need to convert to an open procedure.

Laparoscopic Surgery for GERD

Nissen Fundoplication Surgery for GERD

Nissen Fundoplication surgery is a procedure to treat gastroesophageal reflux disease (GERD). GERD occurs when stomach contents reflux and enter the lower end of the oesophagus (LES) due to a relaxed or weakened sphincter. GERD is treatable disease and serious complications may occur if left untreated.

Heartburn is a form of indigestion and the most common symptom when acid from the stomach refluxes into the oesophagus (food pipe). It is the sensation of discomfort in your chest. It is usually temporary and if persistent or long standing (2 or 3 times a week) it could be gastroesophageal reflux disease or GERD.

GERD is treatable disease and serious complications may occur if left untreated. GERD is a chronic condition where the stomach contents reflux into the oesophagus. Normally, the stomach contents do not enter the oesophagus (food pipe) due to a constricted lower oesophageal sphincter. In GERD, the LES is weak or relaxed enabling stomach acids to reflux into the oesophagus.

Causes of GERD

The exact cause of what weakens or relaxes the lower oesophageal sphincter in GERD is not known. However, the following triggers are known to make the reflux worse:

  • Lifestyle - Use of alcohol or cigarettes, poor posture (slouching)
  • Certain medications - NSAIDS (aspirin, ibuprofen), calcium channel blockers, theophylline, nitrates, and antihistamines
  • Diet - spices, pepper, onions, tomato sauce, peppermint, fatty and fried foods, chocolates, drinks with caffeine, and acid foods such as citrus fruits & tomatoes
  • Eating habits - large meals, sleeping or lying down soon after eating

Other contributing factors for GERD include the following medical conditions:

Symptoms

The main symptom of GERD is heartburn. Heartburn is a form of indigestion. It is usually felt as a burning pain in the centre of the chest. Other symptoms can include:

  • An acid, sour taste in the mouth
  • Burning pain in the throat
  • Bloating and belching
  • Difficulty in eating
  • Stomach pains
  • Nausea and vomiting
  • Regurgitating food (when food comes out of your stomach and back up your oesophagus)
  • Vomiting blood
  • Dark tarry stools

Symptoms tend to get worse after eating, especially after a large fatty meal. Some unusual symptoms may include:

  • Coughing, when lying down
  • Chest pain.
  • Hoarseness or changes in the voice because the acid gets into the windpipe and voice box (larynx) and irritates it.

Tips for Control

Many people can relieve their symptoms by changing their habits and lifestyle. The following steps, if followed, may reduce your reflux significantly:

  • Don’t eat within 3 hours of bedtime. This allows your stomach to empty and acid production to decrease.
  • Similarly, don't lie down right after eating at any time of day.
  • Elevate the head of your bed 6 inches with blocks. Gravity helps prevent reflux.
  • Split meals or eat small meals. Eating a lot of food at one time increases the amount of acid needed to digest it.
  • Avoid fatty or greasy foods, chocolate, caffeine, mints or mint-flavoured foods, spicy foods, citrus, and tomato-based foods. These foods decrease the competence of the LES.
  • Avoid drinking alcohol: Alcohol increases the likelihood that acid from your stomach will back up.
  • Stop smoking: Smoking weakens the lower oesophageal sphincter and increases reflux.
  • Lose excess weight: Overweight and obese people are much more likely to have bothersome reflux than people of healthy weight.
  • Talk to your health care provider about any medications you are taking. These may aggravate reflux in some people.

Diagnosis

Your doctor usually diagnoses GERD based on your medical history alone, but may ask you to undertake the following tests: Endoscopy A thin endoscope with a camera on the end is passed down the oesophagus towards the stomach. It enables doctors to see the inside of your oesophagus on a television monitor.

Barium X-rays

These are diagnostic x-rays in which barium is used to diagnose abnormalities of the digestive tract. The patient drinks a liquid that contains barium, which will coat the walls of the oesophagus and stomach. X-rays are then taken, which can then show if there are strictures, ulcers, hiatal hernias, erosions, or other abnormalities.

Oesophageal Manometry

This is a test that measures the function of the lower oesophageal sphincter and the motor function of the oesophagus. Oesophageal manometry, also called Oesophageal Motility Study or EMS, is a test to measure the motor function of the oesophagus and lower oesophageal sphincter. EMS is performed by a technician who places a small pressure sensitive catheter through the patient’s nostril and advances it into the stomach. The catheter is then slowly withdrawn back up into the oesophagus. The patient is asked to swallow at various times during the procedure and measurements are taken to assess the pressure of the muscle contractions in the oesophagus.

PH Study or Acidity Test

This is done on the inside of the oesophagus by passing a thin wire through your mouth or nose and into your oesophagus. The wire will measure how acidic your oesophagus is and record the results electronically.

Ambulatory 24 hr. PH Probe Study: This study measures the acid that refluxes back up from the stomach. A very thin tube is inserted up through the nostril and then down the throat and oesophagus until it reaches just above the stomach. The tube has a very small probe at the end that will register any acids that are refluxed from the stomach. An x-ray is taken to make sure that the probe has been positioned correctly. The other end of the thin tube is attached to a small computer (small black box) for 12 or 24 hours. During this period you are given a diary sheet to complete, on which you should record the time of each activity that takes place, basically a running history.

PH Capsule: This is a new type of pH probe which requires no tube though the nose. It is a sensor that is attached to the lining of the oesophagus, with an endoscope. Often this procedure is carried out at the same time as having an endoscopy (upper GI) performed. The pH sensor sends signals to a portable computer which collects the data about the acid exposure over the usual 24 hrs. There is no removal procedure, the sensor will slowly detach itself from the oesophagus with time and is then passed through a normal stool.

Impedance Study Similar to a standard pH test, but with two probes; one sits in the stomach and the other just above the stomach. The advantage of the dual sensor is that it can detect both acid and alkaline reflux travels. The tube is inserted through the nostril (this can be placed while still sedated after an endoscopy), and the other end is attached to a small computer.

Conservative Treatment Options

GERD, in general, cannot be cured at present. The principles of GERD treatment are:

  • Reducing reflux
  • Relieving symptoms
  • Preventing damage to the oesophagus.

However, in temporary conditions such as in pregnancy, GERD may completely recover following delivery of the baby.

Treatments options include:
  • Antacids - These medications neutralize the acid in the stomach and provide temporary relief for heartburn.
  • Other Medications

H2 antagonists or Histamine receptor blockers - These reduce the production of acid in your stomach by blocking a signal that leads to acid secretion.

Proton Pump Inhibitors - Proton pump inhibitors (PPIs) are a group of prescription medications that prevent the release of acid in the stomach and intestines. Doctors prescribe PPIs to treat people with heartburn (acid reflux), ulcers of the stomach or intestine, or to decrease excess stomach acid.

Surgical Introduction

Surgery - If the non-invasive treatments are not effective, surgery may be an option. Talk to your surgeon about which procedure is best for your particular situation. Surgical options include: Endoluminal gastroplication: Also known as endoscopic fundoplication, this surgery involves the use of an endoscope with a small sewing device attached to the end, known as the EndoCinch device. The procedure stitches a pleat or plication just below the lower oesophageal sphincter muscle. The process is repeated for the necessary amount of pilications. The surgery can be performed on an outpatient basis under sedation. Nissen's fundoplication: The Nissen fundoplication (fundo) is a surgical technique that strengthens the sphincter (LES). When performing a fundoplication, the part of the stomach that is closest to the entry of the oesophagus (the fundus of the stomach) is gathered, and wrapped around the lower end of the oesophagus and oesophageal sphincter, where it is then sutured (sewn) into place. This surgery may be performed through a large, open abdominal incision or endoscopically, through 5 smaller incisions.

Surgical Treatment

Surgical Procedure

Nissen Fundoplication is performed as day surgery either in the hospital or outpatient surgery centres usually with the patient under general anaesthesia. The surgeon uses a needle to inject a harmless gas into the abdominal cavity near the belly button to expand the viewing area of the abdomen giving the surgeon a clear view and room to work. The surgeon makes a small incision in the upper abdomen and inserts a tube called a trocar through which the laparoscope is introduced into the abdomen. Additional small incisions may be made for a variety of surgical instruments to be used during the procedure.

With the images from the laparoscope as a guide, your surgeon wraps the upper part of the stomach, the fundus, around the lower oesophagus to create a valve, suturing it in place. The hole in the diaphragm through which the oesophagus passes is then tightened with sutures.

The laparoscope and other instruments are removed and the gas released. The tiny incisions are closed and covered with small bandages. Laparoscopy is much less traumatic to the muscles and soft tissues than the traditional method of surgically opening the abdomen with long incisions (open techniques).

Post-Operative Precautions

Post-Operative Guidelines

After surgery, your surgeon will give you guidelines to follow. Common post-operative guidelines following laparoscopy include the following:

  • You will need someone to drive you home after you are released as the anaesthesia may make you feel groggy and tired.
  • Do not remove the dressings over the incisions for the first two days and keep the area clean and dry. No showering or bathing during this time. The incisions usually heal in about 5 days.
  • Your surgeon may give you diet and activity restrictions. It is very important that you follow your surgeon’s instructions for a successful recovery.
  • You may feel soreness around the incision areas. Your surgeon may give you a prescription pain medicine or recommend NSAID’s (non-steroidal anti-inflammatory drugs) for the first few days to keep you comfortable.
  • If the abdomen was distended with gas, you may experience discomfort in the abdomen, chest, or shoulder area for a couple days while the excess gas is being absorbed.
  • Contact your doctor immediately if you have a fever, chills, increased pain, bleeding or fluid leakage from the incisions, chest pain, and shortness of breath, leg pain, or dizziness.

Risks and Complications

As with any surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Most patients do not have complications after Nissen Fundoplication; however complications can occur and depend on which type of surgery your doctor performs as well as the patient’s health status. (I.e. obese, diabetic, smoker, etc.) Complications can be medical (general) or specific to Nissen Fundoplication. Medical complications include those of the anaesthesia and your general wellbeing.

Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reaction to medications
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attack, strokes, kidney failure, pneumonia, bladder infections
  • Complications from nerve blocks such as infection or nerve damage
  • Serious medical problems can lead to on-going health concerns, prolonged hospitalization, or rarely death.

Because the abdominal muscles are not cut in laparoscopic surgery, the pain and complications associated with abdominal surgery are lessened. However, complications can occur with any surgery. Your surgeon feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you. Specific complications for Nissen Fundoplication include:

  • Post-operative fever and infection - Antibiotics given at the time of surgery lessen this risk but symptoms of infection should be reported to your physician and can include: fever, chills, increasing pain, bleeding, and foul smelling drainage.
  • Surgical injury to blood vessels - A rare complication that is usually recognized during surgery and repaired. Rarely, a blood transfusion may be necessary.
  • Surgical injury to stomach or oesophagus - Also a rare complication that is usually recognized during surgery and repaired.
  • Swallowing difficulties - If the new valve is too tight, swallowing can be difficult and may require dilation to loosen the valve.
  • Gas embolism - If gas is used to distend the abdominal cavity for better viewing there is a risk of gas embolism or gas bubbles in the bloodstream. This is a serious condition that can impede blood flow to vital organs or cause a blood clot to occur in a blood vessel.
  • Adhesions - Extensive scar tissue formation can form in the surgical area. Rarely adhesions can obstruct the valve opening requiring additional surgery.
  • Conversion to Laparotomy - There is occasions when a laparoscopy cannot be completed successfully without converting to a traditional “open” surgery called a laparotomy. A laparotomy is similar but is done through a larger abdominal incision.
  • Repeat Surgery - Sometimes the new valve weakens or loosens months or years after the surgery causing symptoms again. If symptoms are severe, the surgery may need to be repeated.

Risk factors that can negatively affect adequate healing after surgery include:

Summary

A good knowledge of this procedure will make the stress of undertaking the procedure easier for you to bear. The decision to proceed with the procedure is made because the advantages of the procedure outweigh the potential disadvantages. It is important that you are informed of these risks before the procedure.

Although every effort is made to educate you on Nissen Fundoplication and take control, there will be specific information that will not be discussed. Talk to your doctor or health care provider about any concerns you have about this surgery.

Laparoscopic Adrenalectomy

Adrenal glands are two triangle-shaped glands located above the kidneys, which secrete hormones that control your metabolism, blood pressure, chemical levels in blood and usage of glucose. Laparoscopic adrenalectomy is a minimally invasive procedure used to remove an adrenal gland affected with a tumour.

Laparoscopic adrenalectomy is performed under general anaesthesia. Your surgeon makes 3 to 4 small incisions (1/4 to ½ inches) in your abdomen. A laparoscope (small tube with camera attached at one end) is inserted into one of the incisions to help your surgeon view your internal organs and perform the surgery. Surgical instruments are inserted into the other incisions to separate the adrenal gland from its connections and dissect it away from the kidney. The gland is placed in a bag and removed through one of the incisions. All the incisions are then closed. Laparoscopic adrenalectomy requires a very short hospital stay and causes less pain compared to the traditional open procedure. Like all surgeries, laparoscopic adrenalectomy may be associated with a few complications such as bleeding, injury to the surrounding organs, high blood pressure, blood clots and infection.

Laparoscopic Gastric Surgery

Laparoscopic Gastric bypass

Gastric bypass is a type of weight loss surgery used for the treatment of obesity. In gastric bypass surgery, a small stomach pouch is created by stapling along the upper part of the stomach. Next the small intestine is cut two sections. The lower section of the small intestine is attached to the opening in the stomach pouch. This pouch enables food to bypass the lower stomach and portion of the small intestine. The pouch can hold only a few ounces of food at a time and by bypassing the small intestine and the stomach, fewer calories and nutrients from the food are absorbed. As a result the patients consume less food, absorb fewer calories and achieve weight loss.

The procedure is performed as a standard open procedure or as a laparoscopic procedure. Laparoscopic approach can be made by making several small incisions rather than open procedure which involves single large incision. In laparoscopic procedure small instruments and a tiny camera are used to guide the surgery

Roux-en-Y gastric bypass is the most commonly performed gastric bypass surgery. In this surgery, a small pouch is created by stapling the upper part of the stomach. The smaller portion of the stomach is then attached directly to the small intestine, bypassing large portion of the stomach and the upper part of the small intestine (duodenum).

Your obesity surgeon will decide which surgery is best for you. In addition to quick and dramatic weight loss, gastric bypass surgery could also improve health issues associated with severe obesity.

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