OPEN SURGERY

  • Upper GI: Transhiatal / Transthoracic Esophagectomy, Gastrectomy,Oesophageal replacements with Colonic conduit
  • Small Bowel Resections
  • Colorectal: Major Colonic Resections,Surgery for Colovesical,Rectovaginal fistulae,Total Mesorectal Excisions, Pouch procedures for Ulcerative Colitis, Sphincter saving operations for rectal cancer, Obscure GI bleeding
  • Liver Resection, Portosystemic shunts
  • Pancreaticoduodenectomy (Whipple's Procedure) for malignancies of Periampullary region and Head of Pancreas, Distal Pancreatectomy, Frey's / Puestow's Procedure for Chronic Pancreatitis
  • Radical cholecystectomy for Gall Bladder, Liver & Bile duct resections for Bile duct tumours etc
  • Composite / Polyvisceral resections (esp. for Tumours involving two or more organs)
  • Reoperative Abdominal Surgery for Complications following Surgery performed elsewhere or for previously failed operations.

LAPAROSCOPIC SURGERY

Imagine a doctor says - " you have to undergo surgery", things which strike your mind are pain, ugly scars and the question ' When can I return to work?' No more worries. We are in the era of Laparoscopy (minimally invasive surgery). Laparoscopic surgery has grown to such an extent that things formerly considered impossible are possible now.

Laparoscopic surgery is also known as "keyhole surgery", as no large cut is made. This is a mode of surgery, which is performed through small holes created in the abdominal wall. The telescope, which is used to visualise organs inside the body, is passed inside the tummy via the navel. The tummy is distended with a gas to make more room. Picture images of the abdominal organs can be viewed on a TV screen. It gives visualization and clarity of the internal organs better than that of conventional surgery since the image is magnified. Two or three small pencil-like instruments are passed on the sides along with it to perform the procedure.

It is virtually painless and cosmetic (skin marks 1 cms or lesser). Your hospital stay is very much reduced so that you can walk home early. Infections and complications are substantially reduced and above all, the trauma of the operation is minimal. There isn't much restriction in games or sports after surgery.

Initially started in adults to remove gallstones, the technique is now successfully being used for surgeries of other organs in the tummy like Gullet, Stomach, Spleen, Liver, Pancreas, Small and large bowels, Uterus, Kidneys and Major Blood vessels. It is usually done under general anesthesia.

In sound hands, removal of the gall bladder is a safe operation. (Oral medication to dissolve gall stones or shattering the stones through sound waves are not as effective as surgery) So is the case with hernias as well. In the case of abdominal wall hernias, the repair is done with the help of mesh as in open surgery. Hyper acidity could also be stemmed through Laparoscopy by tightening the esophagus-gastric junction. Rectal Prolapse is another condition where Laparoscopy has a great role.

Hysterectomy is another surgery, which can easily be done by laparoscopy. In case large uterine tumors (fibroids) it is removed through small holes after cutting up into pieces with the help of an instrument called morcellator.
In case of renal transplantation the kidney can be taken from the donor with the help of key-hole surgery, thus the motivation for donating the kidney for one's blood relative can be improved.

Lack of awareness, inadequately trained surgeons and improperly informed patients are the major problems associated with Laparoscopy, especially in our state. People stay away from the procedure thinking that it's very expensive. But they don't realize that though the technique is expensive, the over all cost is not when the short hospital stay and early return to work are taken into consideration.

Patients often think that with Laparoscopic surgery, the treatment they are getting is sub optimal when compared to open surgery. That is not true. The surgeon can do a better job utilising the magnified image on the screen. Moreover the video images of the surgical procedure can be recorded and reviewed later if any need arises.

Lot of studies are there in the world literature favoring Key-hole surgery for even cancer. Studies have shown that your surgeon can remove the abdominal cancer better by Laparoscopic surgery, than by the conventional surgery. In a case of cancer of the liver, Laparoscopic surgery can remove specified part of the liver affected by the disease with minimal blood loss.

Laparoscopic surgery for obesity is an area, which is evolving very fast. You don't need to exercise a lot; you can reduce your overweight by taking a key-hole surgery.

Though we are living in an era of robotic surgery, and though dedicated surgeons are trying to bring that technology within our reach, our patients are still reluctant to accept and utilise it because of myths and misconceptions existing in our society. Laparoscopic surgery is fast catching on. Let us hope for a new era where with the acceptance of Laparoscopic surgery people will start taking up surgery with a smile, without any apprehension.

Dr Vijay Ramachandran has pioneered in the following surgical procedures:

Appendicectomy
An appendicectomy (or appendectomy) is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. Appendicectomy may be performed laparoscopically or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line.

Cholecystectomy
Cholecystectomy is the surgical removal of the gallbladder. Despite the development of non-surgical techniques, it is the most common method for treating symptomatic gallstones, Surgery options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.

CBD Exploration
Common Bile Duct is a tubular structure connecting hepatic duct to the intestine. Obstruction of the bile duct with stones can cause jaundice with fever and chills. Conventional open surgery for retrieval of the stones is the common procedure done in most of the centers.

If facility like ERCP is available, these stones can be removed as two staged procedure without opening the abdomen.

Hiatus hernia repair
A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm. The symptoms include acid reflux, and pain, similar to heartburn, in the chest and upper stomach. The surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.

Vagotomy & drainage procedures
This procedure is done for Chronic Duodenal Ulcer with scarring causing obstruction of stomach.

Cardiomyotomy
Achalasia Cardia is a condition causing constriction at the junction of the esophagus (Gullet) with stomach. If conventional method is adopted, both chest and abdomen may have to be opened to relieve the obstruction.

Palliative gastro jejunostomy

This procedure is mainly done for patients with stomach cancer causing obstruction of the food pathway.
Laparoscopic GJ includes either utilization of stapler or hand-sewn method of doing a bypass above the level of obstruction to direct the food to the intestine. This procedure is done only if the stomach cancer is not removable.

DU perforation closure

It is an emergency situation where there occurs a hole in the proximal part of intestine. Spillage of food particles outside the intestine causes severe pain with collection of pus in the abdominal cavity.
Laparoscopic surgery can effectively manage the situation by closing the perforated part and cleaning the abdominal cavity.

Cholecysto - jejunostomy
It is a palliative procedure done for jaundice due to obstruction to the flow of bile by cancer. Cholecysto-jejunostomy can be performed laparoscopically if one cannot remove the cancer as a whole.

Cysto - jejunostomy
This is done for pseudocysts of the pancreas, which is a sequelae of pancreatitis. Symptoms like severe back pain and upper abdominal pain can be eliminated by this procedure.

Splenectomy
A splenectomy is a procedure that involves the removal of the spleen by operative means. The spleen, similar in structure to a large lymph node, acts as a blood filter. Current knowledge of its purpose includes the removal of old red blood cells and platelets, and the detection and fight against certain bacteria. It's also known to create new blood cells. The spleen is enlarged in a variety of conditions such as malaria, mononucleosis and most commonly in "cancers" of the lymphatics, such as lymphomas or leukemia. In general, spleens are removed by laparoscopy (minimal access surgery) when the spleen is not too large and when the procedure is elective.

Epigastric hernia repair
An epigastric hernia is a hernia in the epigastric region of a human.It commonly is found in babies. In such cases there is a small defect in the rectus abdominis muscles. This allows tissue from inside the abdomen to herniate anteriorly.The appearance is of a 'bubble' under the skin of the baby's bellyThe 'bubble' can be 'reduced' (pushed back in), and will reappear if the baby coughs or strains. It can be surgically corrected, although the operation is done almost entirely for cosmetic reasons. In general, any laproscopic operation that is proposed on a baby will be delayed until the baby is older, and better able to tolerate anaesthesia.

Incisional hernia repair

An incisional hernia occurs when the area of weakness through which the hernia occurs, is the result of an incompletely healed surgical wound. These can be the most frustrating and difficult hernias to treat! These hernias present as a bulge or protrusion at or near the area of the prior incision scar. Virtually any prior abdominal operation can subsequently develop an Incisional Hernia at the scar area, including those from large abdominal procedures (intestinal surgery, vascular surgery), to small incisions (Appendectomy, or Laparoscopy). These hernias can occur at any incision, but tend to occur more commonly along a straight line from the breastbone straight down to the pubis, and are more complex in these regions. Hernias in this area have a high rate of recurrence if repaired via a simple suture technique under tension and it is especially advised that these be repaired via a TENSION FREE repair method using mesh.

Umbilical hernia repair
It is a defect at the level of the umbilicus through which the intestines bulge out. With tension free 'mesh' repair umbilical hernia can be effectively managed laparoscopically.

Inguinal hernia repair
Laparoscopy is the 'Gold Standard' for bilateral hernia and recurrent hernias. This includes repair of the inguinal area with mesh. The recurrence rate with laparoscopic mesh repair is almost zero percentage.

Lap. Assisted colectomy
This procedure is mainly done for colon cancer. The radicality and extent of the surgery is not compromised while doing a laparoscopic procedure.

Lap. Anterior Resection
This procedure is done for cancer of the rectum. Anterior Resection by conventional method is a complex procedure involving removal of the cancer with adjacent tissues.

Nowadays Laparoscopic Anterior Resection is becoming the Gold Standard for rectal cancer because the procedure does not compromise on removing the whole cancer with adjacent tissues. This procedure spares the patient of colostomy

Lap. Abdominoperineal Resection
This is done for cancer of the lower third of rectum & anal canal where the anal sphincters are involved by tumour or when sparing the sphincter would result in a high incidence of tumour recurrence.


Laparoscopic abdominoperineal resection can be done for such type of cancers especially when the patient is not fit for open surgery.

Lap. Rectopexy
This is done for full thickness prolapse of the rectum. Laparoscopically it is done by dissecting the perirectal area and fixing the rectum upwards.

Lap. Assisted vaginal hysterectomy
A hysterectomy is the surgical removal of the uterus. Hysterectomy may be total or partial. It is the most commonly performed gynecological surgical procedure.

Lap. Distal Pancreatectomy
It is done for benign tumors of the tail part of the pancreas. With the aid of laparoscopic ultrasound the surgeon can decide the margin and can avoid a big scar.

 

WEIGHT LOSS SURGERY

ABOUT OBESITY

OBESITY AND MORBID OBESITY

Obese:
Body Mass Index (BMI) of 26 or greater. (BMI=kg/m2).

Morbidly Obese:
Body Mass Index (BMI) of 37.5 or greater (Roughly equivalent to 35 kg. over your ideal body weight).

The Clinical Guidelines For Consideration Are:
35 kg. or more above ideal body weight or a BMI of 37.5 or greater.
BMI of 32.5 or greater with one or more obesity related health conditions.

Other Considerations:
History of documented dietary weight loss attempts.
Lifelong commitment to follow-up care and extensive dietary, exercise and medical guidelines.
Psychological evaluation.

OBESITY CAN RUIN YOUR HEALTH
Obesity is the root cause of some of the common diseases as follows:

Type 2 diabetes:
People with obesity develop a resistance to the insulin that regulates blood sugar levels. Over a long period, high blood sugar can cause serious damage to the body.

High blood pressure/heart disease:
Excess body weight over-burdens the heart to function properly. The resulting hypertension (high blood pressure) can result in strokes (brain hemorrhage), significant heart and kidney damage.

Osteoarthritis of weight-bearing joints:
The additional weight placed on joints, particularly knees and hips, results in rapid wear and tear, along with pain caused by inflammation.

Sleep apnea/respiratory problems:
Fat deposits in the tongue and neck can cause intermittent obstruction of the air passage leading to interrupted sleep. The resulting loss of sleep often results in daytime drowsiness and headaches.

Gastroesophageal reflux/heartburn:
Obese people are susceptible to acid escaping into the esophagus through a weak or overloaded valve at the top of the stomach.

Depression:
Repeated failure with dieting, disapproval from family and friends, sneers and remarks from strangers, constant struggle with fat puts immense mental strain, pushing patients into depression.

Infertility:
The inability or diminished ability to produce offspring.

Fatty liver or hepatic lipidosis (steatosis):
Fatty liver disease is the accumulation of fat in liver cells. The greater the percentage of fat in the liver, the greater the risk of developing liver inflammation, fibrosis, or cirrhosis (moderate or severe scarring of the liver).

Others:
Other problems include swollen legs/skin ulcers, urinary stress incontinence, menstrual irregularities, lower extremity venous stasis, Idiopathic intracranial hypertension (IIH), dyslipidemia (lipid metabolism abnormalities), pulmonary embolus and cancer.

 

 

BARIATRIC / WEIGHT LOSS SURGERY


"Weight loss surgery is not a cosmetic surgery"

National Institute of Health consensus conference has concluded that surgery is the only effective treatment for long-term and sustained weight loss which results in improvement and/or resolution of co morbid conditions, improved quality of life and self-esteem, and increase in longevity.

The most common question people ask is - what is Obesity surgery? .. is it same as liposuction?.....

No! Liposuction is a surface surgery performed to remove extra unwanted fat from different part of body, this is basically a surgery for body sculpturing not weight loss, where as obesity surgery (bariatric Surgery) gives options for the treatment of this disease evolved into three categories, restrictive procedures, eg. Gastric band, sleeve gastrectomy, malabsorptive procedures, eg. Biliopancreatic diversion with or without duodenal switch, and combined procedures, eg. Roux-en-Y-gastric bypass (RYGB). Hence, selection of the procedure has to be individualized based on the age, BMI, presence or absence of co morbidities, patient's preference and compliance, surgeons experience etc. However, the experience of the bariatric surgeon is the most crucial in selecting the right procedure for an individual.


ANATOMY OF THE DIGESTIVE SYSTEM

Starting from the top we will explain the anatomy of the digestive system to understand how the operation works:

Mouth: Entry point for food; teeth and tongue chew food and move it to the back of the throat for swallowing. The enzyme amylase starts digestion of starches and sugars (carbohydrates).

Esophagus: Carries food to the stomach. It has no digestive function.

Stomach: Holds food and mixes it with acid and saliva. It has no absorptive function.

Pylorus: The valve that controls the emptying of the stomach. It helps to prevent "dumping syndrome".

Small Bowel: This tube, 5 meters (15-30 feet) in length, lies in between the pylorus and the large bowel (the colon). 95% of digestion is carried out here and it is the most important part of the digestive system. It is divided in 3 parts:

1.

Duodenum: Two feet long (60 cm). Bile from the liver and pancreatic enzymes (the digestive juices) enters this segment.

2.

Jejunum: The middle portion of the small bowel.

3.

Ileum: The lower portion.

The jejunum and ileum are the sections where carbohydrates, proteins and fats are absorbed, as well as vitamins and minerals. Iron and Calcium are absorbed in the duodenum.

Large bowel: Starts at the end of the small bowel. Its main function is absorption of water and holding the stools. Nutrients are not absorbed here. The appendix joins the bowel at its beginning.

Liver: Nutrients absorbed from the small bowel go to the liver via the portal veins. Secretes the bile necessary for fat digestion.

Pancreas: Secretes the enzymes necessary to digest carbohydrates, proteins and fats.

 

HOW DIGESTION WORKS ?

Digestion stars in the mouth with saliva's amylase. Food travels to the stomach where it is held, and mixed with acid. It starts to break down here. Stomach emptying is regulated by the pylorus. Digestion and absorption happen in the small bowel when food is acted upon by bile from the liver and pancreatic enzymes. Water is absorbed in the colon and waste is excreted through the rectum.

 

WEIGHT LOSS SURGERY PROCEDURES

Restrictive And Malabsorptive Procedures

There are two basic mechanisms of weight loss surgery.

1.

Restrictive procedures decrease food intake by creating a small upper stomach pouch to limit food intake.

2.

Malabsorptive procedures alter digestion, thus causing the food to be properly digested and completely absorbed. There are several procedures that combine the restrictive and malabsorptive mechanisms of weight loss surgery.

 

HOW EFFECTIVE IS BARIATRIC SURGERY?
"The only way you can truly get more out of life for yourself is to give part of yourself away."

The actual weight a patient will lose after the operation depends upon several factors. These include:

Patient's Age

Weight Before Surgery

Overall Condition of Patient's Health

Surgical Procedure

Ability to Exercise

Commitment to Maintaining Dietary Guidelines and other Follow-up Care

Motivation of Patient and Cooperation of Family, Friends and Associates

 

A recent study established the following criteria for successful bariatric surgery: "the ability to achieve and maintain loss of at least 50 percent of excess body weight without having significant adverse effects".

Clinical studies show that, following surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. Patients may lose 30 to 50 percent of their excess weight in the first six months, and 77 percent of excess weight as early as 12 months after surgery. Many patients with Type II Diabetes, while showing less overall excess weight loss, have demonstrated excellent resolution of their diabetic condition, to the point of having little or no need for continuing medication.

A comprehensive clinical review of bariatric surgery data showed that patients who underwent a bariatric surgical procedure experienced complete resolution or improvement of their co-morbid conditions including diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea etc.


There are five widely performed procedures that can be employed to lose or maintain weight.

  • Laparoscopic Sleeve Gastrectomy (LSG)
  • Laparoscopic Roux en Y Gastric Bypass (LGB)
  • Laparascopic Adjustable Gastric Banding (LAGB)
  • Laproscopic Gastric Imbrication
  • Laparoscopic Biliopancreatic Diversion with Duodenal Switch

Sleeve Gastrectomy

Laparoscopic sleeve gastrectomy (LSG) is a new bariatric technique, which has a unique feature: it combines a satisfying gastric restriction with appetite suppression.

In other words, LSG has a physiological advantage over other restrictive procedures such as gastric banding. Furthermore, in LSG no foreign material is implanted avoiding complications such as migration, erosion and infection.

The risk of peptic ulcer or dumping is low, while absorption of nutrients and orally administered drugs are not altered as may transpire after gastric by-pass. LSG provides substantial weight loss and resolution of co morbidities to 3-5 years follow-up. Comparative data demonstrate percent EBWL at 1 year superior to AGB and approaching that of gastric by-pass.

http://www.obesityindia.in/images/Sleeve-Gastrectomy-1.jpg

No silicone implants.

Great appetite suppression.

Lower risk of peptic ulcer.

No dumping.

No vitamin or drugs malabsorption.

It does not impair patient's dietary habits.

Better weight loss than gastric banding.

No important late complications.

 

Roux en Y Gastric Bypass

Procedure Type : Combined Restrictive / Malabsorptive

Description:  

Stapling is used to create a small, upper stomach pouch which restricts the amount of food to be consumed.

A portion of small bowel is bypassed thus delaying food from mixing with digestive juices to avoid complete calorie absorption.

http://www.obesityindia.in/images/The-Roux-en-Y-Procedure-1.jpg

Results:

Average of 77% of excess body weight loss one year after surgery

Studies show that after 10 to 14 years, patients have maintained 60% of excess body weight loss . Study of 500 patients showed that 96% of certain associated health conditions studied were improved or resolved, including back pain, sleep apnea, high blood pressure, Type II diabetes and depression.

In most cases patients report an early sense of fullness, combined with a sense of satisfaction, that reduces the desire to eat.

http://www.obesityindia.in/images/The-Roux-en-Y-Procedure-2.jpg

 

Lap Adjustable Gastric Banding

Procedure Type: Restrictive

Description:

A band is placed around the upper most part of the stomach separating the stomach into one small and one large portion.

Band can be adjusted to increase or decrease restriction.

Surgery can be reversed.

Digestion and absorption is normal.

Results:

In a U.S. study, the mean weight loss at three years after surgery was 36.2% of excess weight.

http://www.obesityindia.in/images/lapadjustable1.jpg

 

Laproscopic Gastric Imbrication

LAPAROSCOPIC GASTRIC IMBRICATION (LGI) is an innovative restrictive technique for the treatment of morbid obesity. This operation, which initially introduced by Prof. Talebpour* from Tehran University, may be considered as an advancement of the well-known sleeve gastrectomy and it is carried out with the use of pure non-absorbable surgical sutures.

In LGI the gastric capacity is diminished without gastrectomy or foreign implants. Due to the lack of gastric strictures LGI does not cause any food intolerance nor impair patient's dietary habits. The resultant weight loss is comparable or better than gastric banding (55-60% EWL), but with LGI the loss of weight appears more rapidly. Overall, in comparison to the other modern restrictive bariatric techniques the unique advantages of the LGI are:

Minimal risk of early of late complications.

It does not impair patient's dietary habits.

The operation is reversible. Gastric sutures withdrawal will get the stomach back to its normal form.

 

Preliminary results encouraged us to adopt this operation as better bariatric solution for lower BMI's (35-45 Kg/m2) in the stand of gastric banding.

 

Biliopancreatic Diversion with Duodenal Switch

Procedure Type : Malabsorptive

Description:

Combines a lower level of restriction with a high degree of malabsorption.

Stapling is used to create a sleeve of stomach retaining the natural stomach outlet.

The majority of the small intestine is bypassed causing nearly complete malabsorption of food contents.

http://www.obesityindia.in/images/Biliopancreatic-Diversion-1.jpg

Results:

Patients have achieved excess weight loss of 74% at one year, 78% at two years, 81% at three years, 84% at four years and 91% at five years.

Provides less restriction of food consumed than other procedures discussed .

Provides highest levels of malabsorption.

http://www.obesityindia.in/images/Biliopancreatic-Diversion-2.jpg


Video

Surgeries Offered:

Laparoscopic Surgery Gastric Surgery Liver Surgery Gall Bladder and Biliary Tract Surgery Pancreatic Surgery Small Bowel Surgery Colorectal Surgery Bariatric Surgery GI Cancer Surgery GI Bleeding Surgery Complex Reoperative Abdominal Surgery