ODS is a form of chronic constipation that affects thousands of people in the India – primarily women. In many cases, it is part of a more generalized weakness of pelvic support structures. Women with ODS commonly plan their daily activities around their bowel habits.
If you have chronic constipation and also have one or more of the following symptoms at least 25 percent of the time during bowel movements, you may have ODS:
Multiple trips to the bathroom.
Prolonged straining.
Incomplete elimination, and/or prolonged time to have a bowel movement.
Routine use of laxatives or enemas.
The need to press around your genitals or anus to have a bowel movement.

Most of the time, chronic constipation can be relieved using a combination of diet, exercise and medication. If these approaches do not relieve your chronic constipation, you should discuss treatment options with a physician. You may be suffering from a type of chronic constipation known as Obstructed Defecation Syndrome (ODS).

STARR is a surgical procedure that is performed through the anus, requires no external incisions and leaves no visible scars. Using a surgical stapler, the procedure removes excess tissue in the rectum and reduces the deformities that can cause ODS. Patients undergoing STARR are typically hospitalized for one to three days and have minimal recovery time after leaving the hospital.
Is STARR Effective?
Yes. In a recent clinical study, chronic constipation symptoms significantly improved in most patients undergoing the STARR procedure. Overall patient satisfaction with the STARR procedure was high, with 90 percent of patients rating the results as either good or excellent.

http://www.youtube.com/watch?v=W856DcOny60

CONSTIPATION can affect anyone at any point in life and whilst for some it is just a small inconvenience that can be endured,for others it can be a chronic condition with serious implications on their life.One such person is Dr Khan,a retired practitioner who started suffering from piles because of constipation.He was given a painful haemorrhoidectomy which served only as a temporary solution and the recovery from the procedure was incredibly painful.He says,For a while I felt quite relieved but over a period of time,my condition worsened.The urge to continually want to go to the toilet came back and I started suffering with rectal prolapse.
When quizzed about how his condition affected his daily life,his wife replies,Whenever we went out we had to check if he was fine.Sometimes our plans would be disrupted because of his problems and it was frustrating.As time went on I began to worry as nothing seemed to fix his problems.
Eventually,when further surgery did not work,he was referred to a surgeon capable of carrying out STARR.This was when his wife and he visited Pune to meet Dr Ashwin Porwal.He sat us both down and showed us the procedure that was involved.He made me feel safe.I felt very comfortable with him, says Khan.He adds,'Two days after the operation I got myself dressed.After the whole procedure,defecating was easy.About a month after the surgery I felt like I was back to normal.
Nearly one year later,Khan has not had any recurrences of his symptoms and is delighted with his results,so much so that he is anxious to convey his experience to others so that they do not continue to suffer in silence.Khan is now optimistic about the future and is confident that everything is well.He says,Im careful and I dont let myself get constipated now.I would recommend this procedure to patients suffering from the same condition. Although bleeding from the back passage and constipation are fairly common,medical advice should be sought;this is to rule out the potential onset of bowel cancer.
Repeatedly needing to go to the toilet and a feeling of fullness,not fully evacuating and straining to do so,anal burning,bleeding and continuous use of laxatives are some symptoms of chronic constipation.STARR surgery is done through anal opening without any external cut for chronic constipation and piles and requires only 24hours hospitalisation.

By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy.
Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure; sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in which Dr. B C shah plans and executes a therapeutic procedure.
With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced the applications of exploratory laparotomy. Nevertheless, the importance of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be overemphasized.
Indications
Four primary indications for an exploratory laparotomy are noted, as follows.
Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology requiring emergency surgery
In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure.
Peritonitis
Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained.
Intestinal obstruction
Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should be ruled out as a possible cause of the obstruction.
Intra-abdominal collections
Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of ultrasonography or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the presence of enteric contents may suggest perforation, and laparotomy may be required to control the source.
Abdominal trauma with hemoperitoneum and hemodynamic instability
Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay. They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated intestinal perforations that call for emergency repair.
Chronic abdominal pain
Availability of good imaging facilities have restricted the use of exploratory laparotomy in these conditions; however, when limited facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal adhesions, tuberculosis, or tubo-ovarian pathology.
Staging of ovarian malignancy and Hodgkin disease
The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be considered for primary radiotherapy as the sole modality of treatment.
Contraindications
The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis, advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia.
Technical Considerations
Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the suspected condition is confirmed.
Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and guidelines for laparotomy.
The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if DPL findings are negative, the patient is closely monitored.
Periprocedural Care
Preprocedural Planning
The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood transfusions, and bronchodilator nebulizations as required.
Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia. The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended inferiorly for better exposure.
Equipment
Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights, electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory laparotomy.
If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed, appropriate instruments, facilities, and expertise should be available. Similarly, abdominal trauma necessitates major abdominal surgery, for which appropriate infrastructure and expertise are required.
Patient Preparation
Patient preparation includes adequate anesthesia and appropriate patient positioning.
Anesthesia
Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction. Rapid-sequence induction considerably reduces the risk of aspiration.
Positioning
The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary.
Technique
Exploratory Laparotomy
After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows.
Midline incision and opening of peritoneum
A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum and is relatively bloodless and safe.The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the incision small.
The skin is incised with a surgical knife. The incision is then deepened through the subcutaneous fat. Electrodiathermy in coagulation mode provides a bloodless access through this layer. The linea alba is identified as a glistening layer deep to the subcutaneous tissues.
Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba.
The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side, and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy Mayo scissors .
Linea alba is divided to reveal preperitoneal fat.
Abdominal incision is completed to reveal intra-abdominal organs.
Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in 2 straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately.
Exploration of abdominal cavity
The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for life-saving maneuvers.
Massive hemoperitoneum suggests 2 things. First, the patient may have a major source of bleeding. Second, the presence of blood within the peritoneum interferes with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the 4 quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant.
Identification of the source of bleeding is much easier in the absence of massive hemoperitoneum. Common sources include injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries, aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective measures must be taken.
Liver laceration in traffic accident victim who presented with hemoperitoneum.
If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the stomach is inspected for a perforation, followed by the duodenum.
Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure.
Each segment of the intestine is held up by Dr. B C Shah, and all surfaces are inspected. Any slough on the serosal surface is gently separated to allow identification of an underlying perforation (see the image below).
Laparotomy in patient with peritonitis. Image shows perforated duodenal ulcer.
If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status.
In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).
Laparotomy in patient with intestinal obstruction. Intraoperatively, single peritoneal band causing intestinal obstruction was found.
Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.
Multiple omental deposits in patient with disseminated carcinoma of stomach.
Multiple metastatic deposits over small bowel in patient with colonic malignancy.
Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy.
Completion and closure
Placement of drains after an exploratory laparotomy is still a subject of debate. The evidence currently available is inadequate to support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the pelvis.
Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must be double-checked. Dr. B C Shah should manually inspect the peritoneum for any retained pads or instruments, even if scrub nurse has found the count to be correct.
Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg, polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites.
Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of figure-eight sutures.
At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence. Laparostomy and delayed closure may be a better option in such cases.
Complications of Procedure
An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate complications include the following:
Paralytic ileus
Intra-abdominal collection or abscess
Wound infections
Abdominal wall dehiscence
Pulmonary atelectasis
Enterocutaneous fistula
Delayed complications include the following:
Adhesive intestinal obstruction
Incisional hernia

(Dr. B C Shah recently performed Laparoscopic Cholecystectomy on Mr. N_____ G______ who had 512 stones!)
Mr. N_____ G______ came to me with history of chronic pain in upper abdomen. The pain would get aggravated after meals. His sonography revealed that his gall bladder was distended & full of stones. I performed Laparoscopic Cholecystectomy on him. It was a difficult case as there were lot of adhesions. The gall bladder was delivered successfully It was a pleasant surprise to find 512 stones in the Gall Bladder.
One often wonders as to why patients wait so long. Many times patients come to me with Gall Stones. Often they have only one small stone. The common question asked is "Do I still need surgery for just a small stone?"
As per my observation of last 23 years, one stone or many stones – all have a potential to create complications including even death. Its not just the numbers or size. One small stone can just simply slip into the bile duct and is sufficient to trigger Pancreatitis. I personally know of a patient who developed severe pancreatitis due to a 3 mm small stone. She battled for two months in one of the best hospitals in Mumbai and ultimately died.
In kidney stones, one of the criteria on which the therapy is based is the number of stones and its size. Smaller stones can pass out spontaneously and the patient's problem gets solved naturally. However, this is not the situation with gall stones. A gall stone or its fragment passing out can be dangerous as it can cause blockage of bile in liver or swelling in pancreas. Such complications can occur any time and no doctor on earth can predict when this will occur.
Many patients wait for the stones to grow and multiply. Surely this has a potential of inviting big untimely trouble. Don't wait. There are no warning signs.As far as records go, the largest number of gallstones removed was 3,110 in an open surgery in Britain in 1983, reported in the Guinness Book of World Records.

MRS R____ K________ , a 55 year old female was transferred from a local nursing home
She was admitted in a local Nursing home with abdominal pain & vomiting. She was treated as a case of acidity. In spite of the treatment for a week, she did not improve.
When she came to me, her symptoms were suggestive of intestinal obstruction (blockage). A CT scan of abdomen was undertaken. CT scan revealed that she had intestinal obstruction due to a large 5 centimeter stone. This is called Gall stone ileus.
How did the stone land up in her intestine?
No it was not a swallowed stone. This stone had formed in her Gall Bladder over many years. Due to its weight & chronic inflammation, the stone gradually perforated into her small intestine (duodenum). Since the stone was very large it could not pass thro the small intestine and got stuck in the last part of small intestine. Patient was having pain & constantly vomiting due to this blockage.
The treatment was done using minimal access surgery instead of making a big cut on her abdomen – laparotomy. Using laparoscopy, the site of blockage was identified. A small incision was made on her abdomen. The stone was cut open from the intestine (enterolithotomy) and the intestine was placed back into the abdomen.
The blockage was cleared and the patient recovered smoothly and was discharged in few days