1. What is a splenectomy?
Splenectomy is a term referring to the surgical removal of the spleen.
2. What is the spleen and what functions does it serve in our body?
The spleen is a soft organ approximately the size of a fisted hand located behind the stomach in the left upper abdomen and is protected by the lower ribcage. It is part of the blood and lymph system. It functions as a filter, removing bacteria, foreign cells and old red blood cells from the circulation. It also produces red blood cells in children. In addition, spleen produces proteins that help in the immunity against certain bacteria.
3. Why remove the spleen then?
Like any other organ in the body, the spleen can be affected by diseases or injured. The commonest reason for removing the spleen is trauma to the spleen (such as road traffic accident or fall from height) resulting in internal bleeding. Removal of the spleen in such situation is necessary to stop the blood loss and save life.
Spleen may be involved in some blood disorders - causing low platelets counts (as in autoimmune thrombocytopenic purpura, AITP) and decreased life span of red blood cells (eg spherocytosis or other forms of chronic hemolytic anemia). It can also be affected by diseases such as cyst, abscess or hematological malignancy eg. Hairy cell leukemia. Sometimes the spleen can reach a massive size causing significant discomfort to the patient and is associated with increased risk of rupture.
Splenectomy can improve the blood profile of patients with specific blood disorders - in AITP, up to two-third of the patients can be rendered medication-free and have sustained normal platelets count following splenectomy. In hairy cell leukemia, splenectomy can improve the cell count and delay chemotherapy. In those with chronic hemolytic anemia, splenectomy helps to enhance red blood cell lifespan and therefore reduces transfusion requirement. And in those patients with massive enlargement of the spleen, splenectomy can relieve symptoms and eliminate the risk of rupture.
Removal of spleen affected by benign disease such as cyst, abscess or chronic infection can lead to cure of the disease. However, in malignant disease involving the spleen, splenectomy often does not confer a cure, but as part of overall staging (assessment of the severity) of the underlying malignancy.
4. How is the spleen removed?
The spleen is deeply position in the abdominal cavity and closely related to the stomach, the pancreas and the left kidney. These important organs need to be carefully separated from the spleen before it can be safely removed. The operation has traditionally been done via conventional open surgery i.e. through a large incision on the abdominal wall, through the skin and muscle. Now a day, splenectomy can be done laparosocpically. This is done with the patient under general anesthesia and in the right later position. The abdominal cavity is distended with carbon dioxide to create space for the operation. Visualization is achieved with a 10mm diameter telescope and the operation performed with two to three slim 5mm diameter instruments placed at just below the left ribcage.
5. What are the benefits of laparoscopic splenectomy?
The benefits include: -
" Smaller wounds and therefore less pain
" Shorter hospitalization stay
" Faster recovery and return to work
" Reduce overall hospitalization cost
" Better cosmetic outcome
However, in patients with very large spleen or those with severe bleeding tendency, the open operation would be more appropriate.
6. Are there potential complications associated with the operation?
Complications following splenectomy are not common, they include - wound infection, bleeding at surgical site, blood clots in the deep vein of the legs & embolism of the clot to the lungs, pancreatitis (inflammation of the pancreas), collapse of the lung and pneumonia.

7. How do I prepare for the operation?
Prior to the operation, radiologic imaging (commonly computerized tomography {CT scan} or Ultrasonography) of the spleen will be done to delineate the spleen and its congenital accessories.
You will be reviewed by an anesthesiologist to assess your general fitness for general anesthesia. Blood tests, chest X-ray and ECG are done during this review. We will also discuss with you on the pain control option you prefer after the operation.
You will need to have vaccinations to certain bacteria at least one week to 10 days prior to the operation.
You will be admitted to the hospital one day prior to the operation. Upon your admission, blood tests need to be repeated in order to arrange for blood or blood product necessary for the operation. You will meet the physiotherapist who will instruct you on the exercises to help you breathe better following operation.
There will be restriction on the diet and liquid laxative will be given to clear your bowel in preparation for the operation.
8. What is it like after the operation?
This can be broadly divided into 3 categories -
a. The after effects of general anesthesia - headaches, nausea and sore throat. There are medications that can help lessen these unpleasant feelings and they usually improve over the next 24-48 hours.
b. Wound pain - Pain from the laparoscopic wounds are usually minimal. Majority of patients find oral analgesics adequate in relieving pain. If need arise, additional patient-control-analgesia can be prescribed.
c. Surgical tubes and drains - This will include intravenous line for drip, nasogastric tube, urinary catheter as well as surgical drain for residual blood and fluid at the surgical site brought out through the abdomen near the surgical wounds. These tubes do cause some discomfort but are necessary for the first couple of days after operation. Please do bear with the discomfort and inconvenience; they will be removed as soon as they are not needed.
You will be allowed only small amount of clear fluid initially after the operation. As your condition improves and gut function returns, you can progress to more substantial diet.
You are likely to stay in the hospital for 3-4 days after the operation.
9. What should I look out for after discharge from hospital?
You should have recovered to a good extent from the operation when leaving the hospital. You should ambulate as much as the pain / discomfort in the wound permits and take a balance diet and ensure adequate fluid intake to avoid dehydration.
You will be given a date to remove the stitches (or metallic clips) from the skin wound approximately one week after the operation. This is a simple clinic procedure and will not be painful. Meanwhile, you should look out for redness, pain and discharge from the wound that may suggest infection. Consult your surgeon if you develop wound infection or if you have high fever especially when it's associated with abdominal pain.
After laparoscopic splenectomy, most patients are able to return to normal daily activities or deskwork by the end of first week. Strenuous physical exercise should be postponed until 4-6 weeks later. You should return for review with your surgeon and your primary physician on the scheduled date.
10. What are the long term effects of splenectomy?
The bone marrow and the other lymph nodes in the body will take over most of the splenic functions after splenectomy. However, there is still an increased in risk and susceptibility to infection by certain bacteria - pneumococci, meningococci and hemophilus influenza typeB etc. Young children are at a higher risk of infection than adults. Asplenic patients are also at increased susceptibility to malaria.
11. What can be done to reduce the risk of infection?
Awareness of the increased susceptibility to infection after splenectomy and vigilance to minor infection will help a great deal and may potentially be life saving. The following measures helps in reducing the risk of overwhelming infection -
a. Vaccination against pneumococci, meningococci and hemophilus influenza type B are now available and should be given at least one week prior to the operation. A booster is usually necessary every 5-10 years after that.
b. Antibiotic is given during the operation; this usually covers a broad spectrum of gut organisms.
c. Long term antibiotics, usually in the form of penicillin, are recommended in pediatric patients
d. Prophylaxis to malaria when traveling to malaria endemic region.
e. Be mindful of your increased risk to infection and vigilant to potential infective organism such as when you have high fever, severe sore throat, unresolved cough, sudden acute abdominal pain, severe headache and phobia to light or a skin rash. Seek medical attention early to prevent early infection from escalating to potentially fatal septicemia.
f. Seek medical attention early when bitten by animal as there is increased risk of infection. Antibiotic should be started early.
g. Always volunteer the information that your spleen had been removed when consulting a doctor or carry with you an information item stating you are without a spleen (eg information card from your surgeon or a bangle engraved with the information). This is especially important after laparoscopic splenectomy because the surgical wounds can become quite inconspicuous after some time. This will alert the medical personnel attending to you to be more vigilant with potential infection, and more aggressive in treating the infection once detected.

1. What is gastroesophageal reflux disease (GERD)?
GERD is a functional problem that occurs when the door-like sphincter mechanism between the esophagus and the stomach weakens. This results in a backwash or reflux of acid contents of the stomach into the esophagus. When this happens you may get symptoms of heartburn just beneath the breastbone, indigestion after meals and the regurgitation of caustic juices in the mouth.
2. How can GERD be treated?
Most patients with GERD get only occasional symptoms and can be treated by their family doctors. He will usually prescribe medication to reduce the acid in the stomach. Some of these drugs (for example the proton pump inhibitors) are very effective. If symptoms are severe enough to require daily medication, you should probably be seen by a specialist. We recommend a gastroscopy to establish a definitive diagnosis. We can also detect complications of GERD in the lower esophagus, such as inflammation (esophagitis), narrowing (stricture) or Barrett's metaplasia. The latter refers to an abnormal change in the lining of the esophagus which can eventually lead to cancer. We can also look for the presence of a hiatus hernia. This is the slippage of the top of the stomach from the abdominal cavity into the chest. The presence of a hernia can lead to reflux which is difficult to treat medically.
Treatment of GERD needs to be highly individualized. We always recommend losing weight (if the patient is obese), stopping cigarette smoking and avoiding some of the things that are known to aggravate reflux (such as alcohol, caffeine, chocolates and fatty foods). Most patients are put on a course of anti-acid medication and followed up to see how the symptoms improve.
3. When is surgery necessary?
Surgery should be considered if medical treatment is ineffective or if long term medication is required. Taking medication for a long period is probably safe but many patients prefer a permanent cure rather than a lifetime of dependency on drugs. This is especially so if the operation can be done with keyhole surgery. For many patients, their quality of life after surgery also improves. Some studies have also suggested (although not conclusively proven) that the long term risk of developing cancer from constant esophageal damage leading to Barrett's metaplasia is reduced since the reflux no longer occurs.
Before surgery is contemplated, it is necessary to perform a 24 hour pH and motility test to confirm the diagnosis and to establish a baseline before surgery. This test can be a little uncomfortable as a fine tube is passed down from the nostril into the esophagus and left there for a day to measure the frequency and degree of acid reflux on a typical 24 hour period.
4. How is surgery performed?
The operation done is called a fundoplication; this is essentially a repair of the diaphragmatic hiatus, mobilization of the esophageal-gastric junction and a wrap of the stomach around the lower esophagus to create a high-pressure zone that prevents reflux.
We do this operation laparoscopically, using a 1 cm keyhole incision for the telescope and 4 other 5 mm incisions for the operating instruments. Most patients are admitted on the morning of surgery and stay over in hospital for 1 night after the operation. Recovery is usually quick as the operation is minimally invasive. The risk that we may have to convert from a keyhole approach to an open operation is less than 1%.
5. What are the results of Laparoscopic Fundoplication?
There is a 90% chance that you will be completely satisfied with the operation and need no further treatment. Some patients do get occasional minor symptoms after surgery but this can usually be controlled with medication as and when necessary.
Most patients should expect to get some food sticking for the first 4 to 6 weeks after surgery, and will require a sloppy diet eaten slowly. The new valve that is created is usually made tighter than actually required so that it will be just nice over time. For the same reason, some patients find it impossible to belch after surgery. Fizzy drinks should be avoided as it can be uncomfortable when this happens.

1. What is an adrenal gland?
The adrenal glands are paired endocrine glands that produce hormones involve in regulating blood pressure, blood electrolytes and body metabolism. There is one adrenal gland located at the upper pole of each kidney.
2. What are the symptoms of adrenal gland tumor?
Adrenal gland tumors commonly overproduce one hormone. This can result in high blood pressure that is difficult to control, muscle weakness due to low blood potassium or excessive weight gain, skin striae, moon face etc consistent with Cushing's syndrome. Alternatively, they can present with symptoms related to the mass effect of the tumor or pain when the size is large and invades surrounding tissues. Occasionally, the adrenal tumor maybe detected incidentally during investigation for unrelated reason.
3. How can adrenal tumor be detected?
Detecting an adrenal tumor requires combination of biochemistry tests for hormones in the blood and radiologic imaging of the adrenal glands, usually computerized tomography (CT scan) or magnetic resonance imaging (MRI scan). Angiography (radiography with the use of contrast in the blood vessel) maybe indicated in selected cases. Majority of the adrenal tumor are benign.
In the rare incidence of adrenal gland hyperplasia due to excessive external stimulating factors from the pituitary, CT scan or MRI of the brain may be needed.
4. What are the indications for laparoscopic adrenalectomy?

• Benign functioning adrenal tumors, such as pheochromocytoma, Conn's syndrome.
• Adrenal hyperplasia with excess hormone production resulting in disturbance of body metabolism eg Cushing Syndrome.
• Non-functioning or incidental adrenal mass without malignant feature
• As part of adjuvant hormonal ablation for hormone sensitive tumor eg breast cancer.

*Laparoscopic adrenalectomy is generally not recommended for malignant adrenal tumor, large adrenal masses (>10 cm) and in patients with bleeding tendency.
5. How do I prepare for the operation?
Your endocrinologist will check and ensure that your hormonal balance, blood pressure and electrolytes are optimally controlled prior to the operation. These may take several days to few weeks.
Arrangement will be made for an anesthesiologist to assess your general fitness for general anesthesia and the operation. Some baseline blood tests, chest X-ray and ECG will be done.
You will be admitted to the hospital one day before the scheduled operation. Blood tests may need to be checked one more time, and blood and blood product standby for the operation. You may be given laxative to clear your bowel in preparation for the operation.
6. How is the operation conducted?
Laparoscopic adrenalectomy is performed under general anesthesia and with the patient in the semi-lateral position. We prefer the trans-abdominal approach. The abdominal cavity is distended by insufflation with carbon dioxide to create space for the operation. Visualization is achieved with a 10mm diameter rigid telescope and the operation carried out using two to three 5mm-diameter instruments. Majority of the adrenal tumor secrete active hormones, the approach is to detach the adrenal gland from its surrounding tissue, ligating its connecting blood vessels and minimal handling of the gland; to minimize sudden release of active hormones to the blood circulation causing fluctuation in blood pressure. The completely detached adrenal gland is then retrieved using a plastic pouch.
7. Are there dangers associated with the operation?
Complications following laparoscopic adrenalectomy are few. Symptoms related to anesthesia such as nausea, headache and sore throat are quite common. Collapse of lungs bases, leg vein thrombosis and embolism of clots to the lung, and wound infection may affect small number of patients. These complications are more common among patients with Cushing disease.
More specific surgical complications such as bleeding, damage to adjacent organs occurs rarely but may necessitate conversion to conventional operation via open wound.
Fluctuation of blood pressure may occur during operation especially in patients with pheochromocytoma. The anesthesiologist in attendance will be prepared to counter these with intravenous drugs.
8. What can I expect after the operation?
Post anesthetic nausea, headache and sore throat are common; you will be prescribed medications to relieve these symptoms and they usually resolve after 1-2 days.
Majority of patients have good pain relief with oral analgesics only. If needed, patient control analgesia can be added and is very effective in relieving surgical wound pain.
Most patients recover without complications and are well enough to go home on 2nd or 3rd post-operative day. The surgical stitches can be removed after one week.
The opposite normal adrenal gland may be suppressed by the abnormally high hormones level from the tumor and may take a while to regain normal function. During this period, you may need replacement hormone therapy. Your endocrinologist will be attending to you and these medications will be weaned off in the next few weeks.
9. When can I return to work and resume normal activities?
This varies from patient to patient. One of the advantages of laparoscopic adrenalectomy is the smaller wounds, therefore faster recovery and lesser wound pain. Most patients recover very quickly after laparoscopic adrenalectomy and are comfortable returning to normal daily activities such as driving, walking, climbing stairs and deskwork within the one week. However, strenuous physical exercises are usually not recommended until at least 4-6 weeks after the operation.
10. Are there long-term problems after the operation?
There is no significant long-term side effect following removal of one adrenal gland. In fact, excessive hormones production from adrenal gland tumor is one of the causes of the rare form of secondary hypertension; this can be cured after excision of the adrenal tumor. The remaining adrenal gland can normally compensate adequately for the absent counterpart although it may take a while (up to a few weeks) to regain normal function after being suppressed by the abnormally high hormonal level from the tumor. Patients who have had bilateral adrenalectomy need long-term hormonal replacement therapy.

1. What is Endoscopic Thyroidectomy?
Endoscopic Thyroidectomy belongs to a type of minimally invasive procedure called Video Assisted Neck Surgery (VANS). This is a very new procedure that is also technically demanding. Only a few specialized centres worldwide are currently performing this type of operation. VANS uses small telescopes and fine instruments to operate on structures in the neck such as the thyroid and parathyroid glands. Because the neck has no anatomical potential space, the first thing we do is to create a working space under the neck using dissection and inflation with carbon dioxide. A 10 mm incision is used to insert the telescope and to remove the specimen at the end of the operation. Two or three smaller incisions (2mm to 5 mm in size) are used to for the instruments. All the incisions are placed either in the neck, over the chest or in the armpit.
2. What are the indications for Endoscopic Thyroidectomy?
In Endoscopic Thyroidectomy, we usually remove one side of the thyroid gland (similar to the conventional open operation called Hemithyroidectomy). This is done for patients with a goiter or nodule in the thyroid gland. Not all thyroid nodules need to be removed. Only those which are symptomatic, have a risk of malignancy or which are cosmetically unappealing needs to be removed.
Although we have performed Endoscopic Thyroidectomy for nodules that eventually turn out to be early cancer, we do not recommend this for those patients who have clearly have advanced thyroid cancer. This technique is also unsuitable for those nodules which are larger than 4 cm.
3. What are the benefits of Endoscopic Thyroidectomy?
Recovery after conventional open thyroid surgery is usually quick and uneventful. Therefore the main benefit of Endoscopic Thyroidectomy seems to be the superior cosmetic result. The thyroid gland is situated in the front of the neck and open surgery requires a long horizontal scar in a very visible position. Many patients (especially young females), do not want to exchange an ugly thyroid swelling with an even uglier scar. Endoscopic Thyroidectomy may be appealing for them as we need to make only keyhole incisions placed in hidden areas.
Endoscopic Thyroidectomy done by a trained surgeon is a very safe procedure. Since magnification is used we can see the delicate nerves and vessels very clearly. Nevertheless, as with all thyroid surgery, there is always a small risk that injury to the recurrent laryngeal nerves can occur as these nerves are found close to the back of the thyroid gland. If this happens there may be weakness of the voice after surgery. This is usually transient and recovers with time.
The main disadvantage of Endoscopic Thyroidectomy is cost. This approach is more expensive than conventional open surgery because special instruments are necessary.

CONCEPT OF BATH

DR. SHRINIWAS KASHALIKAR

The concept of bath is more profound than is usually considered to be. The bath in neither a mechanical and meaningless ritual of blind religious belief; nor it is a physical procedure that merely involves cleaning the body and simply refreshing the mind.

It has to be appreciated that bath has direct influence on the activities of all the cells of the body through its effects on central nervous system, autonomic nervous system, endocrine system, immune system and metabolic activities.

It is true that the details of the effects are not described in the text- books of physiology as they have are not studied or even thought over adequately.

In addition, there is a tendency amongst researchers to rely on experiments and not accept [or even consider] what appeals to reasoning unless substantiated by experiments, even if it is obvious.

This is somewhat similar to increasing reliance of clinicians on gadgets and investigations. This has prevented us from understanding and appreciating the benefits of bath described in the following shloka.

GUNA DASHAH SNANAPARASYA SADHO
ROOPAM CHA TEJAM CHA BALAM CHA SHAUCHAM
AYUSHYAM AROGYAM ALOLUPATVAM
DUHSWAPNA GHATAHSH CHA TAPAM CHA MEDHA
The meaning is
Oh gentleman! The bath is beneficial in ten different ways.

It improves physical state of existence. It is to be appreciated that ROOPAM does not mean mere appearance. It includes all the physiology. This is why ROOPAM and NAMA are some times compared and contrasted. ROOPAM is everything that is identified by all the terminology [NAMA] in the physiology.

It improves the TEJAM i.e. all the activities that generate energy. In modern parlance this refers to formation of ATP [Adenosine Triphosphate] and CP [Creatine Phosphate].

It improves BALAM. BALAM refers to the actual power, endurance and working capacity of an individual [through efficient formation ATP and CP].

It imparts SHAUCHAM i.e. purity. SHAUCHAM is not merely physical cleanliness of the skin. Bath stimulates the circulation and helps wash away all the waste products likely to be accumulated in and around the cells present in nook and corner of the body.

It gives AYUSHYAM i.e. life. AYUSHYAM is defined as PRAANALAKSHANA VAAYUNAA YOGAH, which means availability and utilization of oxygenation by all the parts of the body. This is achieved through stimulation of central and autonomic nervous systems as well as through their stimulation, stimulation of the respiratory system, cardiovascular system, which are vital in reaching the oxygen to the body cells. But that is not all. It also stimulates the endocrine, immune and metabolic activities.

It improves AROGYAM, which is defined as DHAATUSAAMYAM, which means right proportion of everything in body so as to give power, pleasure, profundity, peace and so on for prolonged time!

It gives ALOLUPATVAM, which means capacity rise above gravitating, enslaving, depressing, and frustrating forces in life. This is important in every sphere of life. In fact ALOLUPATVAM refers to the state of mind which is invincible.

DUSVAPNAGHAATASH means one, which destroys bad dreams or nightmares. Bath can achieve this through achieving a state of alertness by overcoming the unsteady, imbalanced state of mind, which causes bad dreams and nightmares.

TAPAH is of three types [Geeta 17.14, 17.15, 17.16] involving roughly speaking body, intellect and emotions. The TAPAH is also further classified [Geeta 17.17, 17.18, 17.19] into divine, mundane, and devilish. TAPAH means coordinated and controlled activity at an individual level, in the best interest of the universe, which is made easier through bath. Bath taken thrice a day [TRIKAL SNAANA] in itself, is a difficult accomplishment and involves all three types of TAPAH!

MEDHAA means enlightened intelligence. The bath involves not only physical cleanliness but it shifts the level of consciousness. This is particularly important because with such shift in consciousness, the perceptions, desires, aims and actions become increasingly more accurate.
Prayer of Ganga
NAMAAMI GANGE TAVA PAADPANKAJAM
SURAASURAIRVANDITADIVYARUPAM
BHUKTIN CHA MUKTIN CHA DADAASI NITYAM
BHAAAVAANUSAARENA SADAA NARAANAAM

This prayer when recited before actual SNAANA (bath) helps in more than one way. It links us with the river Ganga [who has been worshipped by our ancestors], thereby it links us with the land and our culture and it links us with our history and our forefathers. This very prayer has thus tremendous potential to help us get rid of isolated, alienated, lonely existence.

The diabetics may try bathing thrice a day and verify the beneficial effect of bath on BMR and diabetes.

DR. SHRINIWAS KASHALIKAR