LAPAROSCOPIC GASTRIC BANDING FOR MORBID OBESITY
Posted by on Sunday, 10th May 2009
1. Am I morbidly obese?
The Body Mass Index (BMI) is probably the best way of assessing obesity. Calculate your BMI with this formula:
BMI = weight in kilograms / height in metres2
You are healthy if your BMI is between 20-23, overweight if between 23-27, obese if between 27-40 and morbidly obese if over 40. These cut-off values tend to be lower than those recommended for Caucasians as it has been found that Asians develop medical complications from obesity earlier. Obesity is related to chronic debilitating illnesses such as diabetes, hypertension, heart disease, some cancers, obstructive sleep apnoea and osteoarthritis. In general, if your weight exceeds 50% of your ideal body weight, the risk of an early death is doubled compared to someone who is not obese.
2. Do I need treatment if I am overweight or obese?
Yes, your quality of life will certainly improve with a weight management programme. We always recommend a combination of dieting, exercise, behavior modification and medication. All these work to a certain degree and may be sufficient if you are moderately overweight. Unfortunately, most studies have shown that they will not be effective in the long run for most people. The only treatment that achieves sustainable results seems to be some form of weight loss surgery.
3. What is weight loss surgery?
Weight loss surgery should be considered if the desired weight loss cannot be achieved by non-surgical methods and the obesity poses a serious threat to the patient's health. The main indications for surgery are a BMI of greater than 40, or greater than 32 in the presence of associated medical complications of obesity.
There are a variety of operations that can be done. All of these operations act either by producing early satiety from gastric restriction (eg gastric banding or vertical banded gastroplasty), or by creating a state of malabsorption in the gastrointestinal tract (eg gastric bypass or biliopancreatic diversion). All these operations can be performed by either conventional open surgery (as we used to do in the past) or laparoscopic surgery (the preferred approach nowadays).
We find that for Asian patients, the Laparoscopic Gastric Banding comes close to being an ideal operation as it is a simple procedure with low risks and is also highly effective. There are many types of gastric bands available commercially but our preference if the Swedish Adjustable Gastric Band (SAGB). Most bands are very similar in design but we like the SAGB as it is a soft band. The results of surgery with different bands are also very similar and it is probably best to let your surgeon choose the product he is most comfortable with.
4. How is the Swedish Adjustable Gastric Banding done?
The SAGB procedure is performed laparoscopically through keyhole incisions. The pliable band is inserted around the upper stomach and stiched into place. This creates a small gastric pouch that limits the quantity of food that the stomach can hold. This produces a feeling of satisfaction and fullness even after a small meal. As the band slows down the emptying of food from the pouch, you will remain full for a number of hours after each meal.
The band is attached to a reservoir port that is implanted under the skin over the breastbone. If required, we can inject some saline into this port to adjust the size of the band after surgery. The procedure can be done in the clinic and allows us to calibrate the amount of weight loss required.
5. How do I prepare for Laparoscopic Gastric Banding surgery?
All of our patients are put on a comprehensive weight loss programme. You will be assessed by an endocrinologist to exclude a hormonal problem which may be the cause of the obesity. You will also receive counseling by a dietician and, if necessary, referred to a psychologist for behavior medication and assessment of eating disorders. We will also perform a gastroscopy (to assess the anatomy of the stomach) and an abdominal ultrasound (to exclude gallstones).
6. What happens after surgery?
Most patients are admitted on the day of surgery and stay inpatient for 2 to 3 days after surgery. You will be put on a liquid diet for month after surgery. You will then be re-introduced to puree and solid foods slowly. In general, we target a weight loss of 0.5 to 1 kg a week. You will loss about 60% of your excess weight 2 years after surgery.
7. What are the risks of surgery?
Laparoscopic gastric banding is a safe procedure. Nevertheless, there are definite risks as in any operation for an obese patient. This may be related to the general anaesthesia or to the surgery itself. Specific complications related to the band include band slippage, erosion or infection.
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LAPAROSCOPIC ADRENALECTOMY
Posted by on Sunday, 10th May 2009
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.
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LAPAROSCOPIC GROIN HERNIA REPAIR
Posted by on Sunday, 10th May 2009
1. What are groin hernias?
Hernias are defects and areas of weaknesses in the abdominal wall. These typically occur in the groin area and appear as a soft bulge due to the protrusion of bowel and abdominal cavity contents through this defect. This swelling is small in the beginning and can be pushed back on lying down. With time, however, the hernia invariably gets larger and may become "irreducible". When this happens, complications can occur when the blood supply to the hernia contents get cut off.
2. Do all hernias need surgery?
In the beginning, the hernia may be small and totally asymptomatic. It may not require surgery at this stage but over time it will get troublesome. The hernia will not get smaller on its own. When they become symptomatic, they can cause discomfort or a burning sensation. Surgery is advisable to avoid complications from occurring. There is no other alternative treatment besides surgery. Using a hernia belt (truss) was common in the past, but we now know that this causes scarring and will eventually fail when the hernia becomes too large to be contained.
3. What happens during hernia surgery?
There are many ways of performing hernia surgery. All the procedures are similar in that they involve identification of the hernia sac, reduction of the contents back into the abdominal cavity and a reinforcement of the muscular defect with an inert prosthetic mesh.
For many years, the only way we could do this was with a conventional open operation. This requires a long incision that cuts through all the muscle layers. Recently, however, we have been able to do this using the laparoscopic approach.
4. How is the Laparoscopic Hernia Repair done?
In the early years when we started doing the laparoscopic repair, we had to insert the telescope into the abdominal cavity (the Trans-Peritoneal Approach) to perform the operation from inside. This has certain drawbacks; hence we now use a newer technique which does not require entry into the abdominal cavity (the Extra-Peritoneal Approach). The telescope and 2 fine instruments are placed in the space behind the muscle layers and the whole operation is performed using these keyhole incisions.
5. What are the advantages of Laparoscopic Hernia Repair?
Since only keyhole incisions are used and a long muscle cut avoided, the post op pain is reduced and the return to function is rapid. Our patients are admitted on the day of surgery, and can go home after the operation (i.e. Day Surgery). Older patients may require a night's stay for observation. This operation is usually done under General Anaesthesia.
The laparoscopic repair is definitely superior to conventional open surgery if you need surgery on both sides at the same time (i.e. a bilateral hernia), or if you already have a previous open repair which has failed (i.e. recurrent hernia). We also recommend the laparoscopic approach for patients who are young or those who are active in sports, have a physically demanding job, or simply want a better functional outcome after surgery. We have operated on professional sportsmen (footballers, swimmers etc) who have gone back to training a few weeks after laparoscopic surgery!
6. After your Laparoscopic Hernia Repair.
Avoid straining and driving for the first few days. Walking is encouraged and a shower is allowed after 48 hours. There may be a slight swelling around the groin but this will go away with time (do not massage it). Good support with a pair of fitting briefs is advisable. We will usually review you a week or two after surgery to assess fitness for resuming work. You can usually go back to exercise after a few weeks but heavy straining (eg lifting weights) should be avoided for a few months.
As with open surgery, bleeding and infection can occur. Contact us immediately if there is severe pain, fever, bleeding or swelling. Nerve injury and hernia recurrence can occasionally occur, but this seems to be lower in incidence compared to open surgery. The risk of this happening in the long term is probably less than 1%.
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ENDOSCOPIC THYROIDECTOMY
Posted by on Sunday, 10th May 2009
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.
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Diagnostic Laparoscopy in Primary and Secondary Infertility
Posted by on Thursday, 7th May 2009
Rationale for Procedure
Laparoscopy is typically the final step of a workup for infertility and is used to avoid open surgery. Diagnostic laparoscopy can be used as an adjunct to salpingography to help diagnose causes of infertility. Lesions that may not be seen with salpingography and are viewed better with laparoscopy include endometriosis and adhesions.
Technique
The lithotomy position is employed so that cervical manipulation can be used. When cervical manipulation is not needed, standard supine positioning is used. A primary trocar site is placed in the periumbilical region, and additional trocars are placed in the right and or left lower quadrants as needed [1]. Methylene blue or other dye can be injected into the fallopian tube to check for patency. Peritoneal fluid can be obtained to check for endometriosis. Endometriosis observed should be biopsied and classified with tools such as the American Society for Reproductive Medicine Guidelines. Adhesions can be identified and classified as mild, moderate, or severe. Pathology affecting the fallopian tube can be classified as mild (a superficial vascular pattern suggesting congestion or inflammation and/or minimal kinking, and/or minimal fibrosis), moderate (salpingitis, isthmica, nodosum, distal phimosis, high degrees of vascular change, fibrosis, ampullary dilation after visualization with chromotubation), or severe (obstruction of the tube proximally or distally). Treatment of identified pathology can be initiated at this time.
Indications
• Infertility particularly after normal hysterosalpingography
Contraindications
• Inability to tolerate general anesthesia or significant pelvic adhesions that may preclude safe access or visualization
Risks
• Procedure- and anesthesia-related complications
Benefits
• Identification of the reason for infertility
• Possible therapeutic intervention
• Confirmation of lack of pathology may also be important for further treatment options
Diagnostic Accuracy of the Procedure
The diagnostic yield of the procedure for infertile women after negative hysterosalpingography has been described to range between 21 and 68% (level III) [1,2,4]. Identified pathology includes intrinsic tubal disease (3-24%), peritubal adhesions (18-43%), and endometriosis (up to 43%) [1,3-5]. The procedure has been described to have a higher yield in secondary infertility (54%) compared with primary infertility (22%) (level III) [1]. Furthermore, DL has been shown to alter treatment decisions in at least 8% of patients (level III) [2] and may lead to earlier intervention with assisted reproductive technology [4].
Procedure-related Complications and Patient Outcomes
Procedure-related complications include bowel injuries, bleeding, urologic injuries, vaginal cuff wounds, peritonitis, and pelvic pain. In a large multicenter French study (n=30,000), diagnostic and therapeutic laparoscopy were found to be associated with a 3.3 per 100.000 mortality and a 4.6 per 1,000 morbidity risk (level II) [7]. Complications requiring conversion to laparotomy occurred in 3.2 per 1,000 patients. The risk of complications was related to the complexity of surgery and the experience of the laparoscopist. One in four intraoperative complications was missed during the procedure.
After laparoscopy up to 45% of patients may become pregnant within 1 year, many without in vitro fertilization (level III) [3,4]. While bilateral tubal occlusion on laparoscopic inspection usually signifies the need for in vitro fertilization, pregnancies in patients with this pathology have been described [5].
Cost Effectiveness
There are no available data on the cost effectiveness of DL for infertility.
Limitations of the Available Literature
The quality of the available literature is limited, as all of the available studies are retrospective studies from single institutions. Furthermore, there is a paucity of data on long-term outcomes and pregnancy rates and no data on cost-effectiveness and quality of life. In addition, there is no consistency in the reporting of pregnancy success after laparoscopy, as some studies consider the use of in vitro fertilization a success and others a failure. These shortcomings limit our ability to provide firm recommendations.
Recommendations
Diagnostic laparoscopy can be used safely in female patients with infertility (grade B). Diagnostic laparoscopy may be considered in appropriately selected infertile patients even after normal hysterosalpingograms, as important pelvic pathology may be identified in a significant number of patients (grade C). The paucity of available data and the low level of evidence do not substantiate a firm recommendation for the procedure.
Bibliography
1. Hovav Y, Hornstein E, Almagor M, Yaffe C. Diagnostic laparoscopy in primary and secondary infertility. J Assist Reprod Genet. 1998;Oct;15(9):535-7.
2. Tanahatoe S, Hompes PG, Lambalk CB. Accuracy of diagnostic laparoscopy in the infertility work-up before intrauterine insemination. Fertil Steril. 2003
Feb;79(2):361-6
3. Komori S, Fukuda Y, Horiuchi I, Tanaka H, Kasumi H, Shigeta M, Tuji Y, Koyama K. Diagnostic laparoscopy in infertility: a retrospective study. J Laparoendosc Adv Surg Tech A. 2003; June;13(3):147-51.
4. Corson SL, Cheng A, Gutmann JN. Laparoscopy in the “normal” infertile patient: a question revisited. J Am Assoc Gynecol Laparosc. 2000 Aug;7(3):317-24.
5. Mol BW, Swart P, Bossuyt PM, van der Veen F. Prognostic Significance of Diagnostic Laparoscopy for Spontaneous Fertility. J Reprod Med. 1999 Feb;44(2):81-6.
6. Chapron C, Querleu D, Bruhat M, Madelenat P, Fernandez H, Pierre F, Dubuisson J. Surgical Complications of Diagnostic and Operative Gynaecological Laparoscopy. Human Reproduction. 1998 13(4):867-872.
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