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Anal Fistula, Piles and Fissure are together known as Benign ano-rectal conditions. These conditions are not fatal but they are extremely agonizing..

What further increases the anxiety is the fact that their conventional treatment is even more traumatic and painful resulting in large wounds.

But now procedures are available which have made the treatment of these disorders virtually cut less, woundless and painless.





 

 

 

Single Hole Surgery - Scarless Surgery

You thought that a Surgery, even keyhole, always produces a scar. Not any more!

Gall Bladder                                                   Appendix / Uterus / Hernia, click here

What is Gall Bladder?

The gallbladder is a small organ located high on the right side of the abdomen (tummy)  under the liver. In adults, the gall blabber measures approximately 8 cm in length and 4 cm in diameter when fully distended. It is divided into three sections: fundus, body, and neck. The neck tapers and connects to the biliary tree via the cystic duct, which then joins the common hepatic duct to become the common bile duct.

What is Gall Bladder’s function?

The adult human gallbladder stores about 50-75  millilitres of bile which is released into the small intestine when food containing fat enters the small intestine from the stomach. This bile along with the bile released directly from the liver helps in digestion of fat present in the food.

What are Gall Bladder Stones or Gall stones? How are they formed?

Gall stones are small, hard stones which can sometimes develop in the gall bladder . There are two types of gallstones: cholesterol stones and pigment stones. Eighty percent of gallstones are cholesterol stones. The size of gallstones varies from a grain of salt to golf-ball size. A person can develop a single stone or several stones. When gallstones are present in the gallbladder itself, it is called cholelithiasis. When gallstones are present in the bile ducts, it is called choledocholithiasis.

Gallstones form when bile stored in the gallbladder hardens into stone-like material. Too much cholesterol, bile salts, or bilirubin (bile pigment) can cause gallstones. Slow emptying of the gallbladder can also contribute to the formation of gallstones.

What are the risk factors for developing Gall Stones?

Female sex, obesity, pregnancy, fatty foods, Crohn's disease, terminal ileal resection, gastric surgery, hereditary spherocytosis, sickle cell disease, and thalassemia are all associated with an increased risk for developing gallstones. Only first-degree relatives of patients with gallstones and obesity (defined as body mass index >30 kg/m2) have been identified as strong risk factors for development of symptomatic gallstone disease

What are the symptoms of  Gall stones?

To begin with, most gallstones do not cause symptoms. However, when gallstones become larger, or when they begin obstructing the neck of gall bladder, symptoms or "attacks" begin to occur. Attacks of gallstones typically  occur after a fatty meal and at night. The following are the most common symptoms of gallstones. However, each individual may experience symptoms differently. Symptoms may include, but are not limited to, the following:

·        pain that comes and goes in the abdomen (usually lasting less than 6 hours)

·        nausea and/or vomiting

·        abdominal bloating

·        intolerance of fatty foods

·        belching or gas, and indigestion

Uncomplicated Gall stones usually don’t cause jaundice, fever or longer lasting pain (more than 24 hours). These symptoms appear only after complications of gall stones set in.

The symptoms of gallstones may resemble other medical conditions or problems.

What are complications of Gall stones?

Gall stones can cause a plenty of complications which can be quite dangerous. This is one of the major reason that the Gall stones be removed as soon as they become symptomatic. Some of the major complications are-

1.      Acute Cholecystitis- If stones become lodged in the cystic duct/neck of the gall bladder and block the flow of bile, they can cause cholecystitis, an inflammation of the gallbladder. This causes severe pain in right upper side of tummy ( lasting usually longer than 24 hours), nausea, vomiting and fever. The patient usually requires admission in the hospital for giving intravenous fluids (glucose), analgesics (pain killers), and antibiotics. This gives rest to the gall bladder and leads to recovery with in a couple of days. The diagnosis is done with the help of Ultrasound.  Ultrasound  shows the presence of thickening of the gallbladder wall (>4 mm),  pericholecystic fluid (fluid around the gall bladder),  gallbladder distention, impacted stone, and a sonographic Murphy's sign (focal tenderness directly over the gallbladder).

Complications of Acute Cholecystitis-  Pyocele (Gall bladder full of pus), Gangrene & Perforation of Gall bladder ( It’s a serious condition generally requiring emergency surgery)

Implications of Acute Cholecystitis-  It makes the surgery challenging due to adhesions and increased friability of tissues leading to a higher chances of conversion to conventional laparoscopy and open surgery.

2.      Migration of stone to CBD (Common Bile Duct)- This condition is also called Choledocholithiasis. CBD is the main tube/duct which carries bile from liver to the intestine. The bile stored in the gall bladder is also drained into the CBD. When the stone passes from the gall bladder into the CBD, it can block the main flow of bile and can cause jaundice,  lightening of the stools, and darkening of the urine. If not treated quickly, it can also lead to  fever, pain and shock. Stone in CBD can also block the opening of Pancreatic duct in the CBD leading to Pancreatitis.

 Common bile duct stones may be silent and are often discovered incidentally. About 1% to 2% of patients with normal liver function tests managed with laparoscopic cholecystectomy for gallstones present with a retained stone in the CBD after cholecystectomy.

3.      Gallstone Pancreatitis – As mentioned above, stone in the CBD can block the opening of Pancreatic duct in the CBD leading to Pancreatitis. In Pancreatitis, the patient experiences severe pain in the upper tummy, nausea, vomiting, fever, electrolyte imbalance (disturbances in calcium, potassium and sodium levels), pleural effusion ( Fluid accumulation around the lungs) and even life threatening shock (drop in blood pressures). Diagnosis is usually confirmed by CECT (Contrast enhanced CT scan). An ERCP with sphincterotomy and stone extraction ( An endoscope is put through the mouth, lower end of CBD is dilated and slightly cut and the stone in the CBD is taken out) is the initial treatment and may relieve the pancreatitis. Once the pancreatitis has subsided, the gallbladder should be removed during the same admission. If the pancreatitis is self-limited, the stone has likely passed. For these patients, cholecystectomy is indicated as soon as possible.

4.      Intestinal Obstruction- Passage of a gallstone into the small intestine can lead to a mechanical intestinal obstruction, also known as gallstone ileus. Most (75%) of these fistulas develop between the gallbladder and duodenum (proximal part of the small intestine), occur in elderly people, and account for 1% of all small bowel obstructions. Gallstone ileus may account for as many as 25% of cases of intestinal obstruction in patients older than 70 years who have no previous surgery or hernias on physical exam. The patient has complaints of nausea, vomiting, and abdominal pain

5.      Fistula between Intestine and Gall Bladder- Also known as Biliary-enteric fistula, it usually follow an episode of acute cholecystitis with gangrene and perforation of the gallbladder wall into the adjacent intestine or from pressure necrosis from an impacted gallstone.

Can the patient have symptoms similar to that of Gall stone Disease without having stones in the Gall Bladder?

Yes, its possible. This condition is called Biliary Dyskinesia. If gallstones are not indicated from the test and your symptoms are still not explained, further tests may include a gallbladder emptying. The gallbladder emptying test (CCK-Tc-HIDA scan) is an outpatient test involving an injection into your arm of a substance which will cause your gallbladder to fill with bile quickly. While this is happening, you will lay very still while a radiologist watches by x-ray the speed in which your gallbladder fills. Then you will be injected with another fluid that will cause your gallbladder to spasm violently and empty its contents rapidly. This causes intense, though brief nausea, which should last approximately 5 minutes and end suddenly. By observing the speed your gallbladder empties itself, your doctor will be able to tell whether or not it may be diseased. An ejection fraction less than 35% at 20 minutes is considered abnormal. These patients have functional abnormality of gall bladder and surgery (gall bladder removal) may be indicated in these patients.

What is the treatment of Gall Bladder stones?

The standard treatment of Gall stones is removal of Gall bladder surgically. The surgery to remove the gallbladder is called a cholecystectomy ("Ko-lee-sist-eck-toe-mee").

Is there any effect of Gall Bladder removal on the body? (What's the effect of Gall Bladder removal on the body?)

The liver produces about 750-1100 millilitres of bile every day. The function of the adult human gallbladder is to store about 50-75  millilitres of bile (produced in the liver) and release into the small intestine when food containing fat enters the small intestine from the stomach. This bile along with the bile released directly from the liver helps in digestion of fat present in the food.  The Gall bladder releases only about 15-20% of the total bile produced by the liver, the rest being released directly by the Liver in the intestine.

When the stones develop in the Gall bladder, the capacity of Gall Bladder is markedly reduced due to inflammation and the stones. At the same time, in many patients with gall stones, the function of Gall Bladder to contract and release bile is also deranged (becomes faulty). So, practically in majority of patients with Gall stones, the Gall Bladder is not serving any purpose. Therefore its removal doesn't has any negative effect on the body. Secondly, even after removal of the Gall Bladder, the Liver produce the same amount of bile as it used to produce before its removal. So, the common ducts draining bile (Common Hepatic Duct & Common Bile Duct) dilates to accommodate the flow of bile.

Can Gall Bladder Stones be totally 'silent' (not causing any symptoms) ?

Yes, in some patients the Gall stones can be totally silent causing no symptoms at all. In these patients, the stones in the Gall Bladder are accidentally detected when an Ultrasound is done for some other reason.

Does asymptomatic 'silent' Gall stones need to be removed?

Gall stones not causing any symptoms, may or may not be removed. The medical scientific literature is equivocal (either way) about it. However, there are few conditions when Gall bladder in even asymptomatic Gall stones should be removed. These are

1. Diabetes Mellitus

2. Stone size more than 2 cms (It increases the risk of Gall Bladder Cancer)

3. Polyp in the Gall bladder. (It increases the risk of Gall Bladder Cancer)

4. Porcelain Gall Bladder- (It increases the risk of Gall Bladder Cancer many fold)

5. Regions where Gall Bladder Cancer is very common ( Endemic zones)- As Gall stones increases the risk of developing Gall Bladder Cancer, in regions where Gall bladder cancer is very common like North India, even asymptomatic stones should be treated by Gall bladder removal.

What are the ways to remove Gall Bladder?

The Gall bladder can traditionally be removed by two methods- Open & Laparoscopic (Keyhole). Now Single Hole Laparoscopic Surgery (Single Incision Laparoscopic Surgery- SILS or Scarless Surgery) has revolutionized the way, the Gall Bladder surgery is done.

What is Open Gall Bladder Surgery? How it is done?

In traditional Open  surgery, the gallbladder is removed through a 10-15 cms  long incision  (cut) in the tummy. The cut is made just below the ribs on the right side and goes to just below your waist. This is called an open cholecystectomy.

The Open surgery involves a sizable incision in the upper right abdomen which may take several weeks recovery and cause considerable discomfort and several days of hospitalization. Since the cut is larger, the risk of wound infection is also higher. The long scar leads to cosmetically poor scar. Because of these reasons, Laparoscopic (keyhole) Cholecystectomy has replaced open surgery as the procedure of choice in the last 15 years.

However, even today, Open Surgery is indicated in the following conditions:-

      1. Poor lung or Heart function

      2. Suspected gall bladder cancer

      3. Cirrhosis and portal hypertension

      4. Pregnancy- Third trimester (6th-9th month)

      What is Laparoscopic Cholecystectomy (Gall Bladder Surgery) ?

     About 20 years back, a better  way to remove the gallbladder called laparoscopic ( "lap-are-oh-skop-ick") cholecystectomy was started. In  this surgery, a laparoscope (a small, thin tube with a camera  on the tip of it that is used to see the inside of your body) is used to remove the gallbladder. Several small incisions (cuts) are made rather than one large incision. In USA, about 500,000 to 700,000 cholecystectomies are performed per year.

 

How is Laparoscope used to remove the gallbladder?

The laparoscope is put into your body through a tiny cut made just below your navel. Your doctor can then see your gallbladder on a TV screen and do the surgery with thin long instruments  inserted in 3 other small cuts made in the right upper part of your abdomen. Your gallbladder is then taken out through one of the incisions.

What are the benefits of Laparoscopic Cholecystectomy?

With laparoscopic cholecystectomy, one may return to work more quickly, have less pain after surgery, have a shorter hospital stay, and have a shorter recovery time. Unlike open surgery, laparoscopic surgery to remove the gallbladder can be done without cutting the muscles of your abdomen. The incision is also much smaller and the scars are much less noticeable than those made by open cholecystectomy.

So the advantages of Laparoscopic surgery over Open surgery are

1. Less pain

2. Early discharge from the hospital

3. Early return to work

4. Less risk of wound infection

5. Lesser risk of hernia formation as no muscle is cut

6. Better cosmetic result (as there is no big scar, only multiple small scars)

What are contraindications of Laparoscopic Cholecystectomy?

 Contraindications to laparoscopic cholecystectomy include coagulopathy (inability of blood to clot or bleeding to stop timely), severe chronic obstructive pulmonary disease, end-stage liver disease, and congestive heart failure.

Can Laparoscopic procedure need to be converted to Open surgery? If yes, why and how often?

Yes, the laparoscopic surgery may need to converted to Open surgery at times. The reasons for this could be inability to clearly identify all of the anatomic structures, uncontrolled bleeding, acute cholecystitis (leading to adhesions, swelling and friability of tissues), previous surgery in the region leading to scarring and adhesions or damage to a vital organ/structure. The conversion rate for elective laparoscopic cholecystectomy should be around 5%, whereas the conversion rate in the setting of acute cholecystitis may be as high as 30%. Conversion to an open procedure is not a failure, and the possibility should be discussed with the patient preoperatively.

What is Single Incision Laparoscopic Surgery (SILS) or Single Hole Surgery or Scarless Surgery?

In SILS, the complete surgery is done through a single small puncture/hole/incision of about 1.5 to 2.5 cms. This small cut is made inside the navel (umbilicus) in such a way that the scar is practically invisible after the operation, making it a scarless surgery. SILS has revolutionized the field of laparoscopic surgery as the latter did about 20 years back.

What are advantages of SILS or Single Hole Surgery operation?

SILS has number of distinct advantages,

1. Wonderful cosmesis- The cosmetic result is fantastic as there is no visible scar after the operation. It is very good for ladies who are quite careful about cosmesis.

2. Less pain- As the number of cuts are less.

3. Early recovery

4. Early return to work                                                                                                   

5. Less chances of Infection as there is only one small cut.                                                                                                     

 

 

 

 

 

 

 


 

 

 

 

 


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