MyLapSurgeon

How Surgery Helps to Lose Weight

ost patients lose about 40% of their weight  after gastric bypass surgery and about 30% of their weight after sleeve gastrectomy surgery. Most weight loss results over a period of one year. Patients usually reach their lowest weight 18 months after gastric bypass or sleeve gastrectomy surgery. After lap-band average weight loss is about 15% of preop weight. Weight loss is slower after lap-band but it continues up-to five years after surgery. Optimum weight loss requires life style changes and exercise after surgery. Motivated patients lose more weight because they follow dieting and exercise advice strictly. Weight loss surgery does not cure obesity. It can only help you diet successfully and stay with it, so you do lose weight. The surgery limits the amount of food you can eat at any one time, but it is not an easy way out. If you over eat your small stomach, or continue to snack frequently on high calorie snacks, you will fail to lose weight or regain after losing at first.

By eating only at mealtime and only until you feel full and combining it with 30 minutes of exercise, you will be able to lose significant amount of weight. However, it will be up to you to choose the best and most healthy foods for successful weight loss. Be sure you are willing to change your eating habits. If not, you will be wasting your time and money by having weight loss surgery. You will be most successful if you also make changes in your work, your exercise, and your use of leisure time.

In the beginning most people feel full with a small amount of food and they do not feel like eating more than three meals a day. However it is important to stick to 3 meals a day forever after surgery and avoid unhealthy snacks. You can compromise weight loss by drinking fluids with a lot of calories or eating frequent snacks. You should drink plenty of fluids after surgery. Fluids should be mostly water or diet flavored liquids like Diet Snapple and Crystallite. Avoid carbonated beverages for a few months to prevent the distension of new gastric pouch with gas. Most patients should drink at least 64 ounces or 2 liters of fluids a day.

You will be on liquid diet for first two to three weeks after weight loss surgery. During that period, your diet should be high in proteins. Try to take about 60 to 70 grams of proteins daily. By taking adequate amounts of proteins, you prevent the breakdown of your muscles and your body is forced to breakdown fat in stead of muscle to cause weight loss. You can use a protein powder or a protein shake to supplement your protein intake early on. Be careful and choose a protein supplement with the lowest fat content. Many patients use Designer protein powder for protein supplementation for first 3 to 6 months.

Your diet will be advanced to puree and then semisolid food gradually over next few weeks. Be sure to chew your food very well and avoid liquids for half an hour before and half an hour after meals when you start taking solid food. Liquids fill up your small gastric pouch with fluid and you end up eating less solid food. However liquids do not stay in the pouch long enough and you will feel hungry sooner if you had liquids with your meals because liquids will wash the solid food out of your stomach.

Ultimately you should set a goal of a balanced diet, with 60 to100 grams of proteins, 100 grams of carbohydrates and 30 grams of fats daily. Try to keep the carbohydrate content of your diet low.

Although your gastric bypass can be reversed, it would mean serious surgery again. If you have your stomach returned to normal size, you will most likely gain back any or most of the lost weight. For these two reasons, think of gastric bypass surgery as being forever.

Preparation for Weight Loss Surgery

ncrease the chances of success by following these guidelines.

           
• We recommend that patients attend at least 3 support group meetings before surgery and keep attending support group meetings for at least 6 to 12 months after surgery.
       
• Read the information material. Please read as much as possible about weight loss surgery to prepare yourself for the operation. Make sure you read the material given to you or recommended to you by your surgeon.
       
• Exercise. Start exercising on a regular basis. Your exercise could be as mild as water aerobics, daily walks or any other aerobic workout. It is important to start gradually and build up to at least 30 minutes of regular exercise every day. We recommend our patients to buy a pedometer to count the number of steps daily. Check your pedometer before going to bed and keep track of daily steps. This is a very good way to motivate yourself to walk more.
       
• Stop smoking. You cannot have this surgery until you have been off cigarettes/cigars for one month. Smoking is probably more dangerous to your health than obesity. Smoking paralyzes the lining of your air passages. It hinders good working of your lungs and heart. After weight loss surgery, smoking also increases the risk of development of ulcers in the new stomach pouch.
       
• Do not have weight loss surgery, while you have any other acute medical problem. If you are getting a cold or have a sore throat, ear infection, kidney or bladder infection, open wound or sore, call your doctor. It may be safer to reschedule your surgery.
       
• Begin taking two showers a day a few days before you enter the hospital. Use a good soap. Wash very well from your breasts to below your waist. Make sure you clean between any folds of skin.
       
• Stop taking all herbal products or natural medicines(e.g. St. John’s wort, ginko, biloba, ginsung, garlic etc and even Vitamin E) for at least one week before surgery. Some of these 'natural medicines' can increase the risk of bleeding during and after surgery.
       
• Stop blood thinning medications. If you take any blood thinning medicine, warfarin, coumaden, aspirin or aspirin like medications called NSAIDs (Ibuprofen, Motrin, Advil, and Naproxen), you should stop taking those before surgery and talk to your doctor about it.
       
• Stop Birth Control Pills for a month before surgery. Birth control pills increase the risk of blood clots in the veins of your legs and pelvis. Patients undergoing weight reduction surgery are at higher risk of making these blood clots. Stopping birth control pills will decrease the risk of blood clots. You should switch to a barrier method of birth control for a month before surgery and continue this method of birth control for at least 18 months after surgery.
       
• Avoid "Last Supper Syndrome". Some patients start going out to eat before weight loss surgery and start eating all their favorite foods and deserts before surgery. They are afraid that they will not be able to eat these foods for ever. As a result they put on more weight while they are getting ready for surgery. This makes the surgery technically more challenging and increases the amount of weight they have to lose. In fact most people are able to eat and drink almost everything they ate before surgery. But it takes them some time to get to that stage and they can only eat in small amounts which is good for them anyway.
       
• You may need to go on a liquid protein diet for 1-2 weeks before surgery. You will need to stop eating and drinking the midnight before surgery.
       
• You may want to visit the surgical floor before you have surgery. You can see the unit, meet the nurses, learn about your care, and ask questions. Please ask about scheduling this visit. You may want to write down questions to ask the doctors or nurses, when you see them.
       
• An anesthesiologist will talk with you about anesthesia to put you to sleep during surgery. He or she will put an endotracheal tube in your windpipe (trachea) through your mouth or nose. Your throat will be numbed with a spray. The anesthesiologist moves air in and out of your lungs through this tube, while you are asleep during surgery.
       

Preparation For Surgery

Starting Liquid and Food after Weight Loss Surgery

he day after your surgery, you will undergo a ‘leak test’. If the test looks good, you will be able to start drinking Bariatric clear liquid diet. Your schedule of drinking and eating is likely to be:

Before Surgery, liquid diet for 24 hours the day before surgery and from midnight before your surgery to after surgery: An IV will give you liquid. You may also need bowel prep to clean your bowels and our staff will let you know if you need it.

First or second day after surgery: Bariatric clear liquids (sugar free jello, dilute juice, broth), ice chips and water in 30 cc medicine cups.

Second or third day after surgery: Bariatric full liquids (skim milk, low fat yogurt, low fat pudding, low fat cottage cheese, other foods and liquids that do not need chewing) Take it slowly. You do not have to eat all you are given. Remember, your new stomach is only one to two tablespoons big. The opening into the intestine is only the size of a dime. At first, about ¼ cup of food or less is the most your stomach can hold at one time.

Such liquid food will not stretch your small stomach and will pass through the small opening easily without blocking it. You may find that you need to spread your food or fluids out over the hour when you get to three or four ounces in an hour.

Avoid liquids will a lot of simple sugars, and carbonation. In stead drink water, or flavored diet non carbonated liquids e.g. diet Snapple, crystallite, propel etc. Begin taking daily vitamins. We recommend Optisource multivitamin one tablet 4 times a day. Optisource will also provide you extra iron, calcium and B12. If you do not like their taste, you may take two chewable multivitamin with iron, or one prenatal vitamin a day is fine. Begin taking a calcium supplement, such as three to five Tums per day or other pills to equal 1,000 milligrams of calcium.

Patients stay on full liquid diet for 2 weeks after gastric bypass and 3 weeks after lap-band. It is very important to drink at least 2 liters (64 ounces) of liquids per day and supplement your diet with a protein powder or protein shake at this time. Your goal is 60 to 100 grams of proteins per day. In the beginning, it is very difficult to achieve this goal and 30-40 grams of proteins per day are an acceptable goal for the first few weeks.  Do not take a protein supplement with a lot of fat calories. You can take Designer protein powder mixed in 8 oz of water or skim milk two to three times a day. Some patients like to drink Boost High Protein at this stage. If you choose Boost High protein, you should dilute it with skim milk in a 1:1 ratio. As a rule, any liquid that has more than 20 grams of sugar per serving should be diluted to avoid dumping syndrome symptoms after gastric bypass surgery. Dumping symptoms are not seen in patients after lap-band surgery. Another option is to drink Low Carb Carnation Instant Breakfast. Keep in mind that Boost High Protein and Low Carb Carnation Instant Breakfast are high in calories compared to Designer protein shakes.

When you eat solid food, it is very important to chew your food very well. Place your knife and fork on the table after every bite and concentrate on chewing. Do not watch TV and do not talk to anyone during eating for the first few weeks because you could inadvertently swallow a bite without chewing and if that happens, it will cause a lot of discomfort and pain.  

Stop eating immediately when you feel full.

Most patients suffer from a change in their taste after surgery. Many foods that tasted good before surgery, do not taste good any more and vice versa. It is partly related to the breakdown of fats (ketoacids) and their release into the breath. Mouth washes or low sugar mints are very helpful.

About 15 to 20% of patients suffer from nausea and retching in first few weeks after gastric bypass surgery. It is most noticeable between 4th and 12th week after surgery. Nausea is usually more common and more severe after gastric bypass surgery than lap-band. When you feel nauseous, or have dry heaves, go back to the previous stage of food. If you are on semisolid food stage, go to puree food. If you are at puree food, go to liquids for 24 to 48 hours. Also try hot or cold liquids. If these measures don’t help, call your doctor, you may need a medication for nausea or may even need admission in the hospital to give you intravenous fluids.  It is very common to be able to eat a certain food one day and not be able to eat the same food some other day. This stage can be very annoying but it shall pass too.

Even though nausea is less common after lap-band, it is extremely important to avoid severe nausea, retching and dry heaving for first 3 weeks after lap-band to minimize the possibility of band slippage. We usually advise patients to take scheduled nausea medication for the first 3 weeks and avoid all kind of solid food during that period.

You will receive more detailed information from our dietitian. Please follow those instructions closely.

Recovery at Home

ncreasing your activity slowly, will help your recovery. Follow the tips listed below:

Do:

• Follow your discharge instructions. You can download a copy here

Discharge Instructions

• Walk as much as you can without getting overly tired
• Slowly increase the distance you walk. By your six week follow-up visit, you need to be walking from one to two miles each day
• Begin driving a car as soon as you feel strong and pain-free enough to drive with confidence.  It usually takes two weeks after gastric bypass and 1 week after lap-band
• Have sexual relations when you want to and feel able

Do not:

• Drive a car or use machinery while you are still taking narcotic pain medicines
• Climb more stairs than what is needed to get to your bedroom, the bathroom, or outside
• Lift anything heavier than 10 to 15 pounds for at least six weeks after open surgery and 4 weeks after laparoscopic surgery
• Stand or sit for more than a short time. Instead, do walk and move about when you are up. This will help your circulation
• Do not get pregnant for at least 12 to 18 months after weight loss surgery. Yes it is possible to have children after weight loss surgery. In fact women are more fertile after weight loss surgery. However birth control pills are not completely reliable method of birth control after weight loss surgery for the first 12-18 months
 

Return to the Bariatric Center to have your weight and general health checked:

• 2-3 weeksafter surgery
• 1-2 months after the first follow-up visit
• Then every 3 months for a year.
• Then every 6 months forever
• More frequently if you are having any problems
 

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

       
• Persistent fever (over 100°F)
       
• Bleeding
       
• Increased abdominal swelling or pain
       
• Persistent nausea or vomiting
       
• Chills
       
• Persistent cough or shortness of breath
       
• Difficulty swallowing that doesn't go away within a few weeks
       
• Drainage from any incision
 

Losing Weight after Surgery

any factors affect weight loss, such as age, sex, and weight at the time of surgery.

If you are very overweight, you have more to lose and probably will lose more. On the average, patients lose 40% of their weight  after gastric bypass and 30% of their weight after sleeve gastrectomy in 12-18 months and 15-20% of  weight by 5 years after lap-band. This is an average, so some lose more and some less. If you are younger and get more exercise, you may lose more. Most patients stay 30 to 50 pounds over "ideal" weight, even after surgical weight loss.

After surgery, your small stomach and its small outlet reduce hunger and the amount you can eat. It is then up to you to choose the best and most healthy foods for successful weight loss. The tips below will help you make changes in your eating habits. These changes are yours to make. Pride and feeling good about your weight loss will also be yours.

Tips for Changing Your Eating after Weight Loss Surgery

For the first few weeks after surgery, you will feel very full with 1/3 to ½ cup of liquid. Slowly you will be able to have a bit more at one time. Then, follow the tips below:

• Eat less often. Eat only three small meals per day.
• Try taking only solid food at meals. You will feel full longer on solids. Between meals, have low calorie drinks such as water, water with lemon, diet Snapple, crystallite, coffee or tea(1-2 cups a day), skim milk, vegetable juice, and sugar-free drinks.
• Do not have high calorie, low nutrient drinks, such as regular soda pop, milkshakes, beer and other alcoholic drinks. Such drinks give you many calories but do not make you feel full. You will not lose weight.
• Do not snack between meals. Constant nibbling defeats the purpose of your surgery and you will not lose weight.
• Do not eat sweet foods that may give you unpleasant symptoms, (called Dumping Syndrome) after gastric bypass and make lap-band less effective.
• Take a high potency multivitamin with iron every day.
• Eat a variety of foods. Your needs for protein and vitamins do not change with surgery. Be sure foods you choose to eat are good sources of nutrients.
• Choose protein foods several times a day: meats, chicken or turkey, fish, eggs, dairy foods.
• Limit sugars and fats. Sugars (white and brown sugar, honey, jams syrups) and fats (butter, margarine, oils, mayonnaise, cream, gravies, salad dressings, sauces) greatly increase calories but give you little or no nutritional value.
• Eat slowly. Gulping your food or drinks will make you feel uncomfortable and may make you vomit. When you begin eating solid food, chew until the food is mushy and like liquid.
• Stop eating as soon as you feel full. You will not be able to eat all the food you may want. Taking a few extra bites and frequent over eating can stretch the stomach pouch and limit your weight loss.
  Lap-Band patients are seen in the office every 6-8 weeks. If their weight loss is less than 1-3 lbs per week, despite following the above instructions and 30 minutes of daily exercise, a filling of the band is performed with a small amount of saline solution. Most patients need several fillings and reach an optimum fill volume by the end of the year.
 

Adding Exercise after Weight Loss Surgery

xercise is important to include in your daily routine for good health and weight loss. After open gastric bypass, most people can start a regular exercise schedule by six-weeks after surgery. This may take only 4 weeks after laparoscopic gastric bypass and 2 to 3 weeks after lap-band. At this time, begin active exercise slowly and increase to 30 minutes of exercise daily. Choose exercise you enjoy. Swimming, bicycling, tennis, golf, jogging, and brisk walking use the most calories. We recommend patients to use pedometers to keep track of the daily steps walked.

When you begin to lose weight, you will have more energy than before surgery. Exercise will become more fun. Exercises, such as sit-ups, leg lifts, weight lifting and yoga help to tone muscles. They will strengthen your muscles and improve your health. However, exercises cannot prevent loose, saggy skin if you lose a lot of weight. Check with your doctor before beginning active and/or toning exercises.

Your Decision about Weight Loss Surgery

his Website Information covers weight loss surgery, your hospital stay, recovery, weight loss, and new eating habits. Because you are making a big decision about major surgery, be sure to gather any more information you feel you need. Please ask the Hamot Bariatric Surgery Center staff questions. Talk with your family and others who have had the surgery. Be sure to talk with your own doctor, who knows you and your medical history. If you or your doctor wishes more information, please call our office. You can also get more information from American Society of Metabolic and Bariatric Surgery’s website at www.asmbs.org. Another very useful website is www.obesityhelp.com.

Weight loss surgery sets you up for success with losing weight. However, it still will not be easy. You will need to work to make it work, but feeling healthy and successful will be well worth it.

Psychiatric problems, like depression

Likelihood of a complication

Wound infection

Stomach ulcer

Severe lack of vitamins

Leaks or tears causing internal infection and need for more surgery

Too much weight loss

Blockage needing another surgery

Laparoscopic Gallbladder Removal
(Laparoscopic Cholecystectomy)

he Era of Open Cholecystectomy Removal of gall bladder is one of the most common operations in USA. It used to be performed through a long open incision on the right side of the abdomen. When your surgeon recommended a gallbladder operation perhaps you thought about a friend or family member who had this operation several years ago. They had a large incision and may have had a lot of pain after the operation. They stayed in the hospital for a week and weren't back to normal activities for about six weeks. You may be worried about a similar experience. Perhaps you can't afford to be away from the office, and are concerned about not being fully functional at home for a month or more.

The Era Of Minimally Invasive Gall Bladder Surgery

oday, most gallbladder surgery is performed laparoscopically. The medical name for this procedure is Laparoscopic Cholecystectomy.

• Rather than a five- to seven-inch incision, the operation requires only four small openings in the abdomen
• Patient usually has minimal postoperative pain
• Patient usually experiences faster recovery than traditional gallbladder surgery patients. Most patients go home within one day and enjoy a quicker return to normal activities

Role Of The Gall Bladder

• The gallbladder is a pear-shaped organ that rests beneath the right side of the liver
• Its main purpose is to collect and concentrate a digestive liquid (bile) produced by the liver. Bile is released from the gallbladder after eating, aiding digestion. Bile travels through narrow tubular channels (bile ducts) into the small intestine
• Removal of the gallbladder is not associated with any impairment of digestion in most people

Gall Stones

• Gallbladder problems are usually caused by the presence of gallstones: small hard masses consisting primarily of cholesterol and bile salts that form in the gallbladder or in the bile duct
• It is uncertain why some people form gallstones
• There is no known means to prevent gallstones
• These stones may block the flow of bile out of the gallbladder, causing it to swell and resulting in sharp abdominal pain, vomiting, indigestion and, occasionally, fever
• If the gallstone blocks the common bile duct, jaundice (a yellowing of the skin) can occur

Diagnosis Of Gall Stones
After the patient has symptoms...

• Ultrasound is most commonly used to find gallstones
• In a few more complex cases, other X-ray tests may be used to evaluate gallbladder disease
• Gallstones do not go away on their own. Some can be temporarily managed with drugs or by making dietary adjustments, such as cutting down on fat intake. This treatment has a low, short-term success rate. Symptoms will eventually continue until the gallbladder is removed
• Surgical removal of the gallbladder is the time honored and safest treatment of gallbladder disease

Preparation For Gall Bladder Surgery

• Prior to the operation, you will refrain from eating or drinking after midnight on the night before your operation
• You should shower the night before or the morning of your operation
• If you have difficulties moving your bowels, an enema or similar preparation should be used after consulting with your surgeon
• Some preoperative testing may be required depending on your medical condition
• If you take medication on a daily basis, discuss this with your surgeon as he may want you to take certain of your medications on the morning of your operation with a sip of water. If you take aspirin, blood thinners, vitamin E tablets or arthritis medication, you need to discuss with your surgeon the proper timing of discontinuing these medications before your operation. If you take natural supplements or herbal products e.g. st.john’s wort, ginsung, biloba, garlic etc. you will need to stop them for a week as some of these can interfere with anesthesia or cause excessive bleeding

Surgical Technique Of Laparoscopic Removal Of Gall Bladder

• Under general anesthesia, so the patient is asleep throughout the procedure
• Using a canula (a narrow tube-like instrument), the surgeon enters the abdomen in the region of the navel
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the canula, giving the surgeon a magnified view of the patient's internal organs on a television screen
• Other canulas are inserted which allow your surgeon to delicately separate the gallbladder from its attachments and then remove it through one of the openings
• Many surgeons perform an X-ray, called a cholangiogram, to identify stones which may be located in the bile channels or to insure that structures have been identified
• If the surgeon finds one or more stones in the common bile duct, he may remove them with a special scope, may choose to have them removed later through a second minimally invasive procedure, or may convert to an open operation in order to remove all the stones during the operation
• After the surgeon removes the gallbladder, the small incisions are closed with a stitch or two or with surgical tape

Possibility Of Conversion To Open Procedure

n a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication. It is sound surgical judgment. Factors that may increase the risk of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety.

Duration Of Hospital Stay

ost Laparoscopic Cholecystectomy patients go home the day after surgery. Some may even go home the same day the operation is performed. This compares with a five day stay following the traditional procedure.

Return To Work

ost patients can return to work within seven days following the laparoscopic procedure. Of course, this depends on the nature of your job. Patients with administrative or desk jobs usually return in a few days while those involved in manual labor or heavy lifting may require a bit more time. Patients undergoing the traditional procedure usually cannot resume normal activities for four- to six- weeks.

Will You Have A Large Scar?

aparoscopic techniques allow, the surgeon to avoid a large incision, leaving the patient with only four small marks. You will not have a large scar.

Is Laparoscopic Gallbladder Surgery Safe?

he complication rate for laparoscopic gallbladder surgery has been shown by numerous medical studies to be comparable to the complication rate for traditional gallbladder surgery when performed by a properly trained surgeon.

Risks Of Laparoscopic Cholecystectomy

hile there are risks associated with any kind of operation, the vast majority of laparoscopic gallbladder patients experience few or no complications and quickly return to normal activities. The risks of laparoscopic cholecystectomy are less than the risks of leaving the condition untreated.

Complications of Laparoscopic Cholecystectomy are infrequent, but include bleeding, infection, pneumonia, blood clots, or heart problems. Unintended injury to an adjacent structure such as the common bile duct or duodenum may occur and may require another surgical procedure to repair it. Bile leakage into the abdomen from the tubular channels leading from the liver to the intestine has been described.

Recovery After Gall Bladder Surgery

• Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs. Nausea and vomiting is not uncommon
• Once liquids or a diet is tolerated, patients leave the hospital the same day or day after the laparoscopic gallbladder surgery
• Activity is dependent on how the patient feels. Walking is encouraged. Patients can remove the dressings and shower the day after the operation
• Patients will probably be able to get back to normal activities within a week's time, including driving, walking up stairs, light lifting and work
• In general, recovery should be progressive, once the patient is at home
• The onset of fever, yellow skin or eyes, worsening abdominal pain, distention, persistent nausea or vomiting, or drainage from the incision are indications that a complication may have occurred. Your surgeon should be contacted in these instances
• You should make an appointment with your surgeon within 2 weeks following your operation, even if your post-operative course has been uneventful

Is Laparoscopic Gallbladder Removal Right For You?

lthough there are many advantages to laparoscopy, the procedure may not be appropriate for some patients who have had previous upper abdominal surgery or who have some pre-existing medical conditions. A thorough medical evaluation by your personal physician, in consultation with a general surgeon trained in laparoscopy, can determine if laparoscopic gallbladder removal is an appropriate procedure for you.

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-

• Persistent fever (over 100°F)
• Bleeding
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Drainage from any incision
• Jaundice (yellow discoloration of eyes or itching

Laparoscopic Ventral Hernia Repair

Introduction

Approximately 90,000 ventral hernia repairs will be performed this year in the United States. Many are performed by the conventional "open" method. Some are performed laparoscopically. The following information can help you understand what a hernia is and more about the treatment.

Laparoscopic hernia repair is a technique to fix tears or openings in the abdominal wall using small incisions, laparoscopes (small telescopes inserted into the abdomen) and a patch (screen or mesh) to reinforce the abdominal wall. It may offer a quicker return to work and normal activities with decreased pain for some patients.

What Is A Ventral Hernia?

• When a ventral hernia occurs, it usually arises in the abdominal wall where a previous surgical incision was made. In this area the abdominal muscles have weakened; this results in a bulge or a tear. In the same way that an inner tube pushes through a damaged tire, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a balloon-like sac. This can allow a loop of intestines or other abdominal contents to push into the sac. If the abdominal contents get stuck within the sac, they can become trapped or "incarcerated." This could lead to potentially serious problems that might require emergency surgery
• Other sites that ventral hernias can develop are the belly button (umbilicus) or any other area of the abdominal wall
• A hernia does not get better over time, nor will it go away by itself

How Do I Know If I Have A Hernia?

• A hernia is usually recognized as a bulge under your skin. Occasionally, it causes no discomfort at all, but you may feel pain when you lift heavy objects, cough, and strain during urination or bowel movements or with prolonged standing or sitting
• The discomfort may be sharp or a dull ache that gets worse towards the end of the day. Any continuous or severe discomfort, redness, nausea or vomiting associated with the bulge are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon is recommended

Why Do People Get Ventral Hernias?

• An incision in your abdominal wall will always be an area of potential weakness. Hernias can develop at these sites due to obesity, heavy straining, aging, injury or following an infection at that site following surgery. They can occur immediately following surgery or may not become apparent for years later following the procedure
• Anyone can get a hernia at any age. They are more common as we get older. Certain activities may increase the likelihood of a hernia including persistent coughing, difficulty with bowel movements or urination, or frequent need for straining

Treatment Options For A Ventral Hernia

There are few options available for a patient with a ventral hernia.

• The use of an abdominal wall binder is occasionally prescribed but often ineffective
• Ventral hernias do not go away on their own and may enlarge with time
• Surgery is the preferred treatment and is done in one of two ways

The traditional approach is done through an incision in the abdominal wall. It may go through part or all of a previous incision, skin, subcutaneous fatty layer and into the abdomen. The surgeon may choose to sew your natural tissue back together, but frequently, it requires the placement of mesh (screen) in or on the abdominal wall for a sound closure. This technique is most often performed under a general anesthetic but in certain situations may be done under local anesthesia with sedation or spinal anesthesia. Your surgeon will help you select the anesthesia that is best for you.

The second approach is a laparoscopic ventral hernia repair. In this approach, a laparoscope (a tiny telescope with a television camera attached) is inserted through a cannula (a small hollow tube). The laparoscope and TV camera allow the surgeon to view the hernia from the inside. Other small incisions will be required for extra cannulas for placement of other instruments to remove any scar tissue and to insert a surgical mesh into the abdomen. This mesh, or screen, is fixed under the hernia defect to the strong tissues of the abdominal wall. It is held in place with special surgical tacks and in many instances, sutures. Usually, three or four 1/4 inch to 1/2 inch incisions are necessary. The sutures, which go through the entire thickness of the abdominal wall, are placed through smaller incisions around the circumference of the mesh. This operation is usually performed under general anesthesia.

The Advantages Of The Laparoscopic Repair

he results may vary depending on the type of procedure and each patient's overall condition. Common advantages may include:

• Less post-operative pain
• Shortened hospital stay
• Faster return to regular diet
• Quicker return to normal activity

Who Is A Candidate For The Laparoscopic Repair?

fter a thorough examination, then, only can your surgeon determine whether a laparoscopic ventral hernia repair is right for you. The procedure may not be best for some patients who have had extensive previous abdominal surgery, hernias found in unusual or difficult to approach locations, or underlying medical conditions. Be sure to consult your physician about your specific case.

Complications Of Laparoscopic Hernia Repair

• Although this operation is considered safe, complications may occur as they might occur with any operation. Complications during the operation may include adverse reactions to general anesthesia, bleeding, or injury to the intestines or other abdominal organs. If an infection occurs in the mesh, it may need to be removed or replaced. Other possible problems include pneumonia, blood clots or heart problems if someone is prone to them. Also, any time a hernia is repaired it can come back
• The long-term recurrence rate is not yet known. The early results indicate that it is as good as the standard or traditional approach
• Your surgeon will help you decide if the risks of laparoscopic ventral hernia repair are less than the risks of leaving the condition untreated

Conversion Of Laparoscopic Operation To Open Operation

n a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. In these cases, your surgeon will convert to an open repair. Factors that may increase the possibility of converting to the open procedure may include finding extremely dense scar tissue, obesity, bleeding problems during the operation, or an injury to the intestine or other abdominal tissues. The decision to perform the open procedure is a judgment decision made by your surgeon before or during the actual operation. The decision to convert to an open procedure is based on patient safety. The decision to convert does not necessarily indicate that a complication has occurred.

Preparations Prior To Laparoscopic Ventral Hernia Repair

eeting with your surgeon will include a discussion of your prior surgical and medical history. A thorough examination will be required and possibly some blood tests and X-rays, also. Depending on your particular medical condition, further or more extensive testing of lung or heart function may be required. The following list includes typical preparations for this surgery.

• Your surgeon will review with you the techniques of the operation, the benefits, the risks and the possible need for performing this operation in the traditional manner
• You may need to completely empty your colon and cleanse your intestines prior to surgery. It may be necessary for you to be on a clear liquid diet for one or several days prior to surgery. Our staff will inform you if that is needed in your case
• It is advised that you shower the night before or morning of the operation
• The night before the operation, you should not eat or drink any food or liquid. You should discuss with your physicians what medications are permissible the morning of surgery
• Typically, drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and large doses of Vitamin E may need to be temporarily stopped for several days to a week before your surgery. Similarly natural supplements or herbs e.g. St John’s wort, ginsung, biloba etc need to be stopped for a week before surgery because they can interfere with anesthesia or cause excessive bleeding

What Should I Expect The Day Of Surgery?

• You usually arrive at the hospital the morning of the operation. A qualified medical staff member will typically place a small needle or catheter into your vein to dispense medication during the surgery. Often pre-operative medications, such as antibiotics, may be given
• Your anesthesia will last during and up to several hours following surgery
• Following the operation, you will be taken to the recovery room and remain there until you are fully awake
• Few patients may go home the same day of surgery, while others may need admission for a day or more post-operatively. The need to stay in the hospital will be determined according to the extent of the operative procedure and your general health

What Should I Expect After Surgery?

• Patients are encouraged to engage in light activity while at home after surgery. You should avoid lifting anything heavier than 10 lbs for 4 weeks after laparoscopic and 6 weeks after open repair of ventral hernia
• Post-operative discomfort is usually mild to moderate. Frequently, patients will require pain medication
• Most patients are able to get back to normal activities in a short period of time. These activities include showering, driving, walking up stairs, lifting, work and sexual intercourse
• Occasionally, patients develop a lump or some swelling in the area where their hernia had been. Frequently this is due to fluid collecting within the previous space of the hernia. Most often this will disappear on its own with time
• Typically, patients call to schedule follow-up appointments within 2-3 weeks after their operation

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

• Persistent fever (over 100°F)
• Bleeding
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Drainage from any incision
• Redness surrounding your incisions
• Unable to urinate
• If you have prolonged soreness and are getting no relief from your prescribed pain medicatio

Laparoscopic Inguinal Hernia Repair

Surgery Overview

nguinal hernia is a bulge that appears in the groin. Surgery is needed to prevent complications including incarceration (a condition in which hernia contents get stuck in the groin) and strangulation (a condition when hernia contents lose blood supply and are at risk of dying). The inguinal hernia repair can be performed using the traditional open method or the new minimally invasive or laparoscopic repair.

Laparoscopic hernia repair is similar to other laparoscopic procedures. General anesthesia is given, and a small incision is made in or just below the navel. The abdomen is inflated with carbon dioxide so the surgeon can see the abdominal organs.

A thin, lighted scope called a laparoscope is inserted through the incision. The instruments to repair the hernia are inserted through another small incision in the lower abdomen. Mesh is then placed over the defect to reinforce the abdominal wall.

What To Expect After Surgery

ost people who have laparoscopic hernia repair surgery are able to go home the same day. Recovery time is about 1 to 2 weeks.

Studies have found people have less pain after laparoscopic hernia repair than after open hernia surgery.

Why It Is Done

ost inguinal hernias are recommended for surgical repair.

Laparoscopic hernia repair is being done as an alternative to open surgery. It may be the preferred option for people who need to return quickly to work or other activities and for those who have hernias on both sides.

Laparoscopic surgery repair may not be appropriate for people who:

• Cannot tolerate general anesthesia
• Have bleeding disorders such as hemophilia or idiopathic thrombocytopenic purpura (ITP)
• Are taking medications to prevent blood clotting (blood thinners or anticoagulants, such as warfarin)
• Have had many abdominal surgeries; scar tissue may make the surgery harder to do through the laparoscope
• Have severe lung diseases such as emphysema; the carbon dioxide used to inflate the abdomen may interfere with their breathing
• Are pregnant
• Are extremely obese

How Well It Works

Laparoscopic surgery has the following advantages over open hernia repair:

• People may prefer laparoscopic hernia repair because it causes less pain and they are able to return to work more quickly than they would after open repair surgery
• Repair of a recurrent hernia after open or laparoscopic surgery often is easier using laparoscopic techniques than open surgery
• It is possible to repair or check for a second hernia on the opposite side at the time of the operation
• Because smaller incisions are used, laparoscopy may be more appealing for cosmetic reasons

Risks

Some people may need special preparation before surgery to decrease the risk of complications. These are people who:

• Have a history of blood clots in large blood vessels (deep vein thrombosis)
• Smoke
• Take blood thinners (such as warfarin, heparin, and enoxaparin)
• Take large doses of aspirin. Aspirin slows blood clotting and may increase the chances of bleeding after surgery
• Have severe urinary problems, such as those caused by an enlarged prostate gland

In addition to risks typically associated with any laparoscopic surgery, risks of laparoscopic inguinal hernia repair include:

• Pain in the cord carrying sperm from the testicle to the penis (spermatic cord), in the testicles, or in the thighs
• Fluid (seromas) or blood (hematomas) in the scrotum, the inguinal canal, or the abdominal muscles
• Inability to urinate (urinary retention) or bladder injury
• Infection from the mesh or stitches
• Scar tissue formation (adhesions)
• Injury to abdominal organs, blood vessels, and nerves
• Numbness in the thigh
• Pain in the thigh (nerve entrapment)
• Injury to the testicle, causing testicular atrophy (rare)
• Recurrence of the hernia (usually related to the mesh applied during surgery being too small to cover the groin area or the mesh not being stapled well). In studies, recurrence rates vary widely; experts suggest that the experience of the surgical team plays an important role in recurrence rates because laparoscopic techniques can be difficult to master. Some studies have shown that up to 6% of hernias repaired with laparoscopic surgery may recur. Large, multicenter studies have found recurrence rates as low as 0.4% to 2%; one study of 1,700 people reported a rate of 0.29% about 5 years after surgery, but this figure reflects the work of one surgical team rather than the many teams in multicenter studies

Laparoscopic inguinal hernia repair is different from open surgery in the following ways:

• A laparoscopic repair requires several small incisions instead of a single larger cut
• If hernias are on both sides, both hernias can be repaired at the same time without the need for a second large incision. Laparoscopic surgery allows the surgeon to examine both groin areas and all sites of hernias for defects. In addition, the patch or mesh can be placed over all possible areas of weakness, helping prevent a hernia from recurring in the same spot or developing in a different spot
• A person must receive general anesthesia for laparoscopic repair, whereas open hernia repair can be done under general, spinal, or local anesthesia

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

• Persistent fever (over 100°F)
• Bleeding
• Increased groin swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Drainage from any incision
• Redness surrounding your incision

Gastroesophageal Reflux Disease (GERD)
(repaired by Laparoscopic Nissen Fundoplication)

www.gerdsurgery.info

f you suffer from "heartburn" and medication has failed to control your symptoms, you could benefit from a minimally invasive or Laparoscopic Anti-Reflux Surgery. Heartburn is medically referred to as gastroesophageal reflux disease (GERD). You will find following information about GERD on this page.

• What is gastroesophageal reflux disease (GERD)?
• Medical and surgical treatment options for GERD
• How is this surgery performed?
• Expected outcomes
• What to expect if you choose to have laparoscopic anti-reflux surgery

What Is Gastroesphageal Reflux Disease (GERD)?

lthough "heartburn" is often used to describe a variety of digestive problems, in medical terms, it is actually a symptom of gastroesophageal reflux disease. In this condition stomach acids reflux, or accidentally "back up", from the stomach into the esophagus. Heartburn is described as a harsh, burning sensation in the area in between your ribs or just below your neck. The feeling may radiate through the chest and into the throat and neck. Many adults in the United States experience this uncomfortable, burning sensation at least once a month. Other symptoms may also include vomiting, difficulty swallowing and chronic coughing or wheezing

What Causes GERD?

hen you eat, food travels from your mouth to your stomach through a tube called the esophagus. At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES). The LES acts like a one-way valve, allowing food to pass through to the stomach. Normally, the LES closes immediately after swallowing to prevent back-up of stomach juices which have a high acid content. GERD occurs when the LES does not function properly allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, causing heartburn and eventually may damage the esophagus.

What Contributes To GERD?

number of people are born with a naturally weak sphincter (LES). For others, however, fatty and spicy foods, certain types of medication, tight clothing, smoking, drinking alcohol, vigorous exercise or changes in body position (bending over or lying down) may cause the LES to relax, causing reflux, or the accidental back-up of acid. A hiatal hernia (a common term for GERD) may be present in many patients who suffer from GERD, but may not cause symptoms of heartburn

Treatment Of GERD?

reatment of GERD generally follows three progressive steps:.

• Life Style Changes: In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing smoking and alcohol consumption, and altering eating and sleeping patterns can also help.
• Drug Therapy: If symptoms persist after these life style changes, drug therapy may be required. Antacids neutralize stomach acids and over-the-counter medications reduce the amount of stomach acid produced. Both may be effective in relieving symptoms. Prescription drugs may be more effective in healing irritation of the esophagus and relieving symptoms.
• Surgery: In many cases, changing diet and taking over-the-counter antacids can reduce how often and how harsh your symptoms are. Losing weight, reducing smoking and alcohol consumption, and altering eating and sleeping patterns can also help.
  
  Patients who do not respond well to lifestyle changes or drug therapy, or who continually require medications to control their symptoms, will have to live with their condition or undergo a surgical procedure. Surgery is very effective in treating GERD. However, in the past, this operation required a large abdominal incision resulting in significant pain after surgery and a recovery period of six weeks or greater.
  
  Since early 1990s, this technique has been modified using laparoscopic (minimally invasive) techniques that avoid the necessity of a large abdominal incision.

How Is Laparoscopic Anti-Reflux Surgery Performed?

aparoscopic anti-reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication) involves reinforcing the "valve" between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus - much the way a bun fits around a hot dog.

In a laparoscopic procedure, surgeons use small incisions (1/4 to 1/2 inch) to enter the abdomen through canulas (narrow tube-like instruments). The laparoscope, which is connected to a tiny video camera, is inserted through the small incision, giving the surgeon a magnified view of the patient's internal organs on a television screen.

The entire operation is performed "inside" after the abdomen is expanded by pumping a harmless gas (CO2) into it.

The Expected Results After Laparoscopic Anti-Reflux Surgery

ccording to recent studies the vast majority of patients who undergo the procedure are either symptom-free or have significant improvement in their GERD symptoms.

The advantage of the laparoscopic approach is that it usually provides:

• Reduced postoperative pain
• Shorter hospital stay
• A faster return to work
• Improved cosmetic result

The Risks Of Laparoscopic Anti-Reflux Surgery?

lthough the operation is considered safe, complications may occur as they may occur with any operation.

Complications during the operation may include:

• Adverse reaction to general anesthesia
• Bleeding
• Injury to the esophagus, spleen or the stomach

Complications after the operation may include:

• Infection of the wound, abdomen, or blood
• Other less common complications may also occur

Conversion to an open procedure

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication. It is sound surgical judgment. Factors that may increase the possibility of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety.

Side Effects of The Operation

ong-term side effects to this procedure are generally uncommon.

Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery. Occasionally, these patients may require a simple procedure to expand the esophagus (endoscopic dilation) or rarely re-operation.

The ability to belch and or vomit may be limited following this procedure. Some patients complain of stomach bloating

Rarely, some patients report no improvement in their symptoms.

What To Expect Before Laparoscopic Anti-Reflux Surgery

o determine if you are a candidate for laparoscopic anti-reflux surgery a thorough medical evaluation by your personal physician is necessary. Some diagnostic tests may be necessary. Your surgeon will discuss with you whether or not this operation may be a benefit to you.

• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery
• After midnight the night before the operation no food or liquids should be taken
• If you take medication on a daily basis, discuss this with our staff as we may want you to take some of your medications on the morning of surgery with a sip of water. If you take aspirin, blood thinners or arthritis medication you need to discuss with our staff the proper timing of discontinuing these medications before your operation. Please inform our office If you take a herbal supplement or a natural medicine, e.g. St John’s Wort, Ginsung, Biloba or Vitamin E. These medications can interfere with anesthesia or cause excessive bleeding and need to be stopped for a week before surgery

What To Expect The Day Of Surgery

• You usually arrive at the hospital the morning of the operation
• A qualified medical staff member will place a small needle/catheter in your vein to dispense medication during surgery
• Often pre-operative medications are necessary
• You will be under general anesthesia - asleep - during the operation which may last several hours
• Following the operation you will be sent to the recovery room until you are fully awake
• Most patients stay in the hospital the night of surgery and may require additional days in the hospital

What To Expect After Surgery

• Patients are encouraged to engage in light activity while at home after surgery
• Post operative pain is generally mild although some patients may require pain medication
• Usually, anti-reflux medication is not required after surgery
• You will need to make the following changes in your diet for the first weeks:
• You will stay on full liquid diet for two to three weeks followed by gradual advance to solid foods
• When you get to solid food, you will need to chew your food well and eat very slowly
• Avoid watching TV and talking during your meals
• Put your knife and fork back on the table after every bite and concentrate on chewing
• Take 20 to 25 minutes to eat your meal
• You will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, work and sexual intercourse
• If you have prolonged soreness and are getting no relief from the prescribed pain medication, you should notify our office. You should call and schedule a follow-up appointment within 2 weeks after your operation

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

• Persistent fever (over 100°F)
• Bleeding
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Difficulty swallowing that doesn't go away within a few weeks
• Drainage from any incision

Esophageal Achalasia
(repaired by Heller Myotomy)

Introduction

sophageal achalasia is a primary esophageal motility disorder of unknown etiology, characterized by absence of esophageal peristalsis and increased or normal resting pressure of the lower esophageal sphincter (LES), which fails to relax completely in response to swallowing.

Clinical Presentation

he most common symptom of Achalasia is difficulty of swallowing or,dysphagia. It is virtually experienced by all patients. Fluid and food moving back from the food pipe (esophagus) towards the throat also called regurgitation is the second most common symptom and is present in about 60% of patients. Regurgitation occurs more often when patients lie down in supine position or on their back. Regurgitation can lead to passage of fluid and food from food pipe into the wind pipe and cause infection or pneumonia. Chest pain occurs in about 40% of patients

Diagnosis

he diagnosis of Achalasia can be difficult. It is made more difficult by the rare nature of the disease. In addition to detailed medical evaluation, physicians use following tests for the diagnosis.

A barium swallow is a test performed in x-ray department. The patient is given a white liquid to drink and x-ray pictures of the food pipe and stomach are taken. It usually shows narrowing at the lower end of the food pipe ("bird beak"), and various degrees of esophageal dilatation.

Endoscopy is important to rule out the presence of a peptic stricture or cancer, and gastroduodenal pathology. Esophageal manometry is the key test for establishing the diagnosis. The classic manometric findings are: (a) absence of esophageal peristalsis, and (b) hypertensive or normotensive LES which fails to relax completely in response to swallowing.

The prolonged pH monitoring may be helpful preoperatively in patients who have previously failed treatment with pneumatic dilatation, Botulinum toxin (Botox), or surgical myotomy, for whom a myotomy is planned. Demonstration of reflux clearly indicates the need for a fundoplication in addition to the myotomy.

In patients older than 60 years of age, with recent onset of dysphagia and excessive weight loss, secondary or pseudo-achalasia should be ruled out. Because a cancer of the gastroesophageal junction is the most common cause of pseudo-achalasia, an endoscopic ultrasound or a CT scan of the gastroesophageal junction can help to establish the diagnosis.

Treatment

reatment is palliative, and it is directed toward elimination of the outflow resistance at the level of the gastroesophageal junction. The following treatment modalities are available to achieve this goal:

• Pneumatic dilatation: has a success rate between 70% and 80%. Gastroesophageal reflux occurs after dilatation in 25% to 35% of patients. Up to 5% of patients may sustain a perforation at the time of a dilatation. These patients may require open surgery to close the perforation and perform a myotomy
• Intrasphincteric injection of botulinum: results in initial relief of symptoms in about 60% patients, but this is transitory and symptoms will return in the majority of patients within a year. Subsequent injections are less effective and the benefit is of briefer duration. In addition, this treatment may cause an inflammatory reaction at the level of the gastroesophageal junction, which obliterates the anatomic planes. Consequently, a myotomy is more difficult, a mucosal perforation occurs more frequently, and the relief of dysphagia is less predictable. Because of these shortcomings, botulinum toxin should be reserved for elderly or high-risk patients who are poor candidates for dilatation or surgery
  
  Traditionally, pneumatic dilatation has been the first line of treatment for esophageal achalasia, while surgery was reserved for patients who had persistent dysphagia after multiple dilatations or who had suffered a perforation during dilatation

Laparoscopic Surgery For Achalasia

oday, minimally invasive surgery has completely changed this treatment algorithm and a laparoscopic Heller myotomy and partial fundoplication is preferred by most gastroenterologists and surgeons as the primary treatment modality. Critical details of the operation include a generous myotomy of the lower esophagus in a longitudinal fashion, extending well onto the gastric wall ( cutting the muscles of the esophagus or food pipe in the lower part of the food pipe all the way to the stomach). This procedure has a very high success rate in relieving the major symptom of achalasia i.e. dysphagia or difficulty swallowing. An anti reflux procedure is added to the operation to reduce the possibility of gastro esophageal reflux or GERD. Patients can usually eat the morning of the first postoperative day, and can be discharged home after one or two days. Surgical treatment of Achalasia provides the longest symptom relief compared to all the other modalities.

The need for esophagectomy (removal of esophagus or food pipe) for achalasia is very uncommon, and is reserved for extremely advanced cases.

All patients undergoing treatment for achalasia should be followed by surveillance endoscopy, because they are at increased risk for development of both squamous and adenocarcinoma.

Risks

spiration of retained food in the esophagus at the time of induction of anesthesia and perforation of the esophageal mucosa are the most common operative complications. Persistent or recurrent dysphagia occurs in 5% to 10% of patients. A complete work-up is necessary to evaluate the cause of the dysphagia in these patients, and either pneumatic dilatation or a second operation can often correct the problem. Up to 15% patients may experience gastroesophageal reflux after myotomy, as measured by 24-hour pH monitoring. In patients undergoing elective myotomy the mortality rate is less than 1%.

Expected Outcomes

bout 90% of patients have long-term relief of dysphagia after a myotomy, with a low incidence of symptomatic acid reflux. Patients should undergo 24-hour pH testing routinely after surgery, as reflux is often asymptomatic, and should be treated with proton pump inhibitors if abnormal acid reflux is present.

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

• Persistent fever (over 100°F)
• Bleeding
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Difficulty swallowing that doesn't go away within a few weeks
• Drainage from any incision

Laparoscopic Colon Resection

What Is The Colon?

he colon is the large intestine; it is the lower part of our digestive tract. The intestine is a long, tubular organ consisting of the small intestine, the colon (large intestine) and the rectum, which is the last part of the colon. After food is swallowed, it begins to be digested in the stomach and then empties into the small intestine, where most of the digestion takes place and the food is absorbed into the body. The remaining contents of the intestine are mostly waste which moves through the colon to the rectum and is expelled from the body during bowel movements. The colon and rectum absorb water and hold the waste until we are ready to expel it.

Open or Traditional Colon Surgery?

ach year, more than 600,000 surgical procedures are performed in the United States to treat a number of colon diseases. Although surgery is not always a cure, it is often the best way to stop the spread of disease and alleviate pain and discomfort.

Patients undergoing colon surgery often face a long and difficult recovery because the traditional "open" procedures are highly invasive. In most cases, surgeons are required to make a long incision. Surgery results in an average hospital stay of a week or more and usually 6 weeks of recovery.

What Is Laparoscopic Colon Resection?

technique known as minimally invasive laparoscopic colon surgery allows surgeons to perform many common colon procedures through small incisions. Depending on the type of procedure, patients may leave the hospital in a few days and return to normal activities more quickly than patients recovering from open surgery.

In most laparoscopic colon resections, surgeons operate through 4 or 5 small openings (each about a quarter inch) while watching an enlarged image of the patient's internal organs on a television monitor. In some cases, one of the small openings may be lengthened to 2 or 3 inches to complete the procedure.

What Are The Advantages Of Laparoscopic Colon Resection?

he results may vary depending upon the type of procedure and patient's overall condition. Common advantages are:

• Less postoperative pain
• May shorten hospital stay
• May result in a faster return to solid-food diet
• May result in a quicker return of bowel function
• Quicker return to normal activity
• Improved cosmetic results

Are You A Candidate For Laparoscopic Colon Resection?

lthough laparoscopic colon resection has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by a surgeon in consultation with your primary care physician to find out if the technique is appropriate for you.

What Preparation Is Required?

Advance Tests...

ost diseases of the colon are diagnosed with one of two tests: a colonoscopy or barium enema. A colonoscope is a soft, bendable tube about the thickness of the index finger which is inserted into the anus and then advanced through the entire large intestine. A barium enema is a special X-ray where a white “milk-shake fluid” is flushed into the rectum and by using mild pressure is pushed throughout the entire large intestine. These tests allow the surgeon to look inside of the colon. Sometimes a CT scan of the abdomen will be necessary. Prior to the operation, other blood tests, electrocardiogram (EKG) or a chest x-ray might be required.

Preparing For Surgery...

• Preoperative preparation includes blood work, medical evaluation, chest x-ray and an EKG depending on your age and medical condition
• After your surgeon reviews with you the potential risks and benefits of the operation, you will need to provide written consent for surgery
• Blood transfusion and/or blood products may be needed depending on your condition
• It is recommended that you shower the night before or morning of the operation
• The rectum and colon must be completely empty before surgery. Usually, the patient must drink a special cleansing solution. You may be on several days of clear liquids, laxatives and enemas prior to the operation
• Antibiotics by mouth are commonly prescribed. Your surgeon or his staff will give you instructions regarding the cleansing routine to be used
• Follow your surgeon's instructions carefully. If you are unable to take the preparation or the antibiotics, contact your surgeon
• If you do not complete the preparation, it may be unsafe to undergo the surgery and it may have to be rescheduled
• After midnight the night before the operation, you should not eat or drink anything except medications that your surgeon has told you are permissible to take with a sip of water the morning of surgery
• Drugs such as aspirin, blood thinners, anti-inflammatory medications (arthritis medications) and Vitamin E will need to be stopped temporarily for several days to a week prior to surgery
• Diet medication or natural or herbal supplements like St. John’s Wort, ginsung, biloba and similar medications should not be used for the two weeks prior to surgery
• Quit smoking for at least 2 weeks and arrange for any help you may need at home

How Is Laparoscopic Colon Resection Performed?

he term "Laparoscopic" surgery describes the techniques a surgeon uses to gain access to the internal surgery site.

Most laparoscopic colon procedures start the same way. Using a cannula (a narrow tube-like instrument), the surgeon enters the abdomen. A laparoscope (a tiny telescope connected to a video camera) is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a television monitor. Several other cannulas are inserted to allow the surgeon to work inside and remove part of the colon. The entire procedure may be completed through the cannulas or by lengthening one of the small cannula incisions.

What Happens If The Surgery Cannot Be Performed Or Completed By The Laparoscopic Method?

n a number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the "open" procedure may include:

• Obesity
• A history of prior abdominal surgery causing dense scar tissue
• Inability to visualize organs
• Bleeding problems during the operation
• Large tumors

The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

What Should I Expect After Surgery

fter the operation, it is important to follow your doctor's instructions. Although many people feel better in a few days, remember that your body needs time to heal.

• You are encouraged to be out of bed the day after surgery and to walk. This will help diminish the soreness in your muscles
• You will probably be able to get back to most of your normal activities in one to two weeks time. These activities include showering, driving, walking up stairs, working and engaging in sexual intercourse
• Call and schedule a follow-up appointment within 2 weeks after your operation

What Complications Can Occur?

hese complications include:

• Bleeding
• Infection
• A leak where the colon was connected back together
• Injury to adjacent organs such as the small intestine, ureter, or bladder
• Blood clots to the lungs

It is important for you to recognize the early signs of possible complications. Contact your surgeon if you notice severe abdominal pain, fevers, chills, or rectal bleeding.

When To Call Our Office?

f you develop any of the following, be sure to call our office at (814) 877-6997

• Persistent fever (over 100°F)
• Bleeding from the rectum
• Increased abdominal swelling or pain
• Persistent nausea or vomiting
• Chills
• Persistent cough or shortness of breath
• Redness surrounding any of your incisions that is worsening or getting bigger
• Purulent drainage (pus) from any incision
• You are unable to eat or drink liquids