Angioplasty and stent placement:

Angioplasty is a procedure to open narrowed or blocked blood vessels that supply blood to the heart. These blood vessels are called the coronary arteries.

A coronary artery stent is a small, metal mesh tube that expands inside a coronary artery. A stent is often placed during or immediately after angioplasty. It helps prevent the artery from closing up again. A drug-eluting stent has medicine embedded in it that helps prevent the artery from closing in the long term.
Balloon angioplasty – short segmentWatch this video about:
Balloon angioplasty – short segment
Description

Before the angioplasty procedure begins, you will receive some pain medicine. You may also be given medicine that relaxes you, and blood thinning medicines to prevent a blood clot from forming.

You will lie on a padded table. Your doctor will insert a flexible tube (catheter) through a surgical cut into an artery. Sometimes the catheter will be placed in your arm or wrist, or in your upper leg or groin area. You will be awake during the procedure.

The doctor will use live x-ray pictures to carefully guide the catheter up into your heart and arteries. Dye will be injected into your body to highlight blood flow through the arteries. This helps the doctor see any blockages in the blood vessels that lead to your heart.

A guide wire is moved into and across the blockage. A balloon catheter is pushed over the guide wire and into the blockage. The balloon on the end is blown up (inflated). This opens the blocked vessel and restores proper blood flow to the heart.

A wire mesh tube (stent) may then be placed in this blocked area. The stent is inserted along with the balloon catheter. It expands when the balloon is inflated. The stent is left there to help keep the artery open.
Coronary artery stent

The stent may be coated with a drug (called a drug-eluting stent). This type of stent may lower the chance of the artery closing back up in the future. Currently, drug-eluting stents are used only for certain patients.
Why the Procedure is Performed

Arteries can become narrowed or blocked by deposits called plaque. Plaque is made up of fat and cholesterol that builds up on the inside of artery walls. This condition is called atherosclerosis.

Angioplasty may be used to treat:

Blockage in a coronary artery during or after a heart attack
Blockage or narrowing of one or more coronary arteries that puts you at risk for a heart attack
Narrowings that reduce blood flow and cause persistent chest pain (angina) that medicines do not control

Not every blockage can be treated with angioplasty. Some patients who have several blockages or blockages in certain locations may need coronary bypass surgery.
Risks

Angioplasty is generally safe, but ask your doctor about the possible complications. Risks of angioplasty and stent placement are:

Allergic reaction to the drug used in a drug-eluting stent, the stent material, or the x-ray dye
Bleeding or clotting in the area where the catheter was inserted
Blood clot
Clogging of the inside of the stent (in-stent restenosis)
Damage to a heart valve or blood vessel
Heart attack
Kidney failure (higher risk in people who already have kidney problems)
Irregular heartbeat (arrhythmias)
Stroke (this is rare)

Before the Procedure

Angioplasty is often performed when you go to the hospital or emergency room for chest pain, or after a heart attack. If you are admitted to the hospital for angioplasty:

Tell your doctor what drugs you are taking, even drugs or herbs you bought without a prescription.
You will usually be asked not to drink or eat anything for 6 to 8 hours before the test.
Take the drugs your doctor told you to take with a small sip of water.
Tell your doctor if you are allergic to seafood, you have had a bad reaction to contrast material or iodine in the past, you are taking Viagra, or you are or might be pregnant.

After the Procedure

The average hospital stay is 2 days or less. Some people may not even have to stay overnight in the hospital.

In general, people who have angioplasty are able to walk around within 6 hours after the procedure. Complete recovery takes a week or less. You will be given information about how to care for yourself after angioplasty.
Outlook (Prognosis)

For most people, angioplasty greatly improves blood flow through the coronary artery and the heart. It may help you avoid the need for coronary artery bypass surgery (CABG).

Angioplasty does not cure the cause of the blockage in your arteries. Your arteries may become narrow again.

Follow your heart-healthy diet, exercise, stop smoking (if you smoke), and reduce stress to lower your chances of having another blocked artery. Your health care provider may prescribe medicine to help lower your cholesterol.
Alternative Names

PCI; Percutaneous coronary intervention; Balloon angioplasty; Coronary angioplasty; Coronary artery angioplasty; Percutaneous transluminal coronary angioplasty; Heart artery dilatation

Coronary artery bypass graft

A coronary artery bypass graft (CABG) is a surgical procedure used to treat coronary heart disease.It diverts blood around narrowed or clogged parts of the major arteries (blood vessels), to improve blood flow and oxygen supply to the heart.

Risk factors for coronary heart disease include:

Older age
Smoking
Obesity
A high-fat diet

The procedure

CABG involves taking a blood vessel from another part of the body, usually the chest or leg, and attaching it to the coronary artery above and below the narrowed area or blockage. This new blood vessel is known as a graft.The graft diverts the flow of blood around the part of the coronary artery that is narrowed or blocked

Preparing before the procedure

Before surgery, you will attend a pre-admission clinic, where you will be seen by a member of the team who will be looking after you in Manipal hospital.

At this clinic, you will have a physical examination and be asked for details of your medical history. Any investigations and tests that you need will be arranged. This is a good time to ask questions about the procedure, but feel free to discuss any concerns you might have at any time.
You will be asked:

Whether you are taking any tablets or other types of medication; it helps if you bring details with you of anything you are taking (for example, bring the packaging with you)
About previous anaesthetics you have had, and whether you had any problems with these (such as nausea)
Whether you are allergic to anything

They will also want to know about your teeth, for example, whether you wear dentures or have caps or a plate.
You will be advised to stop smoking. This is because smoking increases your chances of a serious chest infection and slows down the time your wounds will take to heal. Smoking can also increase your risk of blood clots.

Because the procedure is performed using a general anaesthetic (you are put to sleep), you must not eat or drink for at least six hours before the operation. You may be able to have occasional sips of water until two hours before the operation.

Postoperative care

For the first day or two after your operation, you will be in an intensive treatment unit so the medical staff can check your progress regularly.

You will be given painkillers and you should tell your doctor or nurse if the pain increases or if you loose a lot of blood.Recovery after your coronary artery bypass graft (CABG) will take time. It’s likely you will feel groggy and disoriented after the procedure.

Everyone recovers at slightly different speeds. As a rule of thumb, you should be able to sit in a chair after one day, walk after three days and walk upstairs after five or six days.Your stay in hospital will usually be around seven days. It may be longer if the doctors wish to monitor your condition more closely.

Normally, you’d expect to make a full recovery within 12 weeks. However, if you experience complications during or after the surgery, your recovery time is likely to be longer.
Someone from the cardiac rehabilitation team or physiotherapy department will discuss your rehabilitation with you before you go home. They will be able to advise you on the best ways to get back to full health.

At home

To ease any soreness where the cut was made, you may need to continue taking painkillers at home.
For the first three-to-six weeks, you will probably feel tired. By six weeks, you should be able to do most of the things you want to. By three months, you are likely to have regained full health.

Caring for your wound

Care for your chest wound by keeping it clean and free from infection. Make sure you protect it from the sun.You will have a scar where the surgeon cut down your breastbone. This is red at first, but will gradually fade over time.
Recovery

The recovery time after aortic valve replacement surgery varies from person to person and will depend on:

Your age
Your overall health and fitness
How well you were before the operation

Success

After your coronary artery bypass graft (CABG), you should feel relief from most of your symptoms, such as chest pain.

Research has shown that 83% of people are free of heart-related symptoms for five years, and 63% for 10 years after the procedure.
CABG is not a cure for coronary artery disease. To get the most out of the procedure, try to live a healthy lifestyle and make sure you take any prescribed medication as directed by your GP.

Cardiac catheterisation is an invasive diagnostic procedure that provides important information about the structure and function of the heart.

It usually involves taking X-ray pictures of the heart’s arteries (coronary arteries) using a technique called coronary angiography or arteriography. The resulting images are known as coronary angiograms or arteriograms.

Need of coronary angiography

Coronary angiography can be used to help diagnose heart conditions, help plan future treatments and carry out certain procedures. For example, it may be used:

after a heart attack – where the heart’s blood supply is blocked
to help diagnose angina – where pain in the chest is caused by a restricted blood supply to the heart
to plan interventional or surgical procedures – such as a coronary angioplasty, where narrowed or blocked blood vessels are widened

Coronary angiography is also considered to be the best method of diagnosing coronary heart disease
Procedure

During the procedure, a long, thin and flexible tube called a catheter is inserted into a blood vessel in your groin or arm. Using X-ray images as a guide, the tip of the catheter is passed up to the heart and coronary arteries.

A special type of dye called contrast medium is injected into the catheter and X-ray images (angiograms) are taken.
The procedure is usually carried out under local anaesthetic, so you will be awake while the procedure is carried out, but the area where the catheter is inserted will be numbed.
Before the procedure

Before the procedure is carried out, you should tell your cardiologist at Manipal if you have any allergies and if you are taking any medication, either for a heart problem or another medical condition.

You will be told whether to continue taking your medication or if you need to stop. You should not stop taking prescribed medication unless you are advised to do so. You will also be asked not to eat or drink anything for a few hours before the procedure.
Post operative care

You should be able to sit up straight away and you may be able to walk around soon afterwards if the catheter was inserted into your arm.
Going home

Most people are able to go home on the same day the procedure is carried out, although you will need to arrange a lift home from a family member or friend.You should also make sure that someone stays with you overnight in case you experience any problems.
Recovery

You will be advised about things to do or avoid during your recovery before leaving Manipal hospital. Examples of advice you may be given include:

Avoid having a bath for a day or two. You can still take a shower, but try to keep the wound as dry as possible.
Do not drive until advised that it is safe to do so, which may not be for up to three days.
Avoid playing sport, excessive activity or lifting anything heavy for about two days.

Risks and Success rate

Cardiac catheterisation and coronary angiography are generally considered to be safe procedures. However, as with all medical procedures, there are some associated risks.The main risks of coronary angiography include:

bleeding under the skin at the wound site (haematoma)
bruising
allergy to the contrast dye used

Serious complications

In very rare cases, more serious complications of coronary angiography can occur. These include:

damage to the artery in the arm or groin in which the catheter was inserted
heart attack
stroke
damage to the kidneys caused by the contrast dye
tissue damage caused by X-ray radiation if the procedure is prolonged
death

The risk of a serious complication occurring is estimated to be less than 1 in 1,000. People with serious underlying heart problems are most at risk.

Laparoscopic Gastric Banding Surgery
Laparoscopic gastric banding surgery is usually performed through small incisions in the tummy using a camera. This minimally invasive surgical technique results in less discomfort and time off than traditional abdominal surgery. During the 60-90 minute procedure, a band, much like a wristwatch, is fastened around the upper stomach to create a small pouch which restricts the amount of food that can be consumed. In addition to the band, an access port, connected by tubing, is placed in the abdomen wall. This port allows for the size of the band to be increased or decreased with saline. The procedure does not involve cutting or stapling of the stomach or intestines, providing the option to reverse the treatment.
Laparoscopic adjustable gastric band, popularly known as ” lap band ” The procedure entails placing an inflatable silicone device or band around the top portion of the stomach, which reduces the capacity of the stomach, resulting in lesser food intake and thus promoting weight loss . Laparoscopic adjustable gastric banding leads to loss of about 40% of excess weight, on average . The procedure helps with weight loss by restricting the amount of food the stomach can hold. The best part of the procedure is that it is reversible and adjustable. Since a small pouch in the upper part of the stomach is created with a stoma which is adjustable and controllable, the doctor is able to regulate the rate of weight loss according to the patients’ requirements. Gastric banding is considered the least invasive weight loss surgery. It is also the safest. The procedure can be reversed if necessary, and in time, the stomach generally returns to its normal size.
Another very important characteristic of this surgery is that, it is minimally invasive procedure of its kind. The process usually requires a shorter stay at the hospital, has a quicker recovery process, lesser scars and marks, and lesser pain as compared to other bariatric surgery procedures.

Cost Estimate for Laparoscopic Gastric Banding Surgery at World Class Hospital in India – $8200 US Dollars. Cost Estimate for above include stay in a Private Room for 3 days at the hospital, where a Companion can stay with the patient surgeon fee, medicines and consumables, nursing care, food and Airport Pick & Drop. More accurate treatment cost estimates can be provided if medical reports are emailed to us or after the patient is examined by doctors after arrival athospital in Indiaand medical tests are done after admission.

Bariatric Surgery
(Severe Obesity)

*Bariatric surgery is a safe and effective treatment option for those affected by severe obesity. Moreover, these same procedures have also been recognized for their impact on metabolic or hormonal changes that play a major role in hunger (the desire to start eating) and satiety (the desire to stop eating) as well as improvement and/or resolution of conditions that can occur as a result of severe obesity. Bariatric surgery is a recognized and accepted approach for both weight-loss and many of the conditions that occur as a result of severe obesity; however, not all people affected by severe obesity will qualify for bariatric surgery. There are certain criteria that a person must meet in order to be a candidate for bariatric surgery.

*Please Note: It is important to note that there are risks involved with bariatric surgery, as well as any other surgical procedure. Before making a treatment decision, it is important to discuss these risks with your primary care provider and/or surgeon. The OAC also encourages individuals to discuss these risks with their family members. To maintain consistency throughout our materials, total body weight-loss is used when comparing all surgical treatment options. You may encounter other post-surgery materials that report/discuss weight-loss as “excess body weight.” For accuracy, be sure to ask your provider what method they’re reporting when discussing surgical options for weight-loss.

Indications:
At the 1991 National Institutes of Health (NIH) Consensus Conference, bariatric surgery was considered an accepted and effective approach that provides consistent, durable weight-loss for individuals affected by severe obesity. Furthermore, the NIH identified several criteria for candidacy for bariatric surgery, including:

Body Mass Index (BMI) = a number calculated based on a person’s height and weight:
BMI >40, Severe obesity (or weighing more than 100 pounds over ideal body weight)
BMI 35-40 with significant obesity-related conditions (type 2 diabetes, high blood pressure, sleep apnea or high cholesterol)
No endocrine causes of obesity
Acceptable operative risk
Understands surgery and risks
Absence of drug or alcohol problem
No uncontrolled psychological conditions
Failed attempts at medical weight-loss (diets, other weight-loss options)

Consult with your primary care provider (PCP) and insurance provider to see if you are a candidate.

Benefits:
Within two to three years after the operation, bariatric surgery usually results in a weight-loss of 10 to 35 percent of total body weight, depending on the chosen procedure. Those considering bariatric surgery should talk to their PCP about what their personal expectations should be for loss of excess weight. In addition, co-morbidities, such as diabetes, high blood pressure, sleep apnea and others are often reduced or may go into remission. Most will find they require fewer medicines throughout time and many will discontinue their medicines completely.

Risks:
Research indicates that some patients who undergo bariatric surgery may have unsatisfac­tory weight-loss or regain much of the weight that they lost. Some behaviors such as frequent snacking on high-calorie foods or lack of exercise can contrib­ute to inadequate weight-loss. Technical problems that may occur after the operation, like separated stitches, may also contribute to inadequate weight-loss. There are also other potential complications that may occur which have been listed below with each of the various procedures.

Remember, bariatric surgery is not the “easy way out.” This treatment option is a tool that patients use to lose weight. Surgery is a resource to help reduce weight and maintain weight-loss. Lifestyle adjustments encompassing behavioral, diet, physical activity and psychological changes are required for you to maintain a healthy quality of life. Continued positive weight-loss relies upon your desire and dedication to change your lifestyle with a proactive approach.

Throughout this section, you will see terms, such as “metabolic,“ “non-metabolic,” “laparoscopic” and “open,” in which you may not be familiar. Prior to reading about the different surgeries, we have provided you with a brief description of some of the most commonly used terms when talking about bariatric surgery.

Open vs. Laparoscopic Procedures

In each section, you will see the surgeries described as being performed “open” or “laparoscopic.” Although the laparoscopic procedure has increasingly gained in popularity and frequency, open procedures are still used in practice today. The approach will depend on several factors, including surgeon experience as well as your surgical and medical history, which may influence one approach to be used over the other. Please be sure to discuss the surgical approach with your surgeon.

“Open” – The open procedure involves a single incision that opens the abdomen, which provides the surgeon access to the abdominal cavity. The incision can vary in length from as little as three inches to as large as six or more inches.

“Laparoscopic” – In laparoscopic surgery, a small video camera is inserted into the abdomen allowing the surgeon to conduct and view the procedure on a video monitor. Both camera and surgical instruments are inserted through small incisions made in the abdominal wall. The number of incisions will vary depending on the surgical procedure and surgeon experience. Some surgical procedures can be performed via a single incision while other procedures may involve six or more small incisions.

Metabolic vs. Non-metabolic

The operations in this group help patients lose weight by altering their gastrointestinal tracts. Examples include the vertical sleeve gastrectomy (VSG), Roux-en-Y gastric bypass (RNYGB), and the biliopancreatic diversion with duodenal switch (BPD/DS).

“Metabolic Operations” – The operations in this group help patient lose weight by altering their gastrointestinal tracts. By doing this, it changes the patient’s physiological response to fat loss. After metabolic surgery, there is a change in the way that gut hormones are secreted. The result is that after surgery, in the face of fat loss, patients don’t have to fight their hunger which is helpful when attempting to lose weight.

Recent research indicates that each bariatric surgery works not only through the anatomical and mechanical changes from the procedure itself, but through metabolic changes in the “gut hormones.” Numerous studies have examined pre-operative and post-operative gut hormone levels after bariatric surgery. A brief summary of hormonal changes after each bariatric procedure is provided in the next sections. Some of these hormones are:

Ghrelin: functions primarily to stimulate appetite
Glucagon-like peptide 1 (GLP-1): mechanism of action includes increased satiety and reduced stomach emptying
Peptide YY (PYY): reduces appetite and increases efficiency of digestion and nutrient absorption

“Non-metabolic Operations” – The options in this group provide significant weight-loss without altering the physiology of energy (fat) storage. Examples include the laparoscopic adjustable gastric bands (LapBand® and the Realize Band®) and Neuromodulation (VBLOC®). They are considered non-metabolic options because they do not alter the body’s normal mechanisms that occur when dieting. With bandings and with dieting, orexigenic hormones increase and anorexigenic hormones decrease.

What is a laparoscopic sleeve gastrectomy?
It is an operation to convert the stomach into a long thin tube. This is done by stapling it along its length and then removing the excess. It is performed for helping very overweight patients achieve substantial weight loss because it restricts the amount that someone can eat.

It may be used as a stand-alone operation or the first part of a two stage operation for very large patients. The second stage is carried out a number of months later when the patient has lost a significant amount of weight. This means that the risks of needing further surgical procedures are much less.

What does laparoscopic mean?
The operation is carried out laparoscopically, which is also known as keyhole surgery. This means that the surgeon makes five small incisions (cuts) in the abdomen (belly) to get to the stomach. The surgeon may decide to convert to an open procedure (the traditional way of carrying out this operation through a longer incision) if they think it would be safer.

What does the operation involve?

The operation takes up to two hours. For some patients, the surgery can be technically difficult depending on body-build or previous surgery. In these circumstances the operation can take longer.

Laparoscopic Sleeve Gasterectomy Surgery in India Cost Hospital

How Is Sleeve Gastrectomy Performed?
We perform the Sleeve Gastrectomy as a laparoscopic procedure. This involves making five or six small incisions in the abdomen and performing the procedure using a video camera (laparoscope) and long instruments that are placed through these small incisions.

During the Laparoscopic Sleeve Gastrectomy, about 75% of the stomach is removed leaving a narrow gastric “tube” or “sleeve”. No intestines are removed or bypassed during the sleeve gastrectomy.The LSG takes one to two hours to complete.

How Does Sleeve Gastrectomy Cause Weight Loss?
Sleeve Gastrectomy is a restrictive procedure. It greatly reduces the size of your stomach and limits the amount of food that can be eaten at one time. It does not cause decreased absorption of nutrients or bypass your intestines. After eating a small amount of food, you will feel full very quickly and continue to feel full for several hours.

Sleeve Gastrectomy may also cause a decrease in appetite. In addition to reducing the size of the stomach, Sleeve Gastrectomy may reduce the amount of “hunger hormone” produced by the stomach which may contribute to weight loss after this procedure.

Laparoscopic Sleeve Gasterectomy Surgery in India Cost Hospital

Who Do We Offer Laparoscopic Sleeve Gastrectomy?
This procedure is primarily used as part of a staged approach to surgical weight loss. Patients who have a very high body mass index (BMI) or who are at risk for undergoing anesthesia or a longer procedure due to heart or lung problems may benefit from this staged approach. Sometimes the decision to proceed with a two-stage approach is made before surgery due to these known risk factors. In other patients, the decision to perform sleeve gastrectomy (instead of gastric bypass) is made during the operation. Reasons for making this decision intraoperatively include an excessively large liver or extensive scar tissue that would make the gastric bypass procedure too long or unsafe.

In patients who undergo LSG as a first stage procedure, the second stage (gastric bypass) is performed 12 to 18 months later after significant weight loss has occurred and the risk of anesthesia is much lower (and the liver has decreased in size). Though this approach involves two procedures, we believe it is safe and effective for selected patients.

Laparoscopic Sleeve Gastrectomy can also be used as a primary procedure. There is relatively little data regarding the use of LSG as a stand-alone procedure in patients with lower BMI’s and it should be considered an investigational procedure in this patient group. We are offering this procedure to diabetic patients with a BMI between 30 and 40 as a part of a clinical trial that will better define the short and long-term benefits of LSG in this group of patients.

What Are The Risks Of Laparoscopic Sleeve Gastrectomy?
There are risks that are common to any laparoscopic procedure such as bleeding, infection, injury to other organs, or the need to convert to an open procedure. There is also a small risk of a leak from the staple line used to divide the stomach. These problems are rare and major complications occur less than 1% of the time.

Overall, the operative risks associated with LSG are slightly higher than those seen with the laparoscopic adjustable band but lower than the risks associated with gastric bypass.

What Are The benefits Of Laparoscopic Sleeve Gastrectomy?
Depending on their pre-operative weight, patients can expect to lose between 40% to 70% of their excess body weight in the first year after surgery.

Many obesity-related comorbidities improve or resolve after bariatric surgery. Diabetes, hypertension, obstructive sleep apnea and abnormal cholesterol levels are improved or cured in more than 75% of patients undergoing LSG. Though long-term studies are not yet available, the weight loss that occurs after LSG results in dramatic improvement in these medical conditions in the first year after surgery.

Is Laparoscopic Sleeve Gastrectomy A Good Choice For Me?
Your surgeon may talk to you about LSG as an option if you have a BMI over 60 or significant medical problems that increase your risk for undergoing anesthesia or gastric bypass. Laparoscopic Sleeve Gastrectomy may also be offered as part of a clinical investigation if you have a lower BMI and diabetes.

VARICOSE VEINS SURGERY

INTRODUCTION:
The description of varicose veins as a clinical entity can be traced back as early as the fifth century BC. Forefathers of medicine including Hippocrates and Galen described the disease and treatment modalities, which are still used today. Throughout the centuries, surgical treatments have evolved from large, open surgeries to minimally invasive approaches. Varicose veins represent a significant clinical problem and are not just a “cosmetic” issue because of their unsightly nature. The problem arises from the fact that varicose veins actually represent underlying chronic venous insufficiency with ensuing venous hypertension. This venous hypertension leads to a broad spectrum of clinical manifestations, ranging from symptoms to cutaneous findings like varicose veins, reticular veins, telangiectasias, swelling, skin discoloration, and ulcerations.
DEFINITION:
When veins become abnormally thick, full of twists and turns, or enlarged, they are called varicose veins. Generally, the veins in the legs and thighs have a tendency to become varicosed.
INDIAN INCIDENCE
In India, the incidence of varicose veins is reportedly less than in the Western countries. This could be genuinely less or underreported as culturally the society does not permit exposure of legs and therefore it may not be bothering many people.
INDICATIONS:
Surgical removal or obliteration of varicose veins is often for cosmetic reasons alone. Noncosmetic indications include symptomatic varicosities (e.g., pain, fatigability, heaviness, recurrent superficial thrombophlebitis, bleeding), or for the treatment of venous hypertension after skin or subcutaneous tissue changes, such as lipodermatosclerosis, atrophie blanche, ulceration, or hyperpigmentation, have developed.
Conservative treatment with stockings and external compression is an acceptable alternative to surgery, but worsening cutaneous findings or symptoms despite these measure usually warrant intervention. Nonetheless, a patient’s desire for surgical management over conservative treatment or for cosmetic purposes alone are both reasonable relative indications for surgery.
TESTS FOR REFLUX
Trendelenburg test: This physical examination technique distinguish patients with reflux at the SFJ from those with incompetent deep venous valves. The leg is elevated until the congested superficial veins have all collapsed. Direct pressure is used to occlude the GSV just below the SFJ. The patient stands with the occlusion still in place. If the distal superficial varicosities remains empty or fills very slowly, the
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principal entry point of high pressure into the superficial system is at the SFJ. Rapid filling despite manual occlusion means that some other reflux pathway is involved.
Doppler auscultation: A Doppler transducer is positioned along the axis of a vein with the probe at an angle of 45° to the skin. When the distal vein is compressed, audible forward flow exists. If the valves are competent, no audible backward flow is heard with the release of compression. If the valves are incompetent, an audible backflow exists. These compression-decompression maneuvers are repeated while gradually ascending the limb to a level at which the reflux can no longer be appreciated.
Venous refilling time (VRT): This is a physiologic test, again using plethysmography. The VRT is the time necessary for the lower leg to become infused with blood after the calf-muscle pump has emptied the lower leg as thoroughly as possible. In healthy subjects, venous refilling is greater than 120 seconds. In patients with mild and asymptomatic venous insufficiency, VRT is between 40 and 120 seconds. In patients with significant venous insufficiency, VRT is abnormally fast at 20-40 seconds. Such patients often complain of nocturnal leg cramps, restless legs, leg soreness, burning leg pain, and premature leg fatigue. A VRT of less than 20 seconds is markedly abnormal, and is nearly always symptomatic. If the VRT is less than 10 seconds, venous ulcerations are likely.
Duplex US with color-flow imaging (sometimes called triplex ultrasound): This is a special type of 2-dimensional ultrasound that uses Doppler-flow information to add color for blood flow in the image. Vessels in the blood are colored red for flow in one direction and blue for flow in the other, with a graduated color scale to reflect the speed of the flow. Venous valvular reflux is defined as regurgitant flow with Valsalva that lasts great than 2 seconds.
INVESTIGATIONS:
 Haemogram
 Blood sugar
 Serum creatinine
 Bleeding time, clotting time and prothrombin time
 Xray chest
 ECG
 Doppler of lower limb venous system to rule out any DVT
RELEVANT ANATOMY
The greater saphenous vein (GSV) originates on the medial foot as part of the venous arch and receives tributaries from deep veins of the foot as it courses upward along the anterior aspect of the medial malleolus. From the ankle, the GSV continues along the anteromedial aspect of the calf to the knee and into the thigh, where it is found more medially. From the upper calf to the groin, the GSV is usually contained within an envelope of thin fascia. Visualization of this fascial envelope is an important way of identifying the GSV with duplex ultrasound. This fascial envelope often prevents the GSV from becoming significantly dilated, even when large volumes of reflux pass along its entire length. A normal GSV is typically 3-4 mm in diameter in the mid thigh.
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Along its course, a variable number of named perforating veins may connect the GSV to the deep system at the femoral, posterior tibial, gastrocnemius, and soleal veins. The Cockett perforators, between the ankle and the knee, are a special group of perforating veins. Rather than directly connecting the superficial to deep venous systems, they connect the subfascial deep system with the posterior arch vein, which then empties into the GSV.
Besides perforating veins, the GSV has numerous superficial tributaries as it passes through the thigh. The most important of these are the posteromedial and anterolateral thigh veins, found at the level of the mid thigh, and the anterior and posterior accessory saphenous veins at the level of the canal of Hunter in the upper thigh, where a perforating vein often connects the GSV to the femoral vein. Just below the SFJ, the GSV receives several additional important tributary veins. These include the lateral and medial femoral cutaneous branches, the external circumflex iliac vein, the superficial epigastric vein, and the internal pudendal vein. These tributaries are frequently involved in the reflux that leads to the appearance of surface varicose veins on the lower thigh or upper calf.
The termination point of the GSV into the common femoral vein is called the saphenofemoral junction in the English literature but is known as the crosse (i.e., shepherd’s crook) in the French medical literature. The terminal valve of the GSV is located within the junction itself. In most cases, at least one additional subterminal valve is present within the first few centimeters of the GSV. Most patients have a single subterminal valve that can be readily identified approximately 1 cm distal to the junctional valve.
Reflux at or near the SFJ does not always come through the terminal valve of the GSV, nor does it always involve the entire trunk of the GSV. Reflux can enter the GSV below the subterminal valve or even immediately below the junction, passing through a failed subterminal valve to mimic true SFJ incompetence. Reflux can also pass directly into any of the other veins that join the GSV at that level, or it may pass a few centimeters along the GSV and then abandon the GSV for another branch vessel.
When a perforating vein is the primary site of reflux, dilatation of the vessel proceeds both proximally and distally. When dilatation reaches the most proximal portion of the vein, the saphenofemoral or saphenopopliteal junction is often recruited as a secondary point of reflux. Although most large varices are tributaries off of an incompetent GSV or SSV, failed perforating veins or connecting veins can also give rise to independent varices in the greater saphenous distribution without involving the saphenous system itself. Identifying the originating point and the primary pathway of reflux in the thigh is often difficult, which is why duplex ultrasound has become so helpful in varicose vein workup.
OPERATIVE TECHNIQUES:
1. Safenofemoral ligation with long saphenous vein removal for long saphenous vein varicosities. Surgical removal of the GSV has evolved from large open incisions to less invasive stripping. Original methods of stripping used different devices and variations of techniques. The Mayo stripper was an extraluminal ring that cut the tributaries as it was passes along the vein. The Babcock device was an intraluminal stripper with an acorn-shaped head that pleated up the vein
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as it pulled the vessel loose from its attachments. The Keller device was an internal wire used to pull the vein through itself, as is done today with perforation-invagination (PIN) strippers.
Currently, the technique of PIN stripping begins with a 2- to 3-cm incision made at the groin crease. The femoral vein and SFJ are exposed with dissection and all tributaries of the SFJ must be identified and flush-ligated to minimize the incidence of reflux recurrence.
After ligation and division of the junction, the stripping instrument (usually a stiff but flexible length of wire or plastic) is passed into the GSV at the groin and threaded through the incompetent vein distally to the level of the upper calf. The stripper is brought out through a small incision (5 mm or smaller) approximately 1 cm from the tibial tuberosity at the knee. An inverting head is attached to the stripper at the groin and is secured to the proximal end of the vein. The vessel is then inverted into itself, tearing away from each tributary and perforator as the stripper is pulled downward through the leg and out through the incision in the upper calf. If desired, a long epinephrine-soaked gauze or ligature may be secured to the stripper before invagination, allowing hemostatic packing to be pulled into place after stripping is complete.
An older technique of stripping to the ankle (rather than to just the knee) has fallen into disfavor because of a high incidence of complications, including damage to the saphenous nerve, which is closely associated with the vein below the knee
2. Subfacial ligation with below knee removal of long saphenous vein for below knee varicosities associated with incompetent perforators.
3. Removal of the short saphenous vein is complicated by variable local anatomy and risk of injury to the popliteal vein and peroneal nerve. The saphenopopliteal junction must be located by duplex examination before beginning the dissection, and adequate direct visualization of the junction is essential. After ligation and division of the junction, the stripping instrument (often a more rigid stripper that facilitates navigation) is passed downward into the distal calf, where it is brought out through a small incision (2-4 mm). The stripper is secured to the proximal end of the vein, which is invaginated into itself as it is pulled downward from knee to ankle and withdrawn from below.
4. Stab phlebectomy (or ambulatory phlebectomy)
Performed by Galen as early as the second century, this procedure came back into modern favor during the 1960s and has increased in popularity ever since. This procedure is extremely useful for the treatment of residual vein clusters after saphenectomy and for removal of nontruncal tributaries when the saphenous vein is competent. Ambulatory phlebectomy is a treatment for superficial varicose veins. The procedure involves the removal of the varicose veins through small 2–3 mm incisions in the skin overlying the veins. The procedure may be performed in hospital or outpatient settings. The procedure may be performed with tumescent local anesthesia, such as with lignocaine.
70
A microincision is made over the vessel using a tiny blade or a large needle, a phlebectomy hook is introduced into the microincision, and the vein is delivered through the incision. With traction, as long a segment as possible is pulled out of the body until the vein breaks or cannot be pulled any further. Another microincision is made and the process is begun again and repeated along the entire length of the vein to be extracted. Short segments of veins can be removed through tiny incisions without ligatures, and skin closure is not necessary.
NEWER METHODS
1. Endovenous laser
2. Radiofrequency ablation
3. Sclerotherapy
4. Cutaneous electrodesiccation
5. Subfascial endoscopic perforating vein surgery
POST SURGERY INSTRUCTIONS
After treatment of large varicose veins by any method, a 30- to 40-mm Hg gradient compression stocking is applied and patients are instructed to maintain or increase their normal activity levels. Most practitioners also recommend the use of gradient compression stockings even after treatment of spider veins and smaller tributary veins.
Activity is particularly important after treatment by any technique because all modalities of treatment for varicose disease have the potential to increase the risk of DVT. Activity is a strong protective factor against venous stasis. Activity is so important that most venous specialists will not treat a patient who is unable to remain active following treatment.
COMPLICATIONS
A correct diagnosis of superficial venous insufficiency is essential. Veins should be treated only if they are incompetent and if a normal collateral pathway exits. Removal of a saphenous vein with a competent termination will not aid in the management of nontruncal tributary varices.
In the setting of deep system obstruction, varicosities are hemodynamically helpful because they provide a bypass pathway for venous return. Hemodynamically helpful varices must not be removed or sclerosed. Ablation of these varicosities will cause rapid onset of pain and swelling of the extremity, eventually followed by the development of new varicose bypass pathways.
The most annoying minor complications of any venous surgery are dysesthesias from injury to the sural nerve or the saphenous nerve. Subcutaneous hematoma is a common complication, regardless of treatment technique used. It is easily managed with warm compress, NSAIDS, or aspiration if necessary.
71
WHO DOES WHAT?
Doctor:
i) Surgeon: diagnosis & work up
Pre operative planning
Operative procedure
Post operative follow up
j) Anesthetist: PAC, anesthesia
NURSE:
 Dressing of the wound
 Pre & post operative care
TECHNICIAN:
 Pre op equipment and drugs to be checked and kept ready
 Assist anesthetist in the OT
 Assist the surgeon, positioning of the patient
RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60 Kgs)
Human Resources
Investigations
Drugs/Consumables
Equipment
Surgeon – 1
Medical Officer /
Assistant Surgeon – 1
Anesthetist – 1
Staff Nurse – 1
Technician – 1
Haemogram
Blood Sugar
S. Electrolytes
S. Creatinine
ECG
X-Ray – Chest
Antibiotics
Analgesic
I.V. Fluids
Sutures
Drains
Anesthetic drugs
OT Table & lights
Instrument trolley
General Surgery Set
Cautery
Suction
Anesthetic Equipment
72
Nursing Orderly – 1
Sweeper – 1
Doppler
Dressings

FISTULA IN ANO
WHEN TO SUSPECT/RECOGNIZE?
When a patient presents with a discharging opening gin the perianal region, on e should suspect a fistula in ano
INTRODUCTION:
A fistula is an abnormal communication between two epithelial surfaces.
DEFINTION:
By definition a fistula in ano is a communication between the anal canal and skin by a tract which may be straight and simple or complex with ramifications or a horse shoe tract involving the right and / or left halves. The discharge may be pus, fecal matter, flatus or serosanguinous.
Fistula are classified as low or high
Based upon their relationship to the anal sphincter complex, anal fistulas are categorized into:
1. Intersphincteric
2. Trans sphincteric
3. Supra sphincteric
4. Extra sphincteric
Treatment options are based upon these classifications
INCIDENCE:
Indian incidence is not documented
DIFFERENTIAL DIAGNOSIS:
Furunculosis
Crohn’s disease
Pilonidal sinus
Tuberculosis
34
Actimycosis
Lymphogranuloma venereum
Granuloma inguinale
Perianal abcess
PREVENTION:
Adequate drainage of anorectal abscesses may prevent fistula formation
Predisposing causes
1. Crohn’s disease
2. Malignancy
3. Chlamydia
In the presence of a complex, recurrent, non healing fistula these should be suspected.
COUSELLING:
Surgical treatment alone offers permanent cure. So patients should be counseled for early surgey when it is a simple fistula so that it does not become complex.
OPTIMAL DIAGNOSTIC CRITERIA:
SITUATION 1:
CLINICAL DIAGNOSIS:
Patients with anal fistula commonly present with complaints of
 Discharge from external or internal opening, the external opening may be single or multiple
 Pain
 Swelling
 Fever
The presentation may be acute when there is acute perianal sepsis
A chronic anal fistula presents with periodic exacerbation and pus discharging openings around the anus per rectal exam and proctoscopy should be done to visualize both the internal and external openings. This may be adequate for a straight low tract.
35
INVESTIGATIONS:
Fistulogram may be done when branching is suspected, in recurrent fistulae and when internal opening is not appreciable.
Examination under anesthesia
Probe test, caution may cause now internal opening
Injection technique is useful in delineating the tract
Biopsy when specific cause is anticipated
Barium enema – when co existing disease is suspected
Blood sugar – to r/o diabetes mellitus
Complete blood count
Urine r/m
X ray chest – to rule out TB
TREATMENT:
Simple low fistulae can be managed in a secondary hospital where a surgeon is available
SURGICAL PROCEDURES:
Surgical options are dictated by the type of fistula. Aim is to drain the septic focus and remove the fistula with minimal injury to the sphincter complex
Fistulotomy
Fistulectomy
Seton
Combination of the above:
Fistulotomy (of superficial position), with seton division (of the cephalad position)
Staged procedures may be required in high anal fistulae
Fistula presenting as perianal abscess would require drainage, analgesics and antibiotics followed subsequently by a definitive procedure
Fistulotomy and curettage / Fistulectomy – low anal fistula
36
Trans sphincteric fistula that involve =<30 percent of sphincteric muscle – sphincteromy without risk of incontinence
High Trans sphincteric fistulas – seton placement
REFERRAL CRITERIA:
Complex/recurrent/high anal fistulae may need referral to a higher centre for adequate investigation and management. Colostomy and staged procedure may be required.
Co existing conditions like rectal cancers, Crohn’s disease, TB fistulae, HIV infection require referral
SOP:
In patient
SITUATION 2:
Clinical diagnosis as in situation 1
INVESTIGATION:
All investigations as in situation 1
Additional investigations:
MRI, MR Fistulogram in complex, high, trans sphincteric, supra and extrasphincteric fistulae
Colonoscopy – associated ulcerative colitis, carcinoma, TB etc
HIV test in suspected cases
Biopsy when multiple openings are present, malignancy or specific cause is suspected prothrombin time
HbA1C in cases of diabetes mellitus
TREATMENT: as in situation 1
Colostomy – when significant sphincter involvement is present, or non healing ulcer Multiple procedures – complex fistula with multiple tracts
SOP:
Day Care – Low fistulae – subcutaneous / submucous fistula
All others – should be admitted
37
WHO DOES WHAT?
Doctor:
Clinical examination
Diagnosis
Planning surgery
Post op care
Anesthesia
Nurse:
Siting of colostomy when required, by stoma nurse
Care of stoma
Dressing of the wound
Pre & post operative care
Assisting during surgery
Technician:
Pre op equipment and drugs to be checked and kept ready
Assist anesthetist in the OT
Assist the surgeon, positioning of the patient
REFERENCES
Owen G, Keshava A, Stewart P, Patterson J, Chapuis P, Bokey E, Rickard M.
Plugs unplugged. Anal fistula plug: the Concorf experience.
ANZ J Surg. 2010 May, 80 (5):341-3
Department of Colorectal Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia. Owen_g@optusnet.com.
K.Rajgopal Shenoy, Manipal Manual of Surgery second edition; reprint 2009. CBS Publishers and Distributors (Pvt.) Ltd., India
38
Shackelford’s Surgery of the Alimentary Tract 6th Edition by Charles J. Yeo MD Saunders 2006 ISBN: 1416023577
RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60kgs)
Situation
Human Resources
Investigations
Drugs/Consumables
Equipment
1
Surgeon – 1
Medical Officer / Assistant Surgeon – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Haemogram
Urine Analysis
Blood Sugar
Antibiotics
Analgesics
I V Fluids
Sutures
Anesthetic drugs
Lignocaine
dressings
OT Table and lights
Autoclave
General surgery set
Cautery
Suction
Pulse Oximeter
Anesthetic equipment
2
Consultant – 1
Resident – 1
Staff nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Same as above +
hbA1C
coagulation
profile
ECG
X-Ray chest
Same as above + stoma bag
Same as above

COLECTOMY

INTRODUCTION:
Sir William Arbuthnot was one of the early proponents of the usefulness of total colectomies.
Colectomy is commonly performed for the treatment of colon cancer.

DEFINITION:
Colectomy implies the surgical resection of any extent of the large intestine (colon).
Based on the segment of colon removed colectomies are termed as
1. Right hemicolectomy.
2. Extended right hemicolectomy
3. Transverse colectomy
4. V resection
5. Left hemicolectomy
6. Extended left hemicolectomy
7. Sigmoidectomy
8. Proctosigmoidectomy
9. Total colectomy
10. Total proctocolectomy
11. Subtotal colectomy

INDIAN INCIDENCE: not documented
DIFFERENTIAL DIAGNOSIS:
 Polyps
 Inflammatory bowel disease-ulcerative colitis, Crohn’s disease
 Tuberculous stricture of the large bowel with obstruction
21
 Vascular malformations with lower gastro intestinal bleeding
 Amoebiasis
PREVENTION:
In familiar situations like FAP & HNPCC early colectomy is advised.
It is important to understand the carcinogenesis in colorectal cancer & the associated molecular events.
ENVIRONMENTAL FACTORS also pay an important role, particularly dietary factors & estrogen replacement.
Association between hyperplastic polyposis & colorectal cancer & adenomas called sporadic MIS tumuors
Colorectal cancers: are Sporadic in 75% cases & Genetic in 25% (younger age at diagnosis)
Positive Familial history is present in 15%-20%.
HNPCC (5%)-80% risk
FAP(less than 1%)-100% risk of development of CRC – prophylactic total colectomy/proctocolectomy
COUNSELLING:
GENETIC COUNSELLING
PREDISPOSITION SHOULD BE COUNSELLED & SCREENED FOR COLON CANCER.
Screening colonoscopy and polypectomy – reduces colon cancer mortality.
1. OPTIMAL DIAGNOSTIC CRITERIA:
Situation 1
Clinical Diagnosis
Anatomical locations and clinical manifestations of colon cancer
Distribution %
Ascending / Caecum
Transverse
Descending/Sigmoid
Manifestations
Bleeding
Anemia
Malena
Abdominal pain
Mass
obstruction
Abdominal pain
Obstruction
Mass
Changing bowel habit
Obstruction
Mass
Abdominal pain
Mass
22
Diarrhoea
obstruction
Perforation
Low back pain
INVESTIGATIONS:
 Haemogram
 Colonoscopy – investigation of choice
 – Biopsy & HPE
– Brush cytology if biopsy is not possible
 X-ray abdomen – if patient presents with features of large bowel obstruction
 Double contrast barium enema :
– When colonoscopy is contra indicated or not available
– Findings – constant irregular filling defect
– Detects associated lesions
– Small ulcerative lesions can be diagnosed
 USG abdomen
 Endoluminal ultrasound – if available
 CECT – if available is used in large palpable abdominal masses
= To determine local invasion
 Urograms – when evidence of hydronephrosis on USG/ CT in left sided tumours
TREATMENT:
1. Pre op evaluation of staging, respectability, patient’s operative risks are mandatory.
2. Accurate localization of tumour – of particular importance.
a. Sometimes known cancer may not be apparent on serosal aspect.
b. Localization by tattooing during colonoscopy, Barium enema.
c. Pre op CT, USG assessment of iver metastasis should be done
PRE OP PREPARATION:
Mechanical bowel preparation
Prophylactic antibiotics
23
Blood grouping and cross matching
Thromboembolism prophylaxis
OPERATIVE TECHNIQUES:
Resection should follow
Standard oncological principles:
 Proximal ligation of primary arterial supply at its margins
 Adequate proximal & distal margins(5 cm) determined by area supplied by the primary feeder artery
 Appropriate lymphadenectomy – harvesting of minimum 12 nodes
 Extent of resection is an important prognostic factor (SAGES guidelines 2000)
 Any tumour not removed intraoperatively strongly influences prognosis & therapy
Ro – absence of residual tumour, margins free histologically
R1 – no gross residual tumour but margins histologically positive
R2 – residual gross disease remains unresected
RADIAL MARGIN:
T4 lesions are a complex group & should be considered separate from other T groups
Radial tumour free margins should be resected. Radial margin should be histologically free of disease for resection to be curative.
Specimen labeling, marking are important for a good pathological report
R1 & R2 resection – incomplete resection for cure affects curability though TNM stage remains same
LATERAL CIRCUMFERENTIAL MARGIN:
In addition to radial, proximal & distal margins, circumferential margins should also be pathologically assessed. Positive margins are associated with increased rate of local and distal failure.
Disease free survival and mortality significantly related to margin involvement after TME
ADJUVANT Ro stage:
Adjuvant therapies require complete resection
A case is not Ro if it is
24
 Non enbloc resection
 Radial margins positive for disease
 Bowel margin positive for disease
 Residual lymph node disease present or
 Nx (incomplete staging)
LYMPHADENECTOMY:
Should be radical (up to the level of origin of primary feeding artery)
Apical nodes positive for disease may have prognostic significance in addition to number of positive lymph nodes
ENBLOC RESECTION of adherent tumours : En bloc removal of adjacent organs locally invaded by cancer colon can achieve survival rates similar to patients with tumour that do not invade an adjacent organ, provided negatgive resection margins are achieved.
PERFORATION OF TUMOUR SHOULD BE AVOIDED (SAGES GUIDELINE)
Inadvertent full thickness perforation of rectum would probably classify tumour as T4 and resection as R1
Perforation at the site of cancer, as opposed to an area remote from the tumour has a greater impact on survival & local recurrence.
Inadvertent local perforation predisposes to local recurrence and warrants post-operative radiotherapy.
INTRAOPERATIVE SPILLAGE:
HAS AN INDEPENDENTT EFFECT ON PROGNOSIS
Adjuvant radiotherapy may be considered to decrease rates of local recurrence
NO TOUCH TECHNIQUE:
Value inconclusive
25
SURGICAL PROCEDURES:
Anatomical Resection of Colon Cancer
Tumour location
Vascular Ligation
Colon resection
Anastamosis
Caecum, ascending colon
ileo-colic, right colic
Right hemicolectomy
ileotransverse colostomy
Hepatic flexure,
Proximal transverse colon
ileocolic right, middle colic
Extended right hemicolectomy with omentectomy
iIeodescending colostomy
Distal transverse colon splenic flexure
ileocolic right, middle or left branch of middle colic, left colic
Extended right hemicolectomy with omentectomy or Left hemicolectomy
ileosigmoid colostomy or Transverse sigmoid colostomy
Descending colon
Inferior mesenteric or left colic
Left hemicolectomy
Transverse colorectal anastamosis
Sigmoid colon
Inferior mesenteric or sigmoid
Left colectomy or Sigmoid resection
Transverse colorectal anastamosis or descending colorectal anastamosis
Colectomy may be performed by the
i) Conventional open technique
REFERRAL CRITERIA:
Patients suspected of colon cancer & biopsy proven should be referred to a higher centre for further evaluation and treatment when
1) Adequate surgical facilities are not available / surgeon does not have sufficient experience in colon cancer surgery.
2) Competent pathologist to report on malignant lesions as per standard oncological guidelines is not available.
3) For adjuvant / neo-adjuvant radio and chemo therapy
TREATMENT:
Patient requiring colectomy for biopsy proven cancer are best referred to a super specialty centre
26
In view of the need for multi modality treatment.
SITUATION 2:
All investigations as in situation 1
 Spiral CT in elderly patients more than 80 years
 CT colonoscopy also called virtual colonoscopy – 6 mm polyps may be picked up effectively
 CEA – fetal glycoprotein
– Increased pre op CEA in node positive Ca – indication for chemotherapy
 MRI :
 PET : detection of metastasis
 SPECT – if single photon emission is studied, such as technetium or thallium
 FDG-PET – useful in evaluation of recurrent colorectal cancer
-Differentiates post op changes from recurrent / residual disease
-Useful diagnostic tool but prohibitive cost
 CT-PET – fusion tests provide the most powerful integrated images
 NUCLEAR MEDICINE IMAGING:
-Using 131I, 111In, 99mTc bound to monoclonal antibodies, leucocytes & erythrocytes.
TREATMENT:
As outlined in situation 1.
Laparoscopic resection is gaining popularity. However it is not freely available & performed as per protocols.
SPECIAL CONSIDERATIONS
1. Synchronous malignancies or polyps
Patients with synchronous malignancies should be considered for subtotal colectomy depending on the distance between lesions
Colonic cancer with multiple adenomatous polyps – subtotal colectomy
27
(Due to increased risk of metachronous lesion and to facilitate surveillance of the remaining colon)
Factors that influence the decision to perform prophylactic subtotal colectomy
-number
-location
-size of accompanying polyps
-age
-compliance of patient
2. Cancer is a polyp
Complete endoscopic removal of polyp with cancer in situ – no further treatment
Histoplathology shows invasive carcinoma:
Ensure that endoscopic polypectomy was complete
Specimen was submitted with proper orientation to the pathologist for histopathology
Carcinoma at margin of resection requires formal resection
Carcinoma with free margins – a. thorough pathological review,
b. identification of adverse histological features
i. poor differentiation,
ii lymphatic or venous invasion
iii invasion into the stock of the polyp – formal
resection
It is difficult to locate the previous polypectomy site during surgery
Even if polyp is not removed it may be soft and difficult to palpate through the colon wall
28
Endoscopic distance (from anal verge or dentate line) misleading
Polypectomy site should be videotaped for later review and marked with vital dye that can be seen serosally at the time of surgery
3. Obstructing Cancers- 2% of colorectal cancers
Partial obstruction – Gentle bowel preparation over several days-Elective surgery
Total obstruction
– Rt colon cancers – Rt Hemi colectomy – immediate ileocolostomy
– Lt colon cancers
1) Endoscopic decompression by laser passed beyond the obstructed
Segment – This allows mechanical preparation and elective resection.
– This is possible only when the narrowed lumen can be traversed by the endoscope.
– It is not possible when obstruction is complete
2) Primary resection and immediate anastamosis with on-table colonic
washout with or without proximal colostomy.
3) Primary resection with colostomy. Anastamosis at second stage.
4) Subtotal colectomy with primary anastamosis
5) Decompressive colostomy followed by formal colonic resection
4. Adjacent organ involvement- 10%
Locally advanced tumours are potentially curable with multi organ resection.-Do not necessarily
Portend a dismal prognosis.
-A non metastasizing variant of colon cancer grows to a large size without spreading to regional nodes
-Separation of adhesions adjacent to a malignancy can lead to dissemination of tumour cells.
29
-Enbloc resection of these tumours, depending on location can lead to five year survivals of 70%
Hepatic metastases – 10% at the time of exploration.
-Solitary metastasis amenable to –wedge resection with clear margins can be removed concomitantly.
-Formal hepatic lobectomy done as a second stage procedure.
5. Ovarian metastasis – 7% at the time of colon resection
Oophorectomy: at the time of colorectal surgery
Indications
i) Large ovarian metastasis (Krukenbergt’s tumour) which are symptomatic (prevents second surgery for the metastasis, benefit of preventing primary ovarian cancer)
ii) Direct ovarian involvement
iii) Post menopausal women – prophylactic oophorectomy
6. Inadvertent Perforation
-Predisposes to local recurrence
-Warrants post op radiotherapy
Follow up
Aim: Early detection of recurrence or metachronous lesion
History
Physical examination
Faecal occult blood
CBC } every 3 months-first 3 years
LFT every 6 months additional 2 years
30
Tumour markers (CEA) – monthly – 3 years, 3 monthly-next 2 years
Colonoscopy – first colonoscopy within 6-12 months of surgery, yearly-next 2 years, 2-3 yearly thereafter.
CXR
CT abdomen and pelvis – if primary loco regionally advanced
-LFT ↑
-CEA ↑
80-90% of recurrence of colon cancers occurs in the first two years.
SOP
All patients should be admitted when a colectomy is planned
WHO DOES WHAT?
Doctor:
c) Surgeon: diagnosis & work up
Pre operative planning
Operative procedure
Post operative follow up
d) Radiotherapist : radiotherapy – neoadjuvant & adjuvant
e) Medical oncologist : Chemotherapy
f) Anesthetist: PAC, anesthesia, post op ICU management
NURSE:
 Siting of colostomy when required by some nurse
 Care of stoma
 Dressing of the wound
 Pre & post operative care
31
TECHNICIAN:
 Pre op equipment and drugs to be checked and kept ready
 Assist anesthetist in the OT
 Assist the surgeon, positioning of the patient

RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60 Kgs)
Situation
Human Resources
Investigations
Drugs/Consumables
Equipment
1
Surgeon – 1
Medical Officer /
Assistant Surgeon – 1
Anesthetist – 1
Pathologist – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Haemogram
Urine Analysis
Blood Sugar
S. Electrolytes
KFT
ECG
X-Ray – Chest
USG
Antibiotics
Analgesic
I.V. Fluids
Sutures
Drains
Catheters
Anesthetic drugs
Dressings
OT Table & lights
Instrument trolley
General Surgery Set
Cautery
Suction
Anesthetic Equipment
32
Sweeper – 1
Histopathology
Stoma bags
Monitors
2
Consultant – 1
Residents – 1
Anesthetist – 1
Pathologist – 1
Medical Oncologist – 1
Radiotherapist – 1
Staff Nurse – 2
Stoma therapist – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Same as above +
HbA1C
CEA
Coagulation Profile
Colonoscopy
EUS
CT Scan
CEA
Microbiology
ABG
Immunology
PET
Same as above
Same as above +
Laparoscopic Set
Harmonic Scalpel
Endo GI Staplers

by
Dr. V. Ramesh &
Dr Ajit Sinha
Department of Surgery
Safdarjung Hospital
New Delhi

CHOLECYSTECTOMY

INTRODUCTION:
Cholecystectomy is one of the commonest elective surgical procedure performed in India. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis, biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures. Currently, most cholecystectomies are done using the laparoscopic technique in cities; however, the open technique is required in places where facilities or trained staff are not available.
DEFINITION:
Cholecystectomy implies the surgical resection the gall bladder.
INDIAN INCIDENCE
In India, the incidence of gall stones is around six percent in the total population. It is 10 per cent in women and three per cent in men. In elderly people it may go up to 20 percent.
INDICATIONS:
Asymptomatic patients
Cholecystectomy is not indicated in most patients with asymptomatic stones because only 2-3% of these patients go on to become symptomatic per year. To properly determine the indications for elective cholecystectomy, the risk of the operation (taking into account the age and comorbid factors of the individual patient) must be weighed against the risk of complications and death without operation.
The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gallstones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic (silent) gallstones.
Patients who are immunocompromised, are awaiting organ allotransplantation, or have sickle cell disease are at higher risk of developing complications and should be treated irrespective of the presence or absence of symptoms.
Additional reasons to consider prophylactic cholecystectomy include the following:
 Calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gallbladder cancer
 Chronically obliterated cystic duct
 Nonfunctioning gallbladder
 Calcified (porcelain) gallbladder
 Gallbladder polyp >10 mm or showing rapid increase in size

 Gallbladder trauma
 Anomalous junction of the pancreatic and biliary ducts
 Morbid obesity is associated with a high prevalence of cholecystopathy, and the risk of developing cholelithiasis is increased during rapid weight loss. Routine prophylactic cholecystectomy prior to gastric bypass (RYGB) is controversial, but cholecystectomy should clearly precede or be performed at the time of RYGB in patients with a history of gallbladder pathology.
Symptomatic gallstone disease
Biliary colic with sonographically identifiable stones is the most common indication for elective cholecystectomy.
Acute cholecystitis, when diagnosed within 72 hours from the onset of symptoms, can and usually should be treated by surgery. Once 72 hours pass after the onset of symptoms, inflammatory changes in the surrounding tissues are widely believed to render dissection planes more difficult. Interval cholecystectomy after 4-6 weeks or percutaneous cholecystostomy are other options.
Biliary dyskinesia should be considered in patients who present with biliary colic in the absence of gallstones, and a cholecystokinin–diisopropyl iminodiacetic acid (CCK-DISIDA) scanning should be obtained. The finding of a gallbladder ejection fraction <35% at 20 minutes is considered abnormal and constitutes another indication for cholecystectomy.
Complex gallbladder disease
Gallstone pancreatitis
Cholecystectomy can be safely performed during the same hospitalization after the clinical signs of mild to moderate biliary pancreatitis have resolved. Patients diagnosed with gallstone pancreatitis should first undergo imaging to rule out the presence of choledocholithiasis.
Cholecystectomy should be delayed in cases of acute moderate to severe biliary pancreatitis (5 Ranson criteria).
Choledocholithiasis
The following treatment options are available for patients found to have choledocholithiasis:
Preoperative ERCP with sphincterotomy
Postoperative ERCP with sphincterotomy
Laparoscopic intraoperative cholangiogram with laparoscopic common bile duct (CBD) exploration
Open CBD exploration and T-tube placement
Mirizzi syndrome
P.L. Mirizzi described an unusual presentation of gallstones that, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct, causing symptoms of obstructive jaundice.

Although an initial trial of dissection may be performed by an experienced laparoscopic biliary surgeon, one must be prepared for conversion and for biliary reconstruction.
Endoscopic stone fragmentation at ERCP, with papillotomy and stenting, is a viable alternative to operative surgery to treat Mirizzi syndrome in the acute setting.[24 ]Subsequent cholecystectomy may be performed.[25 ]
Cholecystoduodenal fistula
Patients with cholecystoduodenal fistula leading to gallstone ileus should undergo exploratory laparotomy and removal of the stone, followed by exploration of the remainder of the gastrointestinal tract for additional stones. The fistula may be addressed at the time of the initial procedure but is probably better addressed at a second operation (3-4 wk postoperatively) after inflammation has subsided.[25 ]
Cholecystenteric fistula does not represent an absolute contraindication to laparoscopic surgery, although it does require careful visualization of the anatomy and good laparoscopic suturing skills.
Acalculous cholecystitis
A greater proportion of patients with acalculous cholecystitis are too ill to undergo surgery. In these situations, percutaneous cholecystostomy guided by CT or ultrasonography is advised. Ninety percent of these patients demonstrate clinical improvement. Once the patient has recovered, the cholecystostomy tube can be removed, usually at 6 weeks, without sequelae. Interval cholecystectomy is not necessary.[27 ]
Incidental gallbladder cancer
Gallbladder cancer may be an incidental finding at cholecystectomy, with an incidence ranging from 0.3-5.0%.
Uncertainty of diagnosis, uncertainty of the degree of tumor spread, or postoperative identification of cancer on pathological examination of a routine cholecystectomy specimen should engender early reoperation.
Before reoperation, distant metastases should be excluded by a detailed clinical examination including a per-rectal/per-vaginal examination, examination for supraclavicular lymph nodes, and CT/MRI of the chest and abdomen.
Special situations
Children
Cholecystectomy is a safe and effective treatment for most children diagnosed with biliary disease (BD).
Cirrhosis
Cholecystectomy in safe in patients with Child class cirrhosis.
9
Diabetes mellitus
The presence of diabetes mellitus, in and of itself, does not confer sufficient risk to warrant prophylactic cholecystectomy in asymptomatic individuals.
However, consider that acute cholecystitis in a patient with diabetes is associated with a significantly higher frequency of infectious complications such as sepsis.
Pregnancy
The treatment of biliary colic or uncomplicated cholecystitis in a pregnant patient is conservative management followed by elective cholecystectomy. Using antibiotics, analgesics, and antiemetics help most pregnant women avoid surgical intervention. Surgery is generally indicated for patients with recurrent acute cholecystitis who have failed maximal medical therapy.
Classically, the second trimester is considered the safest time for surgery. This is because of the findings of increased risk for spontaneous abortion and teratogenesis during the first trimester, and the increased risk for premature labor and difficulties with visualization in the third trimester.
Pregnancy was formerly considered to be an absolute contraindication to the laparoscopic approach because of concern for potential trocar injury to the uterus and the unknown effects of pneumoperitoneum to the fetal circulation. However, this has not been borne out in the literature, and cholecystectomy is now considered safe.
Recommendations for pregnant patients who undergo laparoscopic cholecystectomy include placing them in the left lateral recumbent position to shift the weight of the gravid uterus off the vena cava and maintenance of insufflation pressures between 10 and 12 mm Hg. In addition, maternal PaCO 2 monitoring must be performed by measuring either arterial blood gases or end-tidal CO 2 , but arterial PaCO 2 may be more accurate.
Other recommendations include avoiding rapid changes in intraperitoneal pressures, avoiding rapid changes in patient position, and using open technique for the umbilical port placement.
Distance from medical centres
In India, another indication can be distance from a treating hospital as long travel that may be needed can lead to complications.
INVESTIGATIONS:
 Haemogram
 Liver Function Tests
 Blood sugar
 Serum creatinine
 Bleeding time, clotting time and prothrombin time
 Xray chest

 ECG
 USG abdomen
 In patients with dilated common bile duct or raised liver functions, MRCP or ERCP may be indicated based on availability. Alternatively, an on table cholangiogram or CBD exploration may be done during surgery. Patient can be referred to another centre in case of non availability of expertise or experience.
OPERATIVE TECHNIQUES:
Principles of surgery remain the same regardless of whether it is being done by open or laparoscopic technique.
 Safe access to abdomen.
 Clear definition of anatomy in the calots triangle showing either the continuity between cystic duct and gall bladder or junction between cytic duct and common bile duct.
 Avoiding diathermy close to common bile duct.
 Securing cystic artery safely and close to the gall bladder.
 Dissection from liver bed staying close to gall bladder.
 Early conversion to open procedure in case of a difficult laparoscopic surgery.
REFERRAL CRITERIA:
 Common bile duct stones if no facilities for management available.
 Suspected gall bladder cancer.
 Bile duct injury during surgery. Patient should be referred to a tertiary centre as soon as possible.
WHO DOES WHAT?
Doctor:
a) Surgeon: diagnosis & work up
Pre operative planning
Operative procedure
Post operative follow up

b) Anesthetist: PAC, anesthesia, post op ICU management
NURSE:
 Dressing of the wound
 Pre & post operative care
TECHNICIAN:
 Pre op equipment and drugs to be checked and kept ready
 Assist anesthetist in the OT
 Assist the surgeon, positioning of the patient
RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60 Kgs)
Human Resources
Investigations
Drugs/Consumables
Equipment
Surgeon – 1
Medical Officer /
Assistant Surgeon – 1
Anesthetist – 1
Pathologist – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Haemogram
LFT
Blood Sugar
S. Electrolytes
KFT
ECG
X-Ray – Chest
USG
Histopathology
Antibiotics
Analgesic
I.V. Fluids
Sutures
Drains
Catheters
Anesthetic drugs
Dressings
OT Table & lights
Instrument trolley
Laparoscopic Surgery set
General Surgery Set
Cautery
Suction
Anesthetic Equipment
Monitors