Over the past two decades, the range of abdominal surgical procedures performed by minimally invasive (or laparoscopic) techniques has grown enormously. The vast majority of common conventional surgery in the abdomen is now carried out safely, quickly and efficiently through a number of small, relatively painless incisions. Surgery for gastroesophageal reflux disease (GERD), hiatal hernia, ulcers and tumors of the stomach, complex procedures involving the gallbladder, bile duct and liver and segmental removal of the small intestine and colon for cancer, diverticulitis and inflammatory bowel disease (IBD) are now everyday occurrences under the care of the surgeons.
Many of these procedures can be performed on an out-patient basis, while others require one or more nights in hospital. The common feature shared by all of these procedures is short hospitalization, earlier return to normal activity and reduced pain. Long-term there is a lower incidence of hernia (known as 'incisional hernia'), quite a common complication of the long incisions used in conventional surgery. Research results show that minimally invasive surgery causes fewer complications and overall is safer than conventional surgery in appropriately selected individuals.
Gallbladder, Gallstones and the Bile Duct Problems
Gallbladder removal (cholecystectomy) is one of the most common surgical procedures performed in the United States. Since it was first performed in the mid 1980s, laparoscopic cholecystectomy has replaced conventional surgery as the "gold-standard" for almost all conditions that affect the gallbladder.
The most common problems are caused by the presence of gallstones in the gallbladder. If the stones are large (e.g. half an inch or more in size), they can block the outlet of the gallbladder, leading to inflammation, severe pain and occasionally perforation. Stones that are small enough to pass from the gallbladder can block the bile duct leading to severe pain and jaundice (yellow skin, dark urine) and inflammation of the pancreas (gallstone pancreatitis), a potentially serious complication.
An ultrasound examination will show gallstones and the gallbladder, and in many cases this is the only imaging needed. Other imaging studies such as MRCP (Magnetic Resonance Cholangiography) may be used to show if anything is blocking or growing in the bile duct. A CT scan may be necessary to display the pancreas. During surgery to the gallbladder it is common to perform a cholangiogram, an X-ray that outlines the branches of the bile duct system which may show suspected and unsuspected stones.
The majority of gallbladder problems just described can be corrected with laparoscopic surgery. Even when stones pass into the common bile duct they can be removed using laparoscopic techniques, with success rates equivalent to endoscopic removal (called ERCP). If pancreatitis has occurred it is necessary to wait until it has settled before removing the gallbladder. Gallbladder cancer is a rare tumor that can occur in the presence of gall stones. Conventional surgery is usually necessary to treat this tumor.
Removal of a segment of the colon is a major operation however it is performed. With conventional surgery, an incision of 6-10 inches and hospitalization of a week or more are typical. We use laparoscopic techniques to perform the same operation through a number of tiny incisions. The result is shortened hospitalization (in some cases as little as two days), significantly less pain and much earlier return to normal activity. Because the incisions are short, the risk of hernia due to weakening of the scar, a common complication of conventional surgery, is nearly eliminated.
This surgery is performed for diverticulitis of the colon, for inflammatory disease of the small intestine or colon (e.g. Crohn's disease, ulcerative colitis), or for colon tumors. It is well accepted that laparoscopy is as equally effective as conventional surgery for the treatment of diseases of the colon.
The Role of the Esophagus and How its Disorders Affect Swallowing
The esophagus delivers liquids and food from the back of the mouth to the stomach. For most of its length as it passes through the neck and chest, its lining resembles skin, which does not secrete any fluid such as mucus. Over the years the esophagus is exposed to many corrosive substances such as acids, enzymes, and bile from the stomach, as well as anything swallowed from above. Ulcers of the lining of the esophagus may result from prolonged exposure to these substances, particularly in the lowermost part near the stomach.
The muscular wall of the esophagus has its own rhythmic action that actively squeezes food toward the stomach. This activity can be impaired (called dysmotility) and difficulty swallowing may result. Sometimes it is necessary to measure the motility of the esophagus by a test known as manometry. Long-standing reflux disease may lead to impaired motility.
Minimally invasive surgery is used to treat many disorders of the esophagus including GERD, achalasia and tumors.
Gastroesophageal Reflux Disease (GERD) Treatment
Gastroesophageal reflux disease (GERD), or reflux, occurs because of a failure of the normal mechanisms that protect the esophagus from the corrosive effects of acid and other stomach secretions. Long-standing reflux can cause ulceration, bleeding and eventually scarring of the lower esophagus. If lifestyle changes such as loss of weight, dietary modifications and sleep position do not produce acceptable relief from reflux, medications such as a Proton Pump Inhibitor (PPI) or an H2 Antagonist are usually prescribed. Although these drugs all reduce acid production in the stomach, there is no effect on the amount of stomach juice that refluxes, or corrosive components such as bile that it contains.
If symptoms require ever increasing doses of drugs, if long-term drug treatment is unacceptable of if complications such as stricture or bleeding have occurred, an anti-reflux procedure could be considered. Over the past two decades, laparoscopic anti-reflux surgery has emerged as the preferable surgical technique for such cases. Hospitalization is usually an overnight stay and return to work can occur in as little as a week.
Normal swallowing requires the muscular valve at the entrance to the stomach (the Lower Esophageal Sphincter or LES) to relax to allow food and liquid to pass through. Achalasia occurs when this valve fails to relax. Difficulty swallowing liquids and solids, chest pain, and regurgitation are common symptoms of this disorder. In time, the esophagus becomes wider, thick-walled, and bent and loses its muscular contractions. The diagnosis is made with a combination of X-rays (a barium swallow or esophagram), endoscopy and esophageal manometry. Treatment consists of defeating the action of the valve either by stretching (esophageal dilatation), or what is now considered the most definitive treatment, cutting of the muscle fibers of the valve. This treatment known as esophagomyotomy is performed by laparoscopic surgery. Recently a novel procedure performed through the mouth known as Per-Oral EsophagoMyotomy or POEM has been developed in Japan to accomplish the same effect without surgery. No treatments can cure achalasia but the swallowing difficulties, regurgitation and chest pain can be markedly improved.
Protrusion of contents of the abdomen through an opening in the belly wall is called an abdominal hernia. Repair of the hernia is necessary if it is causing pain, or if the contents is likely to get stuck or twisted and not return to its normal position. Twisted or strangulated hernia is a surgical emergency. Laparoscopic repair is a particularly good option when the hernia is recurrent, or if it is present on both sides (bilateral).
The laparoscopic procedure, which entails placement of synthetic mesh to cover the hernia opening, is performed under general anesthesia, but in an ambulatory setting so there is usually no overnight stay. Discomfort after the surgery is modest and return to work is commonly possible after 2-3 days. Long-term comparisons have shown the repair to be as durable as regular surgery.
People who have experienced conventional and laparoscopic repair of hernia in the past rarely want regular surgery again. In some instances a laparoscopic surgical approach is not the best option and we recommend hernia repair through a regular incision instead.
The spleen is found in the abdomen high up on the left side under the diaphragm. It has a very generous blood supply for its weight (about five ounces). Because it is made up of brittle tissue the spleen is susceptible to trauma after which it can bleed dangerously. Many blood disorders and infections cause an enlarged spleen. Your hematologist may recommend removal of the spleen (splenectomy) if, by excess consumption, it is causing deficiencies in blood components such as platelets or red blood cells. Immunization against rare but dangerous infections that can occur after splenectomy is necessary before surgery.
The spleen is an ideal organ to remove by laparoscopy. It can be separated very precisely from its attachments, retrieved in a bag and fragmented into small pieces that will fit through an incision � of an inch long. Even a massively enlarged spleen of eight or nine pounds can be removed using hand assisted laparoscopic techniques. An incision about three inches long, in addition to other tiny laparoscopic incisions, is made to let the surgeon place a hand within the abdominal cavity to help manipulate the heavy, bulky organ.