Laproscopic General Surgery

 
Dr. Anurag Dhawan
Senior Consultant
General Surgery
MBBS MS SURGERY
Dr. A.N Sinha
Senior Consultant
General Surgery
Dr. Kapil Kochhar
Senior Consultant
General Surgery
 
Dr. Anurag Dhawan,Book Appointment With Dr. Anurag Dhawan,General Surgeon Dr. Sumita Chawla,Book Appointment With Dr. Sumita Chawla,Pediatrician Dr. Anamika Dubey,Book Appointment With Dr. Anamika Dubey,Pediatrician

Laparoscopy is a commonly performed minimally invasive (keyhole) procedure to investigate and treat various conditions affecting abdominal and pelvic organs like cysts, fibroids, infection etc.

It involves direct visualization of the abdominal cavity, by using a laparoscope, which is a camera with a light source at its tip. Fibreoptic fibres carry images from a lens, also at the tip of the instrument, to a video monitor, which the surgeon and other theatre staff can view in real time. It is done using a thin-light tube in the belly through small incisions in contrast to the laparotomy surgery that involves larger incisions in the belly.

Carbon dioxide (CO2) which is put into the abdomen. helps to separate the organs inside the abdominal cavity, making it easier for the surgeon to visualise the different organs during laparoscopy, and perform a wide range of procedures. The gas is removed at the end of the procedure.

ADRENAL GLAND

WHAT ARE THE ADRENAL GLANDS?
The adrenal glands are two small organs, one located above each kidney. They are triangular in shape and about the size of a thumb. The adrenal glands are known as endocrine glands because they produce hormones. These hormones are involved in control of blood pressure, chemical levels in the blood, water use in the body, glucose usage, and the “fight or flight” reaction during times of stress. These adrenal-produced hormones include cortisol, aldosterone, the adrenaline hormones – epinephrine and norepinephrine – and a small fraction of the body’s sex hormones (estrogen and androgens).

WHAT CAUSES ADRENAL GLAND PROBLEMS?
Diseases of the adrenal gland are relatively rare. The most common reason that a patient may need to have the adrenal gland removed is excess hormone production by a tumor located within the adrenal. Most of these tumors are small and not cancers. They are known as benign growths that can usually be removed with laparoscopic techniques. Removal of the adrenal gland may also be required for certain tumors even if they aren’t producing excess hormones, such as very large tumors or if there is a suspicion that the tumor could be a cancer, or sometimes referred to as malignant. Fortunately, malignant adrenal tumors are rare. An adrenal mass or tumor is sometimes found by chance when a patient gets an X-ray study to evaluate another problem.

WHAT ARE THE SYMPTOMS OF ADRENAL GLAND PROBLEMS?
Patients with adrenal gland problems may have a variety of symptoms related to excess hormone production by the abnormal gland. Adrenal tumors associated with excess hormone production include pheochromocytomas, aldosterone-producing tumors, and cortisol-producing tumors. Some of these tumors and their typical features are given below.

• Pheochromocytomas produce excess hormones that can cause very high blood pressure and periodic spells characterized by severe headaches, excessive sweating, anxiety, palpitations, and rapid heart rate that may last from a few seconds to several minutes.
• Aldosterone producing tumors cause high blood pressure and low serum (blood) potassium levels. In some patients this may result in symptoms of weakness, fatigue, and frequent urination.
• Cortisol producing tumors cause a syndrome termed Cushing’s syndrome that can be characterized by obesity (especially of the face and trunk), high blood sugar, high blood pressure, menstrual irregularities, fragile skin, and prominent stretch marks. Most cases of Cushing’s syndrome, however, are caused by small pituitary tumors and are not treated by adrenal gland removal. Overall, adrenal tumors account for about 20% of cases of Cushing’s syndrome.
• An incidentally found mass in the adrenal may be any of the above types of tumors, or may produce no hormones at all. Most incidentally found adrenal masses do not make excess hormones, cause no symptoms, are benign, and do not need to be removed. Surgical removal of incidentally discovered adrenal tumors is indicated only if:
• The tumor is found to make excess hormones
• Is large in size (more than 4-5 centimeters or 2 inches in diameter)
• If there is a suspicion that the tumor could be malignant.
• Adrenal gland cancers (adrenal cortical cancer) are rare tumors that are usually very large at the time of diagnosis. Removal of these tumors is usually done by open adrenal surgery.

If an adrenal tumor is suspected based on symptoms or has been identified by X-ray, the patient should undergo blood and urine tests to determine if the tumor is over-producing hormones. Special X-ray tests, such as a CT scan, nuclear medicine scan, an MRI or selective venous sampling are commonly used to locate the suspected adrenal tumor.

Surgical removal of the adrenal gland is the preferred treatment for patients with adrenal tumors that secrete excess hormones and for primary adrenal tumors that appear malignant.

WHAT ARE THE ADVANTAGES OF LAPAROSCOPIC ADRENAL GLAND REMOVAL?
In the past, making a large 6 to 12 inch incision in the abdomen, flank, or back was necessary for removal of an adrenal gland tumor. Today, with the technique known as minimally invasive surgery, removal of the adrenal gland (also known as “laparoscopic adrenalectomy”) can be performed through three or four 1/4-1/2 inch incisions. Patients may leave the hospital in one or two days and return to work more quickly than patients recovering from open surgery.

Results of surgery may vary depending on the type of procedure and the patients overall condition. Common advantages are:
• Less postoperative pain
• Shorter hospital stay
• Quicker return to normal activity
• Improved cosmetic result
• Reduced risk of herniation or wound separation

ARE YOU A CANDIDATE FOR LAPAROSCOPIC ADRENAL GLAND REMOVAL?
Although laparoscopic Adrenal gland removal has many benefits, it may not be appropriate for some patients. Obtain a thorough medical evaluation by a surgeon qualified in laparoscopic adrenal gland removal in consultation with your primary care physician or endocrinologist to find out if the technique is appropriate for you.

WHAT PREPARATION IS REQUIRED?
Prior to the operation, some patients may need medications to control the symptoms of the tumor, such as high blood pressure.

• Patients with a pheochromocytoma (see previous page) will need to be started on special medications several days prior to surgery to control their blood pressure and heart rate.
• Patients with an aldosterone-producing tumor (see previous page) may need to have their serum potassium checked and take extra potassium if the level is low.
• Patients with Cushing’s syndrome (see previous page) will need to receive extra doses of cortisone medication on the day of surgery and for a few months afterwards until the remaining adrenal gland has resumed normal function.
• 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.
• Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
• It is recommended that you shower the night before or morning of the operation.
• 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 large doses of Vitamin E will need to be stopped temporarily for several days to a week prior to surgery.
• Diet medication or St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

HOW IS LAPAROSCOPIC ADRENAL GLAND REMOVAL PERFORMED?
• The surgery is performed under a complete general anesthesia, so that the patient is asleep during the procedure.
• A cannula (a narrow tube-like instrument) is placed into the abdominal cavity in the upper abdomen or flank just below the ribs.
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula. This gives the surgeon a magnified view of the patient’s internal organs on a television screen.
• Other cannulas are inserted which allow your surgeon to delicately separate the adrenal gland from its attachments. Once the adrenal gland has been dissected free, it is placed in a small bag and is then removed through one of the incisions. It is almost always necessary to remove the entire adrenal gland in order to safely remove the tumor.
• After the surgeon removes the adrenal gland, the small incisions are closed.

WHAT HAPPENS IF THE PROCEDURE CANNOT BE PERFORMED LAPAROSCOPICALLY?
In a small number of patients the laparoscopic method cannot be performed. In that situation, the operation is converted to an open procedure. 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 the adrenal gland clearly
• Bleeding problems during the operation
• Large tumor size (over 3 or 4 inches in diameter)
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?
After the operation, it is important to follow your doctor’s instructions. Although many people feel better in just a few days, remember that your body needs time to heal.
• After laparoscopic adrenal gland removal, most patients can be cared for on a regular surgical nursing unit. Occasionally, a patient with a pheochromocytoma may require admission to an intensive care unit after surgery to monitor their blood pressure. Most patients can be discharged from the hospital within one or two days after surgery.
• Patients with an aldosterone-producing tumor will need to have their serum potassium level checked after surgery and may need to continue to take medications to control their blood pressure.
• Patients with cortisol-producing tumors and Cushing’s syndrome will need to take prednisone or cortisol pills after surgery. The dose is then tapered over time as the remaining normal adrenal gland resumes adequate production of cortisol hormone.
• Patients are encouraged to engage in light activity while at home after surgery. Patients can remove any dressings and shower the day after the operation.
• Post-operative pain is generally mild and patients may require a pain pill or pain medication.
• Most patients can resume normal activities within one week, including driving, walking up stairs, light lifting, and work.
• You should call and schedule a follow-up appointment within 2 weeks after your operation.

WHAT COMPLICATIONS CAN OCCUR?
As with any operation, there is a risk of a complication. Complications during the operation may include:
• Adverse reaction to general anesthesia
• High blood pressure
• Bleeding
• Injury to other organs
• Wound problems, blood clots, heart attacks, and other serious complications are uncommon after laparoscopic adrenalectomy

ANAL FISSURE, FISTULA

FISTULA IN-ANO
Other conditions which affect the ano-rectum and may be confused with or occur concomitant with hemorrhoids include anal fistula and anal fissures.

A fistula is an abnormal communication between the inside of a hollow organ and the skin. In the case of an anal fistula the communication is from inside the rectum to the skin outside the anus or on the buttock. The inciting cause is trauma of defecation which causes a break in the mucosa of the rectum. Bacteria track into the tissue under the mucosa and form an abscess. The abscess eventually finds its way to the skin where it ruptures and drains. The outer opening may heal but the inner opening remains and permits the cycle to repeat itself. Patients often present with years of repeated abscesses in this area which drain, heal and return again.

Surgical treatment involves opening the entire fistula from its outer opening to its inner opening and allowing the wound to heal from the inside out thus obliterating the fistula. If the fistula track runs deep to the anal sphincter muscle, the muscle will need to be divided; however, doing so carries a risk of causing fecal incontinence. Often, when this is the case, the procedure will be done in two stages. During the first stage, the fistula is opened to the level of the anal sphincter muscle including the overlying skin or mucosa, but the sphincter is left intact. A strip of cotton tape called a "Seton" is passed around the sphincter muscle in this area and tied tight. This causes the sphincter muscle in this area to scar down. A few weeks later, it is safe to cut the muscle as it will not retract and open up but instead just stays in place and the remainder of the fistula can heal. The risk of incontinence is greatly reduced performing the procedure in this way when the sphincter is involved.

Two newer methods for treating anal fistula have recently been introduced. The first step with both methods is to scrape the inside of the fistula to expose fresh tissue that is more prone to healing.

The first method involves simply injecting the fistula with fibrin glue. Fibrin is a protein found in the blood which is involved in the final stages of causing blood to clot. The glue created from fibrin is effective at sealing the fistula. The recurrence rate is high, but it is a reasonable first attempt and has no risk of causing incontinence.

The second option is to use a collagen fistula plug. Collagen is the major structural protein which holds us all together. It is present throughout are bodies and forms the matrix upon which cells grow. Pure collagen has been used to create matrices for a variety of purposes. In this case a small plug of collagen in placed in the fistula tract and sutured into place. The tissues may then grow into the collagen and heal the fistula. This procedure may or may not be augmented with the use of fibrin glue as described above. This procedure still has a significant recurrence rate, but again is a very good option to try as it has no risk of causing incontinence.

ANAL FISSURE
A fissure is simply a crack or tear in the anal skin in the anal canal. The cause is also straining with bowel movement. They are often exquisitely painful. So much so, that when I see a patient in excruciating pain in the anus, the patient will not allow me to do a digital exam and I cannot see a thrombosed hemorrhoid, I will usually just treat for a fissure as the presumptive diagnosis. Surgical treatment involves doing a lateral sphincterotomy. The skin in the outer part of the anus is opened slightly to expose the sphincter muscle and the muscle is divided superficially. This does not carry the same risk of incontinence as when dividing the muscle for a fistula, because the location and degree of muscle division can be completely controlled by the surgeon. With a fistula, the area of muscle involvement is dictated by the disease.

Surgery for fissures can often be avoided with the use of topical Nitroglycerine applied directly to the anus. Nitroglycerine relaxes the muscles of the anal sphincter the same way it relaxes the smooth muscle of blood vessels when treating Coronary Artery Disease. It may cause a low blood pressure in normal patients even when applied to the anus in this manner and therefore, may not be suitable for everyone. It is; however, a good first line treatment option that often resolves the problem and avoids the need for surgery.

Surgical Hemorrhoidectomy may be combined with a Fistulotomy for concomitant anal fistula or with a sphincterotomy for concomitant anal fissure.

APPENDIX – LAP APPENDECTOMY

WHAT IS AN APPENDECTOMY?
An appendectomy is the surgical removal of the appendix, a tube about six inches long or less that branches off the large intestine. The procedure is performed to treat appendicitis, an inflammation of the appendix caused by infection.

Acute appendicitis is the most common condition of the abdomen to require emergency surgery. Because of the likelihood of the appendix rupturing and causing a severe, life-threatening infection, the usual recommendation is that the appendix be removed as soon as possible.

WHAT CAUSES APPENDICITIS?
Appendicitis occurs when the interior of the appendix becomes filled with something that causes it to swell, such as mucus, bacteria, foreign body, stool, or parasites. The appendix then becomes irritated and inflamed. Rupture (or perforation) occurs as holes develop in the walls of the appendix, allowing stool, mucus, and other substances to leak through and get inside the abdomen. An infection inside the abdomen known as peritonitis occurs when the appendix perforates.

Because of the risk of rupture, which may occur as soon as 48 to 72 hours after symptoms begin, appendicitis is considered an emergency and anyone with symptoms needs to see a doctor immediately.

WHAT ARE THE SYMPTOMS OF APPENDICITIS?
Appendicitis may cause pain in the abdomen which may be described as follows:
• May start in the area around the belly button, and move over to the lower right-hand side of the abdomen, but may also start in the lower right-hand side of the abdomen
• Usually increases in severity as time passes
• May become more severe with moving, taking deep breaths, being touched, and coughing or sneezing
• May spread throughout the abdomen if the appendix ruptures

Other symptoms of appendicitis include, but are not limited to, nausea and vomiting, loss of appetite, fever and chills, constipation, diarrhea, inability to pass gas, and abdominal swelling.

The symptoms of appendicitis may resemble other medical conditions or problems. In addition, each individual may experience symptoms differently. Always consult your doctor for a diagnosis.

It is important that people with symptoms of appendicitis not take laxatives or enemas to relieve constipation, as these medications and procedures can cause the appendix to burst. In addition, pain medication should be avoided, as this can mask other symptoms.

TYPES OF APPENDECTOMIES
The appendix may be removed in one of two ways:

• Open method. In this method, a two- to three-inch incision is made in the lower right-hand side of the abdomen. The surgeon locates the appendix and removes it through the incision.
• Laparoscopic method. This procedure uses several small incisions and three or more laparoscopes—small thin tubes with video cameras attached—to visualize the inside of the abdomen during the operation. The surgeon performs the surgery while looking at a TV monitor. The appendix is removed through one of the incisions.

During a laparoscopic appendectomy, your doctor may decide that an open appendectomy is needed.

A laparoscopic appendectomy may cause less pain and scarring than an open appendectomy, although even for open appendectomy, the scar is often hard to see once it has healed.

Open and laparoscopic techniques are thought to be comparable in terms of low rates of complications. However, length of hospital stay, length of overall recovery, and infection rates are reportedly lower with laparoscopic appendectomy.

REASONS FOR THE PROCEDURE
An appendectomy is performed to remove the appendix when appendicitis is strongly suspected. During other abdominal surgical procedures, the appendix may be removed as a precaution to prevent future inflammation or infection of the appendix.

There may be other reasons for your doctor to recommend an appendectomy.

RISKS OF THE PROCEDURE
As with any surgical procedure, complications may occur. Some possible complications include, but are not limited to, the following:
• Wound infection
• Peritonitis. An inflammation of the abdomen that can occur if the appendix ruptures during surgery
• Bowel obstruction

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

BEFORE THE PROCEDURE
• Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
• You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
• In addition to a complete medical history, your doctor may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.
• You will be asked when you last had anything to eat or drink, as you should have an empty stomach before undergoing the procedure. You will be instructed to fast until the procedure.
• If you are pregnant or suspect that you are pregnant, you should notify your health care provider.
• Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents (local and general).
• Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
• You may receive a sedative prior to the procedure to help you relax.
• Based on your medical condition, your doctor may request other specific preparation.

DURING THE PROCEDURE
In general, an appendectomy is performed as emergency surgery and may require a hospital stay. Procedures may vary depending on your condition and your doctor's practices.

An appendectomy is generally performed while you are asleep under general anesthesia.

Generally, the appendectomy follows this process:
• You will be asked to remove any jewellery or other objects that may interfere with the procedure.
• You will be asked to remove clothing and be given a gown to wear.
• An intravenous (IV) line will be inserted in your arm or hand.
• You will be positioned on the operating table on your back.
• If there is excessive hair at the surgical site, it may be clipped off.
• The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.

Open Method Appendectomy
• An incision will be made in the right lower portion of your abdomen.
• The abdominal muscles will be separated and the abdominal cavity will be opened.
• After the appendix has been located, it will be tied off with sutures and removed.
• If the appendix has ruptured, the abdomen will be thoroughly washed out with saline. A small tube may be placed in the incision to drain out fluids or pus.
• The lining of the abdominal cavity and the abdominal muscles will be closed with stitches. A small tube may be placed in the incision to drain out fluids.
• The skin over the surgical site will be cleansed with an antiseptic solution.

Laparoscopic Method Appendectomy
• A small incision will be made for insertion of the laparoscope. Additional incisions may be made so that other instruments can be used during the procedure.
• Carbon dioxide gas will be introduced into the abdomen to inflate the abdominal cavity so that the appendix and other structures can be easily visualized.
• The laparoscope will be inserted and the appendix will be located.
• The appendix will be tied off with sutures and removed.
• When the procedure is completed, the laparoscope will be removed. A small tube may be placed in the incision to drain out fluids.

Procedure completion, both methods
• The appendix will be sent to the lab for examination.
• The skin incision(s) will be closed with sutures or surgical staples.
• A sterile bandage or dressing will be applied.

AFTER THE PROCEDURE
In The Hospital
After the procedure, you will be taken to the recovery room for observation. Your recovery process will vary depending on the type of procedure performed and the type of anesthesia that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room. As a laparoscopic appendectomy procedure may be performed on an outpatient basis, you may be discharged home from the recovery room.

You may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line.

You may have a thin plastic tube inserted through your nose into your stomach to remove gastric secretions and air that you swallow. The tube will be removed when your bowels resume normal function. You will not be able to eat or drink until the tube is removed.

You will be encouraged to get out of bed within a few hours after a laparoscopic procedure or by the next day after an open procedure.

Depending on your situation, you may be given liquids to drink a few hours after surgery. Your diet may be gradually advanced to more solid foods as tolerated.

Arrangements will be made for a follow-up visit with your doctor, usually two to three weeks after the procedure.

AT HOME
Once you are home, it is important to keep the incision clean and dry. Your doctor will give you specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. Take a pain reliever for soreness as recommended by your doctor. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.

Walking and limited movement are generally encouraged, but strenuous activity should be avoided. Your doctor will instruct you about when you can return to work and resume normal activities.

Notify your doctor to report any of the following:
• Persistent fever over 101 degrees F (39 C) and/or chills
• Redness, swelling, or bleeding or other drainage from the incision site(s)
• Increased pain around the incision site(s)
• Loss of appetite and inability to eat or drink fluids
• Persistent coughing, difficulty breathing, or shortness of breath
• Abdominal pain, cramping, or swelling
• Failure to have a bowel movement after two days or longer

Following an appendectomy, your doctor may give you additional or alternate instructions, depending on your particular situation.

EXPERTS SPEAK ABOUT THE PROCEDURE - LAPAROSCOPIC APPENDECTOMY

WHAT IS THE BENEFIT OF LAPAROSCOPIC APPENDECTOMY?
Laparoscopic appendectomy provide less postoperative morbidity. Most cases of acute appendicitis can be treated laparoscopically. Laparoscopic appendectomy is a useful method for reducing hospital stay, complications and return to normal activity. The main advantages are: Less post-operative pain Faster recovery Short hospital stay Less post-operative complications like wound infection and adhesion Cost-effective in working group

HOW IS AN APPENDECTOMY PERFORMED?
In a minimally invasive laparoscopic appendectomy, an endoscope and a few surgical instruments are inserted through a series of small incisions so the appendix can be removed with less pain and a shorter recovery period. The camera on the endoscope allows the surgeon to confirm the presence of appendicitis and perform the surgery without making a large incision. Patients return home in as little as one day, although a week's recovery may be necessary if the appendix is perforated or peritonitis has occurred

ARE THERE LONG-TERM CONSEQUENCES OF APPENDECTOMY?
It is not clear if the appendix has an important role in the body in older children and adults. There are no major, long-term health problems resulting from removing the appendix although a slight increase in some diseases has been noted, for example, Crohn's disease.

WHAT ARE THE POTENTIAL RISKS AND COMPLICATIONS OF AN APPENDECTOMY?
Some possible complications of this procedure include: Infection of the skin Leakage from the bowel causing fistula or abscess, possibly requiring colostomy Prolonged intestinal ileus (paralysis of intestinal function) Very rare complications include: Bleeding requiring transfusion or re-operation Injury to surrounding structures, including ureter and small intestine Adverse reaction to the anesthesia Blood clots and pulmonary embolism Any complication can lead to additional procedures, re-operation and prolonged recovery

IS EVERY PATIENT FIT FOR LAPAROSCOPIC APPENDECTOMY?
Most surgeons would not recommend laparoscopic appendicectomy in those with pre-existing disease conditions. Patients with cardiac diseases and COPD should not be considered a good candidate for laparoscopic appendectomy. Laparoscopic appendectomy may also be more difficult in patients who have had previous lower abdominal surgery. The elderly may also be at increased risk for complications with general anaesthesia combined with pneumoperitoneum.

ARE THERE ANY POTENTIAL COMPLICATIONS FROM APPENDECTOMY?
Complications become more common the more the diagnosis and treatment are delayed. Complications include perforation of the intestines, gangrene (tissue death) of the intestines, peritonitis, and intrabdominal abscess.

WHAT CAN I EXPECT IN TERMS OF RECOVERY FROM AN APPENDECTOMY?
Every case is different, but the following are averages: Back to top Narcotic pain medicine is necessary for 3-5 days after discharge. You should not lift anything heavier than 10lbs for 30 days. You may resume aerobic exercise in 14 - 21 days. You will probably need 2 - 4 weeks off of work.

BARIATRIC SURGERY: OBESITY SURGERY

Surgical procedures to try and help a person to lose weight are becoming more and more popular. This type of surgery, which is also known as bariatric surgery, is increasingly being recognised by GPs, and also by patients, through word of mouth and the internet as much more effective than any type of diet in terms of weight loss and improvements in the quality of a person's life.

The problem with dieting is that once a certain amount of weight is lost the body goes into a starvation type mode, and hormones are produced that cause a voracious appetite to occur and for the person to start craving foods high in sugar and fat.

For this reason it is very common for patients to be able to lose a certain amount of weight but to regain it quite fast and even put more on. This common dieting sequence is referred to as yoyo dieting and is a normal consequence of these appetite driven hormonal changes, which are very difficult to resist.

Bariatric surgery is highly effective in that the procedures will help a patient to lose weight, but also more importantly will stop the longer term urges to regain weight by modifying the appetite drives and food cravings.

In addition to bariatric surgery increasingly being recognised as the most effective weight loss strategy, it is also being accepted that it is a much safer form of surgery than previous public perceptions. In the hands of a surgeon and a surgical unit which is dedicated to this type of surgery, the complication rate is as low as routine gallbladder or hip surgery, and the stay in hospital is only one or two nights. People who have undergone this surgery are usually back to work after one or two weeks.

Bariatric surgery will help dramatically improve a persons' health, particularly if they suffer with conditions associated with their obesity. These include type 2 diabetes, high blood pressure, high cholesterol, sleep apnoea and joint problems. Once a patient has lost weight following bariatric surgery it is a pleasure to see them in the outpatients' clinic with their lives transformed, having finally being able to escape the trap of obesity that is all too common in our Western world.

EXPERTS SPEAK ABOUT THE PROCEDURE - BARIATRIC SURGERY

WHAT IS BARIATRIC SURGERY?
Surgery performed on obese patients for reduction of weight & also for relief from co-morbidities like diabetes , hypertension and sleep apnoea. Bariatric surgery, which is also known as Bypass surgery, Gastric banding, Obesity surgery or more popularly known as weight loss surgery, is a type of procedure performed on people who are dangerously obese, for the purpose of losing weight. This weight loss is usually achieved by reducing the size of the stomach with an implanted medical device (gastric banding) or through removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch) or by resecting and re-routing the small intestines to a small stomach pouch (gastric bypass surgery).

WHAT ARE TYPES OF BARIATRIC SURGERY?
1. Gastric Plication
2. Adjustable gastric band
3. Sleeve gastrectomy
4. Gastric bypass surgery

WHAT IS LAPROSCOPIC GASTRIC PLICATION?
Laparoscopic Gastric Plication, involves sewing one or more large folds in your stomach. During the Laparoscopic Gastric Plication the stomach volume is reduced about 70% which makes the stomach able to hold less and may help you eat less. There is no cutting, stapling, or removal of the stomach or intestines during the Gastric Plication. The Gastric Plication may potentially be reversed or converted to another procedure if needed. The Laparoscopic Gastric Plication procedure is relatively new, and considered investigational as a primary procedure for weight loss. Gastric Plication as an option if you have a BMI over 27 with one or more significant co-morbid medical conditions which are generally expected to be improved, reversed, or resolved by weight loss.

WHAT IS ADJUSTABLE GASTRIC BAND SURGERY?
The restriction of the stomach also can be created using a silicone band, which can be adjusted by addition or removal of saline through a port placed just under the skin. This operation can be performed laparoscopically, and is commonly referred to as a "lap band". Weight loss is predominantly due to the restriction of nutrient intake that is created by the small gastric pouch and the narrow outlet. It is considered one of the safest procedures performed today.

WHAT IS SLEEVE GASTRECTOMY SURGERY?
Sleeve gastrectomy, or gastric sleeve, is a surgical weight-loss procedure in which the stomach is reduced to about 15% of its original size, by surgical removal of a large portion of the stomach, following the major curve. The open edges are then attached together (typically with surgical staples, sutures, or both) to leave the stomach shaped more like a tube, or a sleeve, with a banana shape. The procedure permanently reduces the size of the stomach. The procedure is performed laparoscopically and is not reversible.

WHAT IS GASTRIC BYPASS SURGERY?
A common form of gastric bypass surgery is the Roux-en-Y gastric bypass. Here, a small stomach pouch is created with a stapler device, and connected to the distal small intestine. The upper part of the small intestine is then reattached in a Y-shaped configuration.

This procedure will help a patient to lose weight, and also more importantly will stop the longer term urges to regain weight by modifying the appetite drives and food cravings.

Gastric bypass procedures (GBP) are any of a group of similar operations that first divides the stomach into a small upper pouch and a much larger lower "remnant" pouch and then re-arranges the small intestine to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different GBP names. Any GBP leads to a marked reduction in the functional volume of the stomach, accompanied by an altered physiological and physical response to food.

The operation is prescribed to treat morbid obesity (defined as a body mass index greater than 40), type 2 diabetes, hypertension,sleep apnea, and other comorbid conditions. Bariatric surgery is the term encompassing all of the surgical treatments for morbid obesity, not just gastric bypasses, which make up only one class of such operations. The resulting weight loss, typically dramatic, markedly reduces comorbidities. The long-term mortality rate of gastric bypass patients has been shown to be reduced by up to 40%.[1][2] As with all surgery, complications may occur. A study from 2005 to 2006 revealed that 15% of patients experience complications as a result of gastric bypass, and 0.5% of patients died within six months of surgery due to complications

LIVING WITH GASTRIC BYPASS
Gastric bypass surgery has an emotional and physiological impact on the individual. Many who have undergone the surgery suffer from depression in the following months as a result of a change in the role food plays in their emotional well-being. Strict limitations on the diet can place great emotional strain on the patient. Energy levels in the period following the surgery can be low, both due to the restriction of food intake and negative changes in emotional state. It may take as long as three months for emotional levels to rebound. Muscular weakness in the months following surgery is also common. This is caused by a number of factors, including a restriction on protein intake, a resulting loss in muscle mass and decline in energy levels. Muscle weakness may result in balance problems, difficulty climbing stairs or lifting heavy objects, and increased fatigue following simple physical tasks. Many of these issues pass over time as food intake gradually increases. However, the first months following the surgery can be very difficult, an issue not often mentioned by physicians suggesting the surgery The benefits and risks of this surgery are well established; however, the psychological effects are not well understood.

Even if physical activity is increased patients may still harbor long term psychological effects due to excess skin and fat. Often bypass surgery is followed up with "body lifts" of skin and liposuction of fatty deposits. These extra surgeries have their own inherent risks but are even more dangerous when coupled with the typical nutritional deficiences that accompany convalescing gastric bypass patients

RESULTS & HEALTH BENEFITS OF GASTRIC BYPASS
Weight loss of 65–80% of excess body weight is typical of most large series of gastric bypass operations reported. The medically more significant effects include a dramatic reduction in comorbid conditions:
• Hyperlipidemia is corrected in over 70% of patients.
• Essential hypertension is relieved in over 70% of patients, and medication requirements are usually reduced in the remainder.
• Obstructive sleep apnea improves markedly with weight loss and bariatric surgery may be curative for sleep apnea. Snoring also reduces in most patients.
• Type 2 diabetes is reversed in up to 90% of patients usually leading to a normal blood-sugar level without medication, sometimes within days of surgery.]Furthermore, Type 2 diabetes is prevented by more than 30-fold in patients with pre-diabetes.
• Gastroesophageal reflux disease is relieved in almost all patients.
• Venous thromboembolic disease signs such as leg swelling are typically alleviated.
• Lower-back pain and joint pain are typically relieved or improved in nearly all patients.
• A study in a large comparative series of patients showed an 89% reduction in mortality over the five years following surgery, compared to a non-surgically treated group of patients.
Concurrently, most patients are able to enjoy greater participation in family and social activities.

How Long Does The Procedure Take?
"The procedure is under general anaesthetic and takes on average one and a half hours."

Post Surgery
The morning after surgery the patient should be able to walk around his/her private room, use the bathroom and shower. (S)he should be able to sit comfortably and drink tea, smoothies or milk. Pain should be well controlled with soluble painkillers. Some patients are keen to go home the day after surgery but most prefer to stay and relax in the hospital and return home after the second night.

How Much Weight Can One Expect To Lose?
Following gastric bypass patients will lose about 80% of their excess weight. If a person weighs 20 stone but their ideal weight is 10 stone, then the excess weight they are carrying is 10 stone. Following gastric bypass if they lose 80% of this excess weight, that will equal 8 stone of weight loss. Therefore following gastric bypass this persons weight will decrease from 20 stone to the 12 stone level within nine to twelve months of surgery and remain at this level long term.

CANCER SURGERY

Surgery is the oldest form of cancer treatment. It also has a key role in diagnosing cancer and finding out how far it has spread (staging). Advances in surgical techniques have allowed surgeons to successfully operate on a growing number of patients. Today, less invasive operations often can be done to remove tumors while saving as much normal tissue and function as possible.

Surgery offers the greatest chance for cure for many types of cancer, especially those that have not spread to other parts of the body. Most people with cancer will have some type of surgery.

WHY IS SURGERY USED FOR CANCER?
Surgery can be done for many reasons. Some types of surgery are very minor and may be called procedures, while others are much bigger operations. The more common types of cancer surgeries are reviewed here.

PREVENTIVE (PROPHYLACTIC) SURGERY
Preventive surgery is done to remove body tissue that is likely to become cancerous (malignant), even though there are no signs of cancer at the time of the surgery. For example, pre-cancerous polyps may be removed from the colon.

Sometimes preventive surgery is used to remove an entire organ when a person has an inherited condition that puts them at a much higher risk for having cancer some day. For example, some women with a strong family history of breast cancer are found to have a change (mutation) in their DNA in a breast cancer gene (BRCA1 or BRCA2). Because their risk of getting breast cancer is high, these women may want to consider prophylactic mastectomy (the breasts are removed before cancer is found).

DIAGNOSTIC SURGERY
This type of surgery is used to get a tissue sample to tell whether or not cancer is present or to tell what type of cancer it is. The diagnosis of cancer is often made by looking at the cells under a microscope. Many methods are used to get a sample of cells from a suspicious-looking area. These are described in the section, "Surgery to diagnose and stage cancer."

STAGING SURGERY
Staging surgery is done to find out how much cancer there is and how far it has spread. While the physical exam and the results of lab and imaging tests can help figure out the clinical stage of the cancer, the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. For more information, please see the American Cancer Society document called Staging.

Examples Of Surgical Procedures Commonly Used To Stage Cancers, Such As Laparotomy And Laparoscopy, Are Described In The Section, "Surgery To Diagnose And Stage Cancer."

CURATIVE SURGERY
Curative surgery is done when a tumor appears to be confined to one area, and it is likely that all of the tumor can be removed. Curative surgery can be the main treatment for the cancer. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation. Sometimes radiation therapy is actually used during an operation. This is called intraoperative radiation therapy.

DEBULKING (CYTOREDUCTIVE) SURGERY
Debulking surgery is done to remove some, but not all, of the tumor. It is done when removing all of the tumor would cause too much damage to an organ or near-by tissues. In these cases, the doctor may remove as much of the tumor as possible and then try to treat what's left with radiation therapy or chemotherapy. Debulking surgery is commonly used for advanced cancer of the ovary.

PALLIATIVE SURGERY
This type of surgery is used to treat complications of advanced cancer. It is not intended to cure the cancer. Palliative surgery can also be used to correct a problem that is causing discomfort or disability. For example, some cancers in the abdomen may grow large enough to block off (obstruct) the intestine. If this happens, surgery can be used to remove the blockage. Palliative surgery may also be used to treat pain when the pain is hard to control by other means.

SUPPORTIVE SURGERY
Supportive surgery is used to help with other types of treatment. For example, a vascular access device such as a port-a-cath can be surgically placed into a large vein. The port can then be used to give treatments or draw blood for testing, instead of having needles put in the arms.

RESTORATIVE (RECONSTRUCTIVE) SURGERY
This type of surgery is used to change the way a person looks after major cancer surgery or to restore the function of an organ or body part after surgery. Examples include breast reconstruction after mastectomy or the use of tissue flaps, bone grafts, or prosthetic (metal or plastic) materials after surgery for oral cavity cancers. For more information on these types of reconstructive surgery, please see the American Cancer Society documents Breast Reconstruction after Mastectomy and Oral Cavity and Oropharyngeal Cancer.

SURGERY TO DIAGNOSE AND STAGE CANCER
A biopsy is a procedure done to remove a tissue sample so that it can be looked at under a microscope. Some biopsies may need to be done in surgery, but many types of biopsies involve removing tumor samples through a thin needle or an endoscope (a flexible lighted tube). Biopsies are often done by surgeons, but they can be done by other doctors, too. Some of the more common ways to do a biopsy are reviewed here.

Fine Needle Aspiration Biopsy
Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out a small amount of tissue from a tumor. If the tumor can’t be felt near the surface of the body, the needle can be guided into the tumor by looking at it with an imaging method such as an ultrasound (US) or CT (computed tomography) scan.

The main advantage of FNA is that no surgical incision (cutting through the skin) is needed. A drawback is that in some cases the needle can’t take out enough tissue for a definite diagnosis. A more invasive type of biopsy may then be needed.

Core Needle Biopsy
This type of biopsy uses a slightly larger needle to take out some of the tissue. A core biopsy can be aspirated (removed) with a needle if the tumor can be felt at the surface. Core biopsies can also be guided by imaging methods if the tumor is too deep to be felt.

The advantage of core biopsy is that it usually collects enough tissue to find out whether or not the tumor is cancer.

Excisional Or Incisional Biopsy
For these biopsies a surgeon cuts through the skin to remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy). They can often be done with local or regional anesthesia. This means numbing medicine is used just in the area where the biopsy will be done. If the tumor is inside the chest or abdomen, general anesthesia (drugs that put you into a deep sleep) may be needed.

Laparoscopy, Thoracoscopy, Or Mediastinoscopy
Laparoscopy is much like endoscopy, but a small incision is made in the skin of the abdomen (belly). A thin tube called a laparoscope is then put through the incision and into the abdomen to look for possible areas of cancer that can be biopsied. When this type of procedure is done to look inside the chest it is called a thoracoscopy or mediastinoscopy.

Open Surgical Exploration (Laparotomy, Thoracotomy, Or Mediastinotomy)
When less invasive tests do not give enough information about a suspicious area in the abdomen, a laparotomy may be needed. In this procedure, a surgeon makes an incision, usually from the bottom of the sternum (breastbone) down to the lower part of the abdomen (belly), which allows him to look directly at the area in question. The location and size of the tumor and the surrounding areas can be seen and biopsies can be taken, if needed. Because this is a major surgical procedure, general anesthesia (medicines that put you in a deep sleep) is needed. An operation much like this can be done to open and look inside the chest. It is called a thoracotomy.

If lymph nodes near the trachea are swollen, a mediastinotomy is done. General anesthesia (medicines that put you in a deep sleep) is used for this procedure. A special scope (mediastinoscope) is put in the body through a small incision above the top of the sternum (breastbone) and biopsies are collected from the areas of concern.

GALL BLADDER - LAPAROSCOPIC CHOLECYSTECTOMY

Approximately 8% percent of the adult population or more than 5.5 million people in the United Kingdom have gallstones. About 50,000 of these patients undergoing gallbladder surgery each year. Cholecystectomy Is the surgical removal of the gallbladder. It is a common treatment of symptomatic gallstones and other gallbladder conditions. Surgical options include the standard procedure, called laparoscopiccholecystectomy, and an older more invasive procedure, called open cholecystectomy.

Indications for cholecystectomy include inflammation of the gall bladder (cholecystitis), biliary colic, risk factors for gall bladder cancer,and pancreatitis caused by gall stones.Cholecystectomy is the recommended treatment the first time a person is admitted to hospital for cholecystitis. Cholecystitis may be acute or chronic, and may or may not involve the presence of gall stones. Risk factors for gall bladder cancer include a "porcelain gallbladder," or calcium deposits in the wall of the gall bladder, and an abnormal pancreatic duct.Cholecystectomy can prevent the relapse of pancreatitis that is caused by gall stones that block the common bile duct.

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection. Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS" or Single Incision Laparoscopic Surgery or "SILS". In this procedure, instead of making 3-4 four small different cuts (incisions), a single cut (incision) is made through the navel (umbilicus). Through this cut, specialized rotaculating instruments (straight instruments which can be bent once inside the abdomen) are inserted to do the operation. The advantage of LESS / SILS operation is that the number of cuts are further reduced to one and this cut is also not visible after the operation is done as it is hidden inside the navel. A meta-analysis published by Pankaj Garg et al. comparing conventional laparoscopic cholecystecomy to SILS Cholecystectomy demonstrated that SILS does have a cosmetic benefit over convention four-hole laparoscopic cholecystectomy while having no advantage in postoperative pain and hospital stay.

EXPERTS SPEAK ABOUT THE PROCEDURE - LAPAROSCOPIC GALL BLADDER REMOVAL

Gall bladder removal is one of the most commonly performed surgical procedures in the United States. Today, gallbladder surgery is performed laparoscopically. The medical name for this procedure is Laparoscopic Cholecystectomy.

WHAT IS 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.

WHAT CAUSES GALLBLADDER PROBLEMS?
• 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.

HOW ARE THESE PROBLEMS FOUND AND TREATED?
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 reducing fat intake. This treatment has a low, short-term success rate. Symptoms will eventually continue unless the gallbladder is removed.
• Surgical removal of the gallbladder is the time honored and safest treatment of gallbladder disease.

WHAT ARE THE ADVANTAGES OF PERFORMING CHOLECYSTECTOMY LAPAROSCOPICALLY?
• Rather than a five to seven inch incision, the operation requires only four small openings in the abdomen.
• Patients usually have minimal post-operative pain.
• Patients usually experience faster recovery than open gallbladder surgery patients.
• Most patients go home within one day and enjoy a quicker return to normal activities.

ARE YOU A CANDIDATE FOR LAPAROSCOPIC GALLBLADDER REMOVAL?
Although 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 surgeon trained in laparoscopy, can determine if laparoscopic gallbladder removal is an appropriate procedure for you.

WHAT PREPARATION IS REQUIRED?
The following includes typical events that may occur prior to laparoscopic surgery; however, since each patient and surgeon is unique, what will actually occur may be different:
• 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.
• Your surgeon may request that you completely empty your colon and cleanse your intestines prior to surgery. You may be requested to drink clear liquids, only, for one or several days prior to surgery.
• It is recommended that you shower the night before or morning of the operation.
• 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 St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

HOW IS LAPAROSCOPIC GALLBLADDER REMOVAL PERFORMED?
• Under general anesthesia, so the patient is asleep throughout the procedure.
• Using a cannula (a narrow tube-like instrument), the surgeon enters the abdomen in the area of the belly-button.
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient’s internal organs on a television screen.
• Other cannulas 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, (s)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.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED OR COMPLETED BY THE LAPAROSCOPIC METHOD?
In a small 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 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. 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 LAPAROSCOPIC GALLBLADDER SURGERY?
• Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs. Nausea and vomiting are not uncommon.
• Once liquids or a diet is tolerated, patients leave the hospital the same day or day following 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 return to normal activities within a week’s time, including driving, walking up stairs, light lifting and working.
• 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.
• Most patients who have a laparoscopic gallbladder removal go home from the hospital the day after surgery. Some may even go home the same day the operation is performed.
• Most patients can return to work within seven days following the laparoscopic procedure depending 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 open procedure usually resume normal activities in four to six weeks.
• Make an appointment with your surgeon within 2 weeks following your operation

WHAT COMPLICATIONS CAN OCCUR?
While there are risks associated with any kind of operation, the vast majority of laparoscopic gallbladder patients experiences few or no complications and quickly return to normal activities. It is important to remember that before undergoing any type of surgery–whether laparoscopic or open you should ask your surgeon about his/her training and experience.

Complications of laparoscopic cholecystectomy are infrequent, but include bleeding, infection, pneumonia, blood clots, or heart problems. Unintended injury to adjacent structures such as the common bile duct or small bowel 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 may rarely occur.

Numerous medical studies show that the complication rate for laparoscopic gallbladder surgery is comparable to the complication rate for open gallbladder surgery when performed by a properly trained surgeon.

GASTROINTESTINAL SURGERY

Digestive system surgery can be divided into upper GI surgery and lower GI surgery.

Upper gastrointestinal surgery, often referred to as upper GI surgery, refers to a practise of surgery that focuses on the upper parts of the gastrointestinal tract. There are many operations relevant to the upper gastrointestinal tract that are best done only by those who keep constant practise, owing to their complexity. Consequently, a general surgeon may specialise in 'upper GI' by attempting to maintain currency in those skills.

The following operations:
• Pancreaticoduodenectomy
• Esophagectomy
• Liver resection

Lower gastrointestinal surgery refers to a sub-specialisation of medical practise whereby a general surgeon focuses on the lower gastrointestinal tract.

HERNIAS - LAPAROSCOPIC HERNIORRHAPHY

INGUINAL (GROIN) HERNIA AND LAPAROSCOPIC REPAIR:
Many surgeries are performed by the conventional “open” method. Some inguinal hernia repairs are performed using a small telescope known as a laparoscope

WHAT IS AN INGUINAL HERNIA?
• A hernia occurs when the inside layers of the abdominal muscle have weakened, resulting in a bulge or 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 small balloon-like sac. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems that could require emergency surgery.
• Both men and women can get a hernia.
• You may be born with a hernia (congenital) or develop one over time.
• A hernia does not get better over time, nor will it go away by itself.

HOW DO I KNOW IF I HAVE AN INGUINAL HERNIA?
• The common areas where hernias occur are in the groin (inguinal), belly button (umbilical), and the site of a previous operation (incisional).
• It is usually easy to recognize a hernia. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting.
• The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day.
• Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and immediate contact of your physician or surgeon.

WHAT CAUSES A HERNIA?
The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision or a weakness present from birth. Anyone can develop a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting, persistent coughing, difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate.

WHAT ARE THE ADVANTAGES OF LAPAROSCOPIC HERNIA REPAIR?
Laparoscopic Hernia Repair is a technique to fix tears in the abdominal wall (muscle) using small incisions, telescopes and a patch (mesh). If may offer a quicker return to work and normal activities with a decreased pain for some patients.

ARE YOU A CANDIDATE FOR LAPAROSCOPIC HERNIA REPAIR?
Only after a thorough examination can your surgeon determine whether laparoscopic hernia repair is right for you. The procedure may not be best for some patients who have had previous abdominal surgery or underlying medical conditions.

WHAT PREPARATION IS REQUIRED?
• Most hernia operations are performed on an outpatient basis, and therefore the you will probably go home on the same day that the operation is performed.
• 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.
• It is recommended that you shower the night before or morning of the operation.
• If you have difficulties moving your bowels, an enema or similar preparation may be used after consulting with your surgeon.
• 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 St. John’s Wort should not be used for the two weeks prior to surgery.
• Quit smoking and arrange for any help you may need at home.

HOW IS LAPAROSCOPIC HERNIA REPAIR PERFORMED?
There are few options available for a patient who has a hernia.
• Use of a truss (hernia belt) is rarely prescribed as it is usually ineffective.
• Most hernias require a surgical procedure.
• Surgical procedures are done in one of two fashions.

1. The open approach is done from the outside through a three to four inch incision in the groin or the area of the hernia. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole. This technique is usually done with a local anesthetic and sedation but may be performed using a spinal or general anesthetic.

2. The laparoscopic hernia repair. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.

Other cannulas are inserted which allow your surgeon to work “inside.” Three or four quarter inch incisions are usually necessary. The hernia is repaired from behind the abdominal wall. A small piece of surgical mesh is placed over the hernia defect and held in place with small surgical staples. This operation is usually performed with general anesthesia or occasionally using regional or spinal anesthesia.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED OR COMPLETED BY THE LAPAROSCOPIC METHOD?
In a small 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 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. 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 SHOUD I EXPECT AFTER LAPAROSCOPIC SURGERY?
• Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake.
• Once you are awake and able to walk, you will be sent home.
• With any hernia operation, you can expect some soreness mostly during the first 24 to 48 hours.
• You are encouraged to be up and about the day after surgery.
• With laparoscopic hernia repair, 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, working and engaging in sexual intercourse.
• Call and schedule a follow-up appointment within 2 weeks after you operation.

WHAT COMPLICATIONS CAN OCCUR?
• Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair.
• There is a slight risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle.
• Difficulty urinating after surgery is not unusual and may require a temporary tube into the urinary bladder for as long as one week.
• Any time a hernia is repaired it can come back. This long-term recurrence rate is not yet known. Your surgeon will help you decide if the risks of laparoscopic hernia repair are less than the risks of leaving the condition untreated.

WHEN TO CALL YOUR DOCTOR
Be sure to call your physician or surgeon if you develop any of the following:
• Persistent fever over 101 degrees F (39 C)
• Bleeding
• Increasing abdominal or groin swelling
• Pain that is not relieved by your medications
• Persistent nausea or vomiting
• Inability to urinate
• Chills
• Persistent cough or shortness of breath
• Purulent drainage (pus) from any incision
• Redness surrounding any of your incisions that is worsening or getting bigger
• You are unable to eat or drink liquids

EXPERTS SPEAK ABOUT THE PROCEDURE - LAPAROSCOPIC HERNIORRHAPHY

WHAT IS HERNIA?
A hernia is a weakness in the abdominal wall resulting in abnormal protrusion of abdominal contents (e.g. intestines) through the defect. Hernias enlarge over time and may become incarcerated (fail to reduce) or strangulated (loss of hernia contents due to lack of blood supply). A hernia should be surgically repaired. Although most hernias occur in the groin (eighty-percent), they may also be located in the navel, upper-inner thigh, and along previous abdominal incisions.

WHAT TO EXPECT AFTER SURGERY?
• Most people who have laparoscopic hernia repair surgery are able to go home the same day.
• Recovery time is about 1 to 2 weeks.
• You most likely can return to light activity after 1 to 2 weeks.
• Strenuous exercise should wait until after 4 weeks of recovery.
• Studies have found that people have less pain after laparoscopic hernia repair than after open hernia surgery.

WHY IT IS DONE?
Surgical repair is recommended for inguinal hernias that are causing pain or other symptoms and for hernias that are incarcerated or strangulated. Surgery is always recommended for inguinal hernias in children.

Laparoscopic surgery repair may not be appropriate for people who:
• Have an incarcerated hernia.
• Cannot tolerate general anesthesia.
• Have bleeding disorders such as hemophilia or idiopathic thrombocytopenic purpura (ITP).
• Are taking medicines 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.

Laparoscopic hernia repair usually is not done on children. But a laparoscope may be used during open hernia repairs in children to explore the opposite groin for a hernia. This can be done by inserting the laparoscope into the side that is being operated on and looking at the opposite side. If a hernia is present, the surgeon can repair both sides during the same operation.

HOW WELL IT WORKS?
The chance of a hernia coming back after laparoscopic surgery ranges from 1 to 10 out of 100 surgeries done.

Laparoscopic surgery has the following advantages over open hernia repair:
• Some 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 often is easier using laparoscopic techniques than using open surgery.
• It is possible to check for and repair 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.

WHAT TO THINK ABOUT?
Laparoscopic 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. Also, 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.
• General anesthesia is needed for laparoscopic repair. Open hernia repair can be done under general, spinal, or local anesthesia.
• Laparoscopic repair of a hernia is more expensive than open surgery because of the higher cost of the slightly longer operating-room time and the cost of laparoscopic technology

MICRO LAPROSCOPY

One of the newest areas in minimally invasive gynecological surgery is microlaparoscopy. By using a microlaparoscope, physicians can replace an incision of up to 10 millimeters with one that is just two millimeters or 1/11 inch. "The microlaparoscope allows for diagnosis of many problems in a doctor's office or outpatient unit without general anesthesia," says Dr. Sunil Garg. "This makes the procedure safer and the recovery time less than one hour. Unlike traditional laparoscopic surgery which has been referred to as 'band-aid' surgery, microlaparoscopy does not require a single stitch or band-aid. That's why it is called 'non-band-aid surgery.'"

Even newer in the area of microlaparoscopy is interactive diagnosis, generally used for women with obscure pelvic pain. Performed on a fully awake patient, the procedure involves touching various internal areas with the tiny scope while at the same time asking the woman to identify the intensity and location of pain.

Minimally invasive microlaparoscopic surgery continues to revolutionize and redefine contemporary medicine as laparoendoscopic surgeons invade the 21st century. The availability of this technology in operative medicine will force surgeons to perform procedures in a more minimally invasive and cost-effective manner. Myriad technique and instrumentation changes mark the developments that have led to microlaparoscopy. The advances in microlaparoscopy noted today have arisen primarily from continued progress in fiberoptic technology. Microlaparoscopy uses small-caliber laparoscopes, 2 mm or less in diameter, made of microfiber-optic bundles measured in micrometers. The current 2-mm microlaparoscopes have a 50000-fiber image bundle that produces enhanced resolution and a 75 degreeg field of view, comparable to a standard 10-mm rod lens laparoscope

PAIN ABDOMEN

Pelvic pain that lasts 6 or more months, and is not associated with the menstrual period, is called chronic pelvic pain (menstrual pain is discussed in chapter 3). Chronic pelvic pain is a fairly common problem. It is estimated that about 20% of the visits to gynecologists are for pelvic pain, and one out of every seven hysterectomies are performed for this reason. Chronic pelvic pain can lead to significant distress and even disability.

Laparoscopy is a surgical procedure that involves placement of a thin telescope through an incision in the navel in order to see inside the abdomen and pelvis. It is often utilized to help establish the cause of pelvic pain and, in many cases, can be used to treat the cause of the pain as well. The procedure is performed in a hospital or outpatient surgery center under general anesthesia. With the laparoscope, the doctor is able to see the uterus, tubes, ovaries, intestines, appendix, gall bladder, and liver. With a careful inspection, gynecologic problems such as endometriosis, pelvic infection, adhesions, ovarian cysts, and tubal pregnancy can be diagnosed. Inflammation or infection of the appendix, intestines or gall bladder may also be detected, so that appropriate treatment may be started. In addition, by using specialized instruments during the laparoscopy, many of these problems may be treated at the same time. Adhesions and endometriosis may be cut away, and ovarian cysts or a tubal pregnancy removed.

PILES: MINIMALLY INVASIVE HEMORRHOID SURGERY

ABOUT HEMORRHOIDS
Hemorrhoids are clusters of veins that lie under the skin of the anus. They extend from inside the anus (internal hemorrhoids) to just outside the anus (external hemorrhoids). Things that cause increased pressure on these veins (pregnancy, prolonged sitting on the toilet, straining, long-term constipation, long-term diarrhea, liver disease, etc.) cause them to enlarge. Everyone has hemorrhoids, but not everyone is bothered by them.

SYMPTOMS
Internal hemorrhoids can bleed when enlarged and inflamed. This is usually red blood that is seen on the toilet paper or on the stool or in the toilet bowl. It is rarely a large amount of blood, but it takes very little blood in the toilet to look like a lot.

Internal hemorrhoids can also grow large enough to prolapse, or fall out of the anus, usually with bowel movements. They can go back in on their own, but sometimes they have to be pushed back in. Rarely, they cannot be pushed back in, in which case you should go to the emergency room.

External hemorrhoids form skin tags when enlarged. These are usually noticed when wiping after bowel movements. If a blood clot forms under an external hemorrhoid, it is said to be “thrombosed”. This tends to happen suddenly and is quite painful. If emergency care is sought promptly, the clot can be removed by a colon and rectal surgeon, and the duration of pain can be shortened.

Many diseases that are much more deadly than hemorrhoids have similar symptoms. Any bleeding from the rectum should be evaluated by a doctor.

DIAGNOSIS
History and physical exam are usually adequate to diagnose hemorrhoids. Anoscopy, in which a small tube is inserted into the rectum in the doctor’s office, is the best way to see and evaluate hemorrhoids. It is actually better for hemorrhoids than colonoscopy.

TREATMENT
Non-Operative Treatment
Probably 95% of patients with hemorrhoid trouble can be treated without surgery. The principles of non-operative treatment of hemorrhoids are:
• A high fiber diet or taking a fiber supplement
• Having soft, formed bowel movements
• Avoid sitting on the toilet beyond the time needed for each bowel movement (Do not read or watch TV on the toilet. If you did not really need to go or are not sure if you’re done, get up and come back if needed)
• Use baby wipes instead of toilet paper if you have pain, itching or irritation

Operative Treatment: Minimally Invasive Hemorrhoid Surgery
Minimally invasive techniques to treat hemorrhoids are good for internal hemorrhoids, since that area has nerve endings for pressure but not for pain.

Banding
The internal hemorrhoid is lifted up and a tiny rubber band dropped around it, effectively choking it off and scarring it down.

Stapled Hemorrhoidectomy (PPH)
A ring of rectal tissue above the internal hemorrhoids is cut out and stapled together, drawing the hemorrhoids up and cutting off their blood supply. This is most effective for patients with large circumferential internal hemorrhoids. This is performed in the operating room under spinal or general anesthesia.

External hemorrhoids, unfortunately, cannot be treated with “painless” techniques because the skin over them is very sensitive.

Hemorrhoidectomy
Traditional surgery for hemorrhoids involves cutting out an ellipse of skin over the hemorrhoid (usually both the internal and external parts) and sewing it up in a straight line. It is very effective, but the discomfort that it causes means that colon and rectal surgeons reserve it for those who will truly benefit.

THYROID SURGERY

WHAT IS THE THYROID GLAND?
The thyroid gland is a butterfly-shaped endocrine gland that is normally located in the lower front of the neck. The thyroid’s job is to make thyroid hormones, which are secreted into the blood and then carried to every tissue in the body. Thyroid hormone helps the body use energy, stay warm and keep the brain, heart, muscles, and other organs working as they should.

Thyroid operations are advised for patients who have a variety of thyroid conditions, including both cancerous and benign (non-cancerous) thyroid nodules, large thyroid glands (goiters), and overactive thyroid glands. There are several thyroid operations that a surgeon may perform, including:
1. excisional biopsy – removing a small part of the thyroid gland (rarely in use today);
2. lobectomy – removing half of the thyroid gland;
3. removing nearly all of the thyroid gland (subtotal thyroidectomy – leaving a small amount of thyroid tissue bilaterally or near-total thyroidectomy – leaving about one gm or cm of thyroid tissue on one side); or
4. total thyroidectomy, which removes all identifiable thyroid tissue.

There are specific indications for each of these operations. The main risks of a thyroid operation involve possible damage to important structures near the thyroid, primarily the parathyroid glands (which regulate calcium levels) and the recurrent and external laryngeal nerves (which control the vocal cords).

WHY DO I NEED AN OPERATION?
The most common reason for thyroid surgery is to remove a thyroid nodule, which has been found to be suspicious through a fine needle aspiration biopsy (see Thyroid Nodule brochure). Surgery may be recommended for the following biopsy results:
1. cancer (papillary cancer);
2. possible cancer (follicular neoplasm); or
3. inconclusive biopsy.

Surgery may be also recommended for nodules with benign biopsy results if the nodule is large, if it continues to increase in size or if it is causing symptoms (pain, difficulty swallowing, etc.). Surgery is also an option for the treatment of hyperthyroidism (see Hyperthyroidism brochure), for large and multinodular goiters and for any goiter that may be causing symptoms.

ARE THERE OTHER MEANS OF TREATMENT?
Surgery is definitely indicated to remove nodules suspicious for thyroid cancer. In the absence of a possibility of thyroid cancer, there may be nonsurgical options of therapy depending on the diagnosis. You should discuss other options for therapy with your physician.

HOW SHOULD I BE EVALUATED PRIOR TO THE OPERATION?
As for other operations, all patients considering thyroid surgery should be evaluated preoperatively with a thorough and comprehensive medical history and physical exam, including cardiopulmonary (heart) evaluation. An electrocardiogram and a chest x-ray prior to surgery is often recommended for patients who are over 45 years of age or who are symptomatic from cardiac disease. Blood tests may be performed to determine if a bleeding disorder is present. Any patients who have had a change in voice or who have had a previous neck operation should have their vocal cord function evaluated preoperatively. This is necessary to determine whether the recurrent laryngeal nerve that controls the vocal cord muscles is functioning normally. Finally, if medullary thyroid cancer is suspected, patients should be evaluated for coexisting adrenal tumors (pheochromocytomas) and for hypercalcemia and hyperparathyroidism.

HOW DO I SELECT A SURGEON?
In general, thyroid surgery is best performed by a surgeon who has received special training and who performs thyroid surgery on a regular basis. The complication rate of thyroid operations is lower when the operation is done by a surgeon who does a considerable number of thyroid operations each year. Patients should ask their referring physician where he or she would go to have a thyroid operation or where he or she would send a family member.

WHAT ARE THE RISKS OF THE OPERATION?
The most serious possible risks of thyroid surgery include:
1. bleeding that can cause acute respiratory distress,
2. injury to the recurrent laryngeal nerve that can cause permanent hoarseness, and
3. damage to the parathyroid glands that control calcium levels in the body, causing hypoparathyroidism and hypocalcemia.

These complications occur more frequently in patients with invasive tumors or extensive lymph node involvement, in patients requiring a second thyroid surgery, and in patients with large goiters that go below the collarbone. Overall the risk of any serious complication should be less than 2%. However, the risk of complications discussed with the patient should be the particular surgeon’s risks rather than that quoted in the literature. Prior to surgery, patients should understand the reasons for the operation, the alternative methods of treatment, and the potential risks and benefits of the operation (informed consent).

HOW MUCH OF MY THYROID GLAND NEEDS TO BE REMOVED?
Your surgeon should explain the planned thyroid operation, such as lobectomy or total thyroidectomy, and the reasons why such a procedure is recommended. For patients with papillary or follicular thyroid cancer many, but not all, surgeons recommend total or neartotal thyroidectomy when they believe that subsequent treatment with radioactive iodine might be beneficial. For patients with large (>1.5 cm) or more aggressive cancers and for patients with medullary thyroid cancer, more extensive lymph node dissection is necessary to remove possibly involved lymph node metastases.

Thyroid lobectomy may be recommended for overactive one-sided nodules or for benign one-sided nodules that are causing symptoms such as compression, hoarseness, shortness of breath or difficulty swallowing. A total or near – total thyroidectomy may be recommended for patients with Graves’ Disease or for patients with enlarged multinodular goiters

WHAT CAN I EXPECT ONCE I DECIDE TO PROCEED WITH SURGERY?
Once you have met with the surgeon and decided to proceed with surgery, you will be scheduled for your pre-op evaluation (see above) and will meet with the anesthesiologist (the person who will put you to sleep during the surgery). You should have nothing to eat or drink after midnight on the day before surgery and should leave valuables and jewelry at home. The surgery usually takes 2-2½ hours, after which time you will slowly wake up in the recovery room. Surgery may be performed through a standard incision in the neck or may be done through a smaller incision with the aide a a video camera (Minimally invasive video assisted thyroiectomy) Under special circumstances, thyroid surgery can be performed with the assistance of a robot through a distant incision in either the axilla or the back of the neck. There may be a surgical drain in the incision in your neck (which will be removed the morning after the surgery) and your throat may be sore because of the breathing tube placed during the operation. Once you are fully awake, you will be moved to a bed in a hospital room where you will be able to eat and drink as you wish. Most patients having thyroid operations are hospitalized for about 24 hours and can be discharged on the morning following the operation. Normal activity can begin on the first postoperative day. Vigorous sports, such as swimming, and activities that include heavy lifting should be delayed for at least ten days.

WILL I BE ABLE TO LEAD A NORMAL LIFE AFTER SURGERY?
Yes. Once you have recovered from the effects of thyroid surgery, you will usually be able to doing anything that you could do prior to surgery. Many patients become hypothyroid following thyroid surgery, requiring treatment with thyroid hormone (see Hypothyroidism brochure). This is especially true if you had surgery for thyroid cancer. Thyroid hormone replacement therapy may be delayed for several weeks if you are to receive radioactive iodine therapy

VEINS SURGERY

Varicose veins are swollen and twisted veins that are visible just under the surface of the skin. They appear most commonly in the legs, but also can develop in other parts of the body.

Veins are blood vessels that carry blood from the tissues of the body to the heart. In the heart, blood is pumped to the lungs to pick up oxygen. The oxygen-rich blood is then pumped out to the body through the arteries. From the arteries, blood flows through tiny blood vessels called capillaries, where it gives up its oxygen to the body tissues. The blood then returns back to the heart through the veins to pick up more oxygen.

Varicose Veins have one-way valves that help to keep the blood flowing toward the heart. When the valves don’t work well, blood backs up and pools in the veins. This causes them to swell and become varicose veins.

Varicose veins usually don’t cause medical problems. On occasion, they require treatment for pain, skin problems, blood clots, or other complications. People may choose to have cosmetic treatment to improve the appearance of varicose veins.

RELATED VEIN PROBLEMS
A number of other types of vein problems are related to varicose veins.

Spider Veins
Spider veins are a smaller version of varicose veins. They occur in the capillaries, which are the smallest blood vessels in the body. Spider veins are commonly found on the legs and face, and they usually resemble a spider web or tree branch in shape. They can be red or blue. Spider veins are usually not a medical concern. Telangiectasias

Telangiectasias (tel-AN-juh-ek-TA-ze-uhs) are small clusters of blood vessels that look similar to spider veins. They are red in color and are commonly found on the upper body, including the face. They can develop during pregnancy and in people who have certain genetic disorders, viral infections, and other medical conditions (such as liver disease). Newly developed telangiectasias are often a reason to see a doctor.

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