Other Keyhole Procedures

As a specialist in advanced laparoscopic abdominal surgery, Dr Craig Taylor regularly performs other common procedures on the abdomen including removal of the gallbladder, repair of the reflux valve, and fixing of groin hernias. All procedures are performed using the very latest keyhole techniques resulting in minimal pain, short hospital stay, and an early return to work and everyday life.
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Removal of Gallbladder (including stones in the bile duct)

A gallstone, is a lump of hard material usually range in size from a grain of sand to 3-4 cms. They are formed inside the gallbladder formed as a result of precipitation of cholesterol and bile salts from the bile.

Types and causes of gallstones

Cholesterol stones: Cholesterol stones are usually yellow-green and are made primarily of hardened cholesterol. They account for about 80 percent of gallstones. Scientists believe cholesterol stones form when bile contains too much cholesterol, too much bilirubin, or not enough bile salts, or when the gallbladder does not empty as it should for some other reason.
Mixed stones: the most common type. They are comprised of cholesterol and salts
Pigment stones: Pigment stones are small, dark stones made of bilirubin. The exact cause is not known. They tend to develop in people who have cirrhosis, biliary tract infections, and hereditary blood disorders such as sickle cell anaemia in which too much bilirubin is formed.

Other causes are related to excess excretion of cholesterol by liver through bile. They include the following:

Gender. Women between 20 and 60 years of age are twice as likely to develop gallstones as men.
Obesity. Obesity is a major risk factor for gallstones, especially in women.
Oestrogen. Excess oestrogen from pregnancy, hormone replacement therapy, or birth control pills.
Cholesterol-lowering drugs.
Diabetes. People with diabetes generally have high levels of fatty acids called triglycerides .
Rapid weight loss. As the body metabolizes fat during rapid weight loss, it causes the liver to secrete extra cholesterol into bile, which can cause gallstones.

Symptoms

Many people with gallstones have no symptoms. These patients are said to be asymptomatic, and these stones are called "silent stones."Gallstone symptoms are similar to those of heart attack, appendicitis, ulcers, irritable bowel syndrome, hiatal hernia, pancreatitis, and hepatitis. So accurate diagnosis is important.

Symptoms may vary and often follow an hour or two after fatty meals, and they may occur during the night:

Abdominal bloating
Recurring intolerance of fatty foods
Steady pain in the upper abdomen that increases rapidly and lasts from 30 minutes to several hours
Pain in the back between the shoulder blades
Pain under the right shoulder
Nausea or vomiting
Indigestion and belching

Diagnosis

Ultrasound is the most sensitive and specific test for gallstones.

Other diagnostic tests may include:

Computed tomography (CT) scan may show the gallstones or complications
Endoscopic retrograde cholangiopancreatography (ERCP). The patient swallows an endoscope--a long, flexible, lighted tube connected to a computer and TV monitor. The doctor guides the endoscope through the stomach and into the small intestine. The doctor then injects a special dye that temporarily stains the ducts in the biliary system. ERCP is used to locate and remove stones in the ducts
Blood tests. Blood tests may be used to look for signs of infection, obstruction, pancreatitis, or jaundice.

Stones in the Bile Ducts

Bile-duct blockage and infection caused by stones in the biliary tract can be a life-threatening illness. With prompt diagnosis and treatment, the outcome is usually very good. Cholangitis is an infection of the common bile duct, which carries bile (which helps in digestion) from the liver to the gallbladder and then to the intestines. Long term obstruction to the bile ducts caused by a gallstone may lead to cirrhosis, a type of chronic liver disease that causes scarring of the liver (fibrosis - nodular regeneration) and liver dysfunction. This is a complex problem and is difficult to treat. Treatment options include long term antibiotic use, removal of the most scarred parts of the liver, and multiple attempts to clear stones by endoscopy and radiology.

Treatment

Surgery to remove the gallbladder is the standard way to treat symptomatic gallstones. The operation is called laparoscopic cholecystectomy. In the past various alternatives to removing the gallbladder have been tried but do not work. Thes include attempting to dissolve the gallstones with various medications and remedies, and shock waves to shatter the stones. Unfortunately these methods have universally failed, and the only treatment method that has been proven to work is removal of the gallbladder.

For this operation, 4 tiny incisions are made to insert surgical instruments and a miniature video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts and other structures. The whole procedure usually takes less than one hour, and patients are discharged the next day. Only a few days off work are needed.

During the procedure an X-ray is performed to see if any gallstones are also present in the bile ducts. It is usually possible to remove any stones with a special wire basket during the same operation. However if this is unsuccessful then an ERCP (endoscopic retrograde cholangiopancreatography) can be performed by a Gastroenterologist after the gallbladder surgery.

People are often concerned that the removal of their gallbladder might in some way affect their diet- this is not correct. Just remember, its the liver that makes bile, not the gallbladder. The gallbladder just stores it between meals. After removing the gallbladder, the liver continues to make the same amount of bile, which now is secreted directly into the small intestine where it is needed rather than being temporarily stored in the gallbladder. The ability to digest fatty foods is not affected. Besides, when a gallbladder has stones, it becomes chronically inflammed and doesn't function properly anyway. It is no longer of any use.

Hernia Surgery

A hernia is a weakness or defect in the abdominal wall. It may be present from birth, or develop over a period of time. If the defect is large enough, abdominal contents such as the bowels, may protrude through the defect causing a lump or bulge felt by the patient.

Hernias develop at certain sites which have a natural tendency to be weak; the groin area, umbilicus (belly button), and previous surgical incisions.

Signs and Symptoms

Lump in groin area when standing/straining and disappears when reclining
Pain at the site of the lump, especially when lifting a heavy object
Swelling of the scrotum
Excruciating abdominal pain (if you have strangulation)
Nausea, vomiting & crampy pain in the central and lower abdomen (if intestinal obstruction occurs)

Course of Hernia

Once a hernia has developed, it will tend to enlarge and cause discomfort. If a loop of bowel gets caught in the hernia, it may become obstructed or its blood supply may be cut off. This could then become a life-threatening situation. Since hernias can be repaired effectively and with minimal risk, most surgeons therefore recommend that hernias be repaired when diagnosed, unless there is serious medical problem which makes it too risky.

Treatment- Surgical Repair

Dr Taylor specialises in a newer type of hernia repair that involves minimally invasive laparoscopic techniques. This type of groin hernia repair is called the Laparoscopic Totally Extra-Peritoneal (TEP) approach, and involves just 3 tiny incisions. As well as virtually invisible scars, the main advantages of this approach over the traditional open method are less pain and a faster recovery. Another key difference is that the reinforcing mesh is placed behind the muscle layer rather than in front. This creates a stronger repair which is less likely to fail long term- its a bit like patching a tyre puncture from the inside. The procedure can be performed as day surgery, and patients are able to return to work within 3 days. This type of hernia repair is particularly advantageous if you have hernias on both sides (bilateral) or have had an open hernia repair in the past that has now recurred. We usually perform our hernia repairs on a Friday so that you can use the weekend to recover and be back at work on the Monday. Dr Taylor has repaired over 1000 hernias using this technique with no major complications.

Anti-reflux and Heartburn Surgery

The oesophagus carries food from the mouth to the stomach. The lower oesophageal sphincter is a ring of muscle at the bottom of the oesophagus that acts like a valve between the oesophagus and stomach.

Gastro Oesophageal reflux disease, or GORD, is a chronic disease that occurs when the lower oesophageal sphincter does not close properly and stomach contents leak back, or reflux, into the oesophagus.

When refluxed, stomach acid touches the lining of the oesophagus, it causes a burning sensation in the chest or throat called heartburn. The fluid may even be tasted in the back of the mouth, and this is called acid indigestion. Occasional heartburn is common but does not necessarily mean one has GORD. Heartburn that occurs more than twice a week may be considered GORD, and it can eventually lead to more serious health problems. Anyone, including infants, children, and pregnant women, can have GORD.

Symptoms

The main symptoms are persistent heartburn and acid regurgitation. Some people have GORD without heartburn. Instead, they experience pain in the chest, hoarseness in the morning, or trouble swallowing. You may feel like you have food stuck in your throat or like you are choking or your throat is tight. GORD can also cause a dry cough and bad breath.

The most frequent symptoms of GORD are so common that they may not be associated with a disease. Self-diagnosis can lead to mistreatment. Consultation with a physician is essential to proper diagnosis and treatment of GORD.

Causes

Hiatus hernia. An Hiatal hernia is when the upper part of the stomach slides up above the diaphragm, the muscle wall that separates the stomach from the chest, which greatly interferes with the function of the reflux valve.
Alcohol use
Overweight
Pregnancy
Smoking.

Also, certain food and drinks are associated with reflux, such as spicy and fatty foods, and caffeine.

Diagnosis

The diagnosis of GORD is based on a history of heartburn which is often relieved by anti-acids or medication such as Zantac, confirmed by specialised medical tests including:

upper endoscopy
pH and manometry
Barium Swallow X-ray

Sometimes the presentation of GORD may be atypical, such as difficulties swallowing, chronic cough or breathing difficulties mislabelled as 'asthma', bad breath, and dental caries. The tests above will usually uncover the underlying diagnosis of GORD, however in borderline cases more specialised tests such as a Medical Isotope scan or impedence manometry may be required.

Treatment

In mild or occassional cases simple lifestyle modification with weight-loss, cessation of smoking, reduction in alcohol and the avoidance of precipitating foods should be tried. Propping up the head of the bed can help relieve night-time reflux.

Medication designed to reduce acid production by the stomach is the next step. Medications include H2-blockers such as Zantac or Rani, and Proton Pump Inhibitors including Somac, Losec, Nexium, and Pariet. These medications are usually effective in reducing the feeling of heartburn, however they do not improve the function of the anti-reflux valve or treat volume reflux.

Surgical treatment

Surgery is an option when medicine and lifestyle changes do not work. Surgery may also be a reasonable alternative to a lifetime of drugs and discomfort. In recent years there has been a dramatic improvement in the results from anti-reflux and hiatus hernia surgery. One of the major advances has been the ability to perform these procedures using laparoscopic keyhole techniques, reducing pain, wound size, and making recovery much quicker.

Laparoscopic Nissen Fundoplication

If a combination of lifestyle changes and drug therapy does not remedy reflux symptoms, a Nissen Fundoplication can be a very effective surgical procedure to correct reflux. This procedure involves wrapping the upper portion of the stomach around the base of the oesophagus to reinforce the strength of the lower oesophageal sphincter. Newer versions of the Nissen Fundoplication involve a partial rather than a complete 360 degree wrap, and these appear to have fewer side effects such as bloating, and are therefore preferred by Dr Taylor.

The surgery is performed under General Anaesthesia and 4 or 5 small incisions are made in the upper abdomen. The procedure usually involves a 1-2 night hospital stay, and 1 week off work.

Laparoscopic Nissen Fundoplication is a safe and effective treatment of GORD. However, in rare cases the laparoscopic approach is not possible because it becomes difficult to visualize or handle organs effectively. In such instances, the traditional incision may need to be made to safely complete the operation. (This is very uncommon however, as Dr Taylor has never had to convert from laparoscopy to open surgery)

Costs

The following are the out-of-pocket costs ("the Gap") for Dr Taylor with private health insurance. This also includes the assistant surgeon, and all of your routine aftercare including post-operative check-ups. The anaesthetic fees are not included and are billed separately. You will be provided with the contact details of your anaesthetist prior to your procedure so that a quotation can be obtained.

groin hernia repair:	$800
gallbladder removal:	$800
incisional hernia repair:	$1000
hiatus hernia and antireflux surgery:	$1000