Surgery and Allied Specialities

Advanced Centre for Surgery and Allied Specialities

Gastroenterology department at Aster RV Hospital JP Nagar, Bangalore is offering a world-class, dedicated facility for comprehensive management of diseases and disorders of the digestive system. The Gastroenterology team includes renowned and experienced surgical gastroenterologists, general, robotic and laparoscopic surgeons, medical gastroenterologists, bariatric surgeons, interventional endoscopists and stomach-care therapists with highly qualified support teams trained in basic and advanced endoscopy, nutrition and GI oncology. We also have a dedicated specialist in GI oncology, dealing with cancer of the GI tract.

 

Surgical Gastroenterology:

One of the most advanced facilities in the region for surgical management of gastrointestinal disorders/diseases, the Aster RV's Centre of Excellence in Gastroenterology has an exceptional team of highly experienced surgical gastroenterologists with international expertise. The centre offers state-of-the-art facilities and clinical support including South Asia’s first OR1 Karlstroz fusion integrated surgical suites, a highly advanced endoscopy suite, ERCPs, GI motility studies and endosonography, high-definition laparoscopy, harmonic scalpel, ligature, CUSA excel, image intensifiers and intraoperative ultrasound for high-precision procedures.

 

Bariatric surgery:

The experts at Aster RV Hospital perform various successful weight loss surgeries like a keyhole or laparoscopic bariatric surgeries. Our surgeons have expertise in performing various bariatric surgical procedures such as Gastric banding, SILS sleeve gastrectomy, and Gastric bypass (RYGB and MGB), Endoscopic intragastric balloon placement, and Biliopancreatic diversion with duodenal switch depending on the patient’s need and assessment. Long-term follow-up with continued access to the bariatric team for advice and support is extended to all patients.

Aster RV Hospital in JP Nagar, Bangalore has a team of surgical gastroenterologists with experience at the national and international level. The department is backed by state-of-the-art facility inclusive of South Asia’s first OR1 Karl Storz fusion integrated surgical suites, which is further complemented by high-definition laparoscopy unit, CUSA excel, harmonic scalpel, image intensifiers, highly advanced endoscopy suite, intraoperative ultrasound allowing for advanced and complex laparoscopic procedures using cutting-edge technology.

For example:

  • Minimal access oesophageal surgeries-oesophagectomy for benign and cancerous conditions
  • GE Junction surgeries- fundoplication and cardiomotomy
  • Gastric cancer surgery, biliary tract surgery, pancreatic surgeries
  • Surgery for colorectal diseases-benign and malignant diseases
  • Solid organ surgery- splenectomy, hepatic resections
  • SILS (Single Incision Laparoscopic Surgery)- cholecystectomy, appendectomy, hernia surgery
  • TAMIS (Transanal Minimal Invasive Surgery)
Our experts perform various weight loss surgery – keyhole / laparoscopic surgery with results comparable to international standards. A multimodal approach to obesity includes a team of an experienced endocrinologist, physician, psychiatrist and dietician in addition to an excellent team of anaesthetists. This multimodal approach to the treatment of obesity has led to excellent longterm results ensuring improvement in diseases like diabetes, high cholesterol level, hypertension in addition to significant weight loss. Strict adherence to evidence based preoperative and postoperative protocols has enabled for a safe and effective bariatric programme with excellent long term outcome. We at Aster RV perform sleeve gastrectomy, gastric bypass - MGB, RYGB. endoscopic intragastric balloon placement.
The department has a DaVinci Surgical Robot which complements the state-of-the-art laparoscopic unit. The surgical robot enables complex surgeries to be performed with the smallest of cuts, maximum precision and safety.
The department is one of the very few to be doing endoscopic thyroidectomy (scarless neck thyroid surgery) allowing an excellent cosmetic result. In addition, surgeries for parathyroid and adrenal tumours are performed routinely.
The centre for hernia surgery at Aster RV Hospital specializes in the surgery of complex large and recurrent hernias by the open and laparoscopic method. This is in addition to the performing routine laparoscopic repairs for standard hernias. Ex: ETEP, E-TAR, SCOLA, component separation.
Emergency laparotomy for perforation of the intestinal tract, obstruction/strangulation of bowel oesophageal perforation surgery and chest trauma.
Thoracic sympathectomy, decortication, lobectomy and oesophagus surgery.
Excision of lipoma, sebaceous cyst, lymph node biopsy, small tumours excision, hydrocele surgery, circumcision, varicocele, foot ulcers etc.

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FAQs

Robotic Surgery

What is Robotic Surgery?

Robotic Surgery is a Minimal Access Surgical technique where the Surgeon uses a Surgical Robot to perform the surgery. Surgery is performed under General Anaesthesia.

What are the advantages of Robotic Surgery?

Robotic Surgery has several advantages for the patient of which the following are most relevant;

1. Improved Surgical accuracy due to 3D vision with Magnification.

2. Enhanced ability to perform complex surgeries in challenging anatomical areas e.g Male pelvis, using Minimal Access Techniques.

3. Lesser blood loss due to improved vision, smaller incisions, and the use of advanced energy sources.

4. Decreased postoperative pain and quicker recovery.

How is Robotic Surgery performed?

Robotic Surgery is performed in the following manner:

1. The patient is anaesthetized( General anaesthesia) and positioned appropriately on the operating table

2. The Robot is positioned and the Surgeon with the help of his assistant places the Robotic ports into the Abdominal cavity(similar to Laparoscopy) and these are then attached to the Robot(Docking the Robot). The instruments are then placed through the ports and connected to the Robot.

3. The Surgeon then sits at the Master Console and using the Robot completes the planned operation. The Surgeon’s operative view is a 3d stereoscopic HD with magnification. The Robot also eliminates any tremors. This allows for very accurate surgery.

4. After the procedure is completed, the Robotic instruments are removed and the Robot is detached from the patient(Undocking the Robot). The Surgeon then completes the closure of the port sites(small cuts) and then the patient is brought out of Anaesthesia by the Anaesthetist.

Does the Robot independently perform any steps of the Surgery?

No, the Surgical Robot cannot and does not operate independently of the Surgeon. Current Robotic Technology is based on the “Master and Slave” Principle, where the Surgeon is the complete “Master” and the “Robot” is the absolute slave, incapable of doing any step without the Surgeon. In effect the Robot is a very high-tech extension of the Surgeon’s hands and fingers.

What are the types of Surgeries that are performed using the Surgical Robotic?

Most Laparoscopic(Keyhole) Surgeries can be performed using the Robot. The Robot is most useful in Surgeries needing manipulations in narrow, deep areas with many critical structures in the vicinity, for e.g:

1. Rectal and Colon Cancer Surgeries.

2. Stomach and Oesophageal Cancer Surgeries.

3. Surgeries on the Oesophagus(Food pipe) for conditions like Achalasia Cardia(Swallowing issue due to non-relaxation of the lower end of the food pipe).

4. Pancreatic and Hepatobiliary Surgeries.

5. Adrenalectomy (removal of the Adrenal gland for tumours).

6. Neck Surgeries e.g Scarless Thyroidectomy(Thyroid gland removal).

7. Urological Surgeries(Radical Prostatectomy-is the most common Robotic Surgery) and Gynecological surgeries.

When should I choose to undergo Robotic Surgery?

Based on the diagnosis of your clinical condition and the planned Surgery, the Consultant Surgeon would give the patient the option of Robotic Surgery if it is deemed to confer an advantage to the patient and would improve outcomes. At this point all the pros and cons of the proposed Surgery and the probable alternatives like Open Surgery are discussed before a fully informed decision is made.

Are there any disadvantages of undergoing a Robotic Surgery?

The only disadvantage of a Robotic Surgery is the cost. Surgery is more expensive than alternative methods of operating, but this is to be expected when such advanced technology and skill is being used. The advantages of Robotic Surgery far outweigh the cost disadvantage for the appropriate surgery.

Laparoscopic appendicectomy

What is Acute Appendicitis?

Acute Appendicitis is one of the commonest surgical emergencies occurring due to acute inflammation or infection of the Appendix. The Appendix is a small tubular structure found attached to the Caecum, which is the first part of the Large Intestine(Colon), situated in the right lower quadrant of the abdomen.

What are the symptoms of Acute appendicitis and how is it diagnosed?

Acute Appendicitis can present with a variety of symptoms, which can sometimes be confusing. The most common symptoms are pain and uneasiness around the belly button(Umbilicus) which later moves to the right lower quadrant of the abdomen. This may be associated with nausea and vomiting. Occasionally the patient may have loose stools or pain lower down in the abdomen on the right side or towards the back, due to the variability in positions of the Appendix.

A diagnosis of Acute Appendicitis is made by a combination of a clinical suspicion that is confirmed by some blood tests and an ultrasound scan or a CT Scan of the Abdomen- Pelvis.

Once confirmed, the gold standard of treatment for Appendicitis is Appendicectomy.

What is an Appendicectomy?

Appendicectomy is a surgical procedure to remove the Appendix. Most of the time the procedure is done Laparoscopically i.e by Keyhole Surgery. In this method,3-4 small cuts are made on the abdominal wall to introduce a camera and instruments. The cuts vary between 5 and 10mm.

However, in some complicated situations, the surgery would be performed by the open technique, which entails cutting a few centimeters on the abdomen to remove the inflamed Appendix.

In either of the methods, if the Surgeon deems it necessary, a tube drain may be placed to vent out the infected fluid. This is usually removed after a few days. Both the methods entail giving the patient a General anaesthetic.

What are the risks of the procedure?

As with any surgery there are certain risks associated with the procedure. Clearly one must understand that the surgery is performed only when it is deemed that the benefit of Surgery is far greater than the risks involved.

Specific to an appendicectomy, the risks are related to the degree of infection in the Appendix. Patients with complicated or ruptured Appendicitis can have the following specific issues:

1. Recurrent infection leading to abscess formation.

2. Leakage from the Appendicular base.

3. Postoperative ileus-gaseous distension of the small intestine.

4. Postoperative sepsis syndrome- a rare life-threatening situation where the infection causes life-threatening dysfunction of multiple organ systems, usually seen in very late cases with diseases like Diabetes or compromised immunity.

Is Surgery mandatory?

Appendicectomy i.e removal of the Appendix is the Gold Standard for treatment of acute appendicitis. However, in certain situations surgery may be deferred to a later date or indefinitely:

1. Appendicular lump formation: This is a situation where due to a delay in the presentation the Appendicitis has been “walled off” by the Omentum and small intestine forming a mass around the Appendix. This is nature’s way of preventing the infection from spreading in the abdomen. It is best to treat this with antibiotics and defer Surgery to a few weeks later when the mass has resolved.

2. Some cases of mild Appendicitis where the inflammation is resolving rapidly and spontaneously with or without antibiotics. In this situation the Surgery may be deferred to the next episode of inflammation. It is a recognised fact that the subsequent Surgery can be more difficult due to adhesions and the possibility of an early rupture of the Appendix.

3. Moribund patient: The very rare situation where the patient is moribund and considered unfit for an anaesthetic or surgery due to pre-existing medical conditions.

Will it be painful?

It is normal to have some pain in your tummy and around the wound for a few days after your surgery. This can be managed with regular painkillers. Your tummy may feel bloated afterward, but this will settle in time. If you have had a keyhole(Laparoscopic) procedure, you may experience some pain in your shoulder. This is due to the air insufflated along with the instruments, which gets absorbed into the body. Walking around can help this to improve. You may also notice that you have a sore throat afterward. This is a transient sensation and is due to the breathing tube placed in your throat for the general anaesthetic.

When can I go home?

Most patients can go home a day after the surgery. In cases where the Appendicitis has been complicated by a rupture or abscess formation, or sometimes due to other conditions, the discharge may be delayed by a few days.

How long before I am back to my normal activities

Most patients can get back to their routines in about a week after the surgery(Laparoscopic). This may change depending on a variety of factors like the severity of the Appendicitis, pain threshold of the patient, intensity of the patient’s routine and pre-existing conditions to name a few.

When can I have a bath or shower?

Dressings on your wound are removed at the time of discharge in most cases. You can wash your body, but please make sure you keep your wounds completely dry for the first 48 hours after your surgery. Pat the wounds gently when drying. Avoid using creams or ointments on your wounds until they have fully unless these have been specifically prescribed by the Surgeon.

Can I eat and drink as normal after the surgery?

You may find small, frequent meals easier in the first few days after your surgery. Increase your intake of foods at your own pace. While you do not need to keep to a specific diet after appendix removal, most patients feel more comfortable with smaller frequent and light meals. It is best to avoid fizzy drinks, alcohol, and large greasy meals until after the clearance is given by the team.

Surgery for Gallstones-laparoscopic Cholecystectomy (Keyhole removal of the Gallbladder)

What is a laparoscopic cholecystectomy?

Laparoscopic Cholecystectomy is an operation to remove the Gallbladder using a Laparoscopic (Keyhole) surgery. This procedure is most commonly performed for symptomatic Gallstones under General anaesthesia. It involves making 3-4 small holes on the abdomen, the largest of which is 10mm and the others being 5mm. The Laparoscope and instruments are inserted into the abdomen through these ports and the Gallbladder is securely detached from its connections and removed along with the Gallstones. The postoperative recovery is usually quite rapid, with most patients being able to walk within 6 hrs of the surgery and able to eat a semisolid meal in 8-10 hours. After being fully out of the effects of the anaesthetic agents.

Occasionally the same procedure can be done by the SILS (Single-incision Laparoscopic surgery) method. This involves performing the entire operation through the Umbilicus (belly button). The post-operative recovery is the same as with a Multi-port laparoscopy. The biggest advantage of the SILS method is that after complete healing the scar is almost invisible, being hidden in the belly button.

What are the symptoms of Gallbladder Stones?

Gallbladder stones can present in different ways, the common symptoms are of “Indigestion”, right upper abdominal pain which may radiate to the right scapular area, Nausea and occasionally vomiting. Sometimes due to the Gallstones causing complications, the symptoms may be more acute and could be associated with severe pain in the upper abdomen and back, fever and jaundice. The symptoms typically occur after a fatty or heavy meal and tend to be recurrent.

What are the benefits of Laparoscopic surgery?

The benefits of removing the gallbladder by the laparoscopic method are:

  • Less pain after surgery
  • Shorter hospital stay
  • Quicker return to full activity and work
  • Less visible abdominal scars

Are there any alternative treatments?

For some conditions, Open cholecystectomy is recommended, where a large incision is made to remove the GallBladder. In very occasional cases, your gallstones may be suitable for treatment with medicines that allow your stones to dissolve. This is typically possible with a single cholesterol stone that is not causing any symptoms. Your doctor will explain this if it applies to you.

Are there risks involved in Laparoscopic Cholecystectomy?

There are risks associated with any surgery. In particular, the risks involved with surgery on the Gallbladder are the following;

1. Bile Leak from the Bile ducts or the Liver.

2. Conversion to open procedure.

3. Injury to the Stomach or Intestine during the procedure.

Quite clearly these risks are very specific to certain clinical situations and your doctor will explain the specific risks of this surgery to you before asking you to sign the consent form. We always insist on the patients clearing all their doubts and understanding the procedure completely before undergoing the surgery.

Will I feel any pain during surgery?

You should expect some discomfort after the operation but the doctor will give you pain relief medications for this. Pain might be there in one or both shoulders. This is caused by irritation to your diaphragm by the carbon dioxide gas used during surgery. You may also feel some discomfort around the incision area and it will be better after taking pain relief. You will gradually reduce the medication after a few days until you no longer need it.

What happens to my gallbladder after surgery?

The gallbladder will be sent to the pathologist for examination. Your doctor will receive a full report from the pathologist after one week which will be discussed with you during your follow up visit.

How long will I be in the hospital?

Most Patients are discharged about 24 hours after the Surgery. Some patients may stay an additional day or two, depending on their recovery.

How long will I be back to my normal activities?

Most people return to work within a week or two of the surgery. Certain specific activity restrictions such as excessive straining and lifting heavy weights will be explained to you before discharge. Similarly, the dietitian will give you instructions on the appropriate post-operative diet. It is best to fully understand the dos and don'ts before discharge to ensure a smooth and early return to normalcy.

When can I bathe or shower?

The wound dressings are removed at the time of discharge in most cases. In most situations, you can have a bath or shower 48hrs after the surgery, unless specifically instructed otherwise.

Can I eat and drink as normal after the surgery?

Removal of the GallBladder does not alter your ability to digest food. However, you may find small and frequent are meals easier to digest in the first few days after your surgery. Increase your intake of foods at your own pace. While you do not need to keep to a specific diet after your gallbladder removal, some people find that they do not tolerate fatty foods in the initial few weeks.

Thyroid Surgery

What is the Thyroid gland and what is its function?

The Thyroid gland is Butterfly shaped organ located in the neck sitting on your windpipe just below the adam’s apple. It has two halves (left and right lobes) connected by a central bridge (isthmus).

The thyroid gland is responsible for secreting a hormone called “Thyroxine” which controls the body’s metabolism, which is essential for maintaining normal health.

Why do I need to undergo Thyroid surgery?

It is usually performed for the following reasons.

Goiter:

- Any increase in the size of a thyroid gland, from any cause, is called a goiter

- Increase in the size of the gland may lead to compression on the windpipe (trachea) or the food pipe (esophagus). This may warrant surgery.

- Even in the absence of pressure effects, a goiter can cause discomfort or cosmetically unacceptable appearance. In such a scenario you should discuss the risk and benefit of surgery with your surgeon

Development of a lump (nodule) in the gland:

- Nodules or lumps may develop in the thyroid gland which may be single (solitary nodule) or multiple (multi-nodular goitre)

- The elderly are more prone to develop nodules. Nodules are seen in 50% of women and 30% of men after the age of 50.

- These nodules are assessed by clinical examination, ultrasound examination, needle biopsy or all three tests as your surgeon suggests

- Sometimes these nodules may be cancerous and your surgeon will advice surgery involving removal of the thyroid gland

Over-active thyroid gland

Over-active Thyroid gland secreting excessive thyroxine may sometimes require thyroidectomy Eg. Graves Disease or toxic adenoma.

What are the types of thyroidectomies:

Depending on the nature of thyroid disease or the location of the thyroid lesion, your surgeon may suggest one of the following surgeries:

  • Hemithyroidectomy: Removal of one lobe of the thyroid and the isthmus
  • Total Thyroidectomy: Removal of the entire thyroid gland (both lobes of the thyroid and the isthmus) leaving no tissue behind.
  • Near Total Thyroidectomy: Occasionally, for surgical reasons, your surgeon may leave a very tiny amount of thyroid tissue behind. It is done to protect important structures that run very close to the thyroid gland in the neck.

What is lymph node surgery and when is it needed?

Lymph nodes are small bean shaped structures present at various locations in the body, which are helpful in the body’s immune system by filtering toxic substances that are harmful.

In patients who have a diagnosis of thyroid cancer, the lymph nodes around the thyroid gland may be involved and need to be removed as part of the cancer operation – This procedure is called as Central Lymph Node Dissection.

Will I Get a bad scar in my neck?

Conventional Thyroid surgeries involve a cut in front of your neck. However as in any surgery involving the face and neck, scars will be usually only mildly noticeable.

Is there any Key Hole surgery for thyroid as with the abdomen?

Yes! Key Hole surgery with a Scarless neck is an option in thyroid surgeries.

- The feasibility of such surgery depends on the size of the thyroid gland.

- Your surgeon will assess clinically and the ultrasound scan and will give you an option for a keyhole surgery or what is called an “Endoscopic Thyroidectomy”.

Pre-Operation Period

What are the precautions I need to take prior to surgery?

- Inform your surgeon and anaesthesiologist about any medications you are on including Thyroid medications. They may need to be continued even on the day of surgery with sips of water.

- If you are on any blood-thinning or antiplatelet medications like aspirin, clopidogrel, inform your surgeon – these may need be stopped 3-5 days prior to surgery.

What are all the preoperative preparations required prior to surgery?

- Routine Pre-operative investigations including thyroid function tests and radiological imaging tests will be done.

- Your vocal cords will be examined by another doctor in the hospital by passing a small nasal endoscope through your nose. This is a very quick and safe test done usually lasting less than a minute without much discomfort.

- An anaesthesiologist will evaluate you and give you the information what you need to know regarding the type of anaesthesia

- You will be asked to be on empty stomach for 6 hours prior to surgery

Post-Operation Period:

How long will I be in the hospital?

This depends very much on the exact diagnosis and the operation being performed. Usually the stay in the hospital post-surgery may vary between 24 - 48hours.

How do I take care of my wound?

- Normally a dressing will be present on the operative site for about 24 hrs which will be removed on the next day of surgery.

- No special care may be required except keeping the wound dry and clean.

- A tube may be in place to drain out excess fluid from the operation site. This may usually be removed 24 – 48 hours after surgery.

When can I take a shower?

- You can take a normal shower 24 hrs after removing the drain tube.

- After a shower, just dab the wound dry with a soft towel.

- However any excessive soakage at the drain or wound site will need to be informed to the surgeon and wetting the wound may be delayed.

Do I need to come for suture removal?

- Normally an absorbable suture would be placed at the operative site and may not require removal of sutures.

- In case of any nonabsorbable suture usage, your surgeon will let you know when can they be removed.

- Thyroidectomy is not a particularly painful operation and pain relief is rarely necessary after 72 hours.

- It is normal to feel tired following thyroid surgery and it may take up to a month before you feel you have your energy levels back.

Will I need Thyroid replacement tablets after my operation?

Patients who have had a total thyroidectomy or near-total thyroidectomy will need thyroid tablets postoperatively and this will be life long.

Are there any complications during or after thyroid surgery?

- Thyroid surgery is generally a safe procedure.

- The vast majority of patients undergoing an operation on the thyroid gland have no complications.

However, as with any surgical procedure, there are some risks associated with the operation and these will be fully explained to you by your surgical team.

What are the potential complications that I should know?

The thyroid gland is close to many nerves and blood vessels and hence the surgery carries a minor risk involving injury to these structures. These are more likely to occur in patients undergoing

  • Surgery for cancer
  • Lymph node surgery
  • Surgery for a large thyroid (goiter)
  • Revision thyroid or lymph node surgery

Nerve Injury:

- There are nerves running in close proximity to the thyroid gland which is responsible for the quality and the pitch of your voice – Recurrent laryngeal nerves and the superior laryngeal nerves one each on each side.

- Injury to these nerves may result in a change in voice

- These voice changes are usually transient lasting for few days to few weeks.

- However in very rare scenarios especially in thyroid cancer surgeries there is a minimal risk of permanent voice damage. Hence professionals whose career involves their voice – like singers and teachers need to discuss with your surgeon prior to surgery.

- Uncommonly injury to laryngeal nerves on both sides may warrant placing a breathing tube through the windpipe (tracheostomy). In most instances it is short term.

Low Calcium levels:

- We have four parathyroid glands, two on each side, each about the size of a grain of a lemon seed attached behind the thyroid gland.

- They are involved in regulating calcium levels in the blood.

- Normally the surgeon identifies and saves some or all of these glands.

However, during thyroid surgery the parathyroid glands can be bruised, damaged, or excised, causing low calcium levels in blood manifested by a sensation of tingling in the fingers and lips (pins and needles sensation) and/or cramps in the fingers.

- Even if the parathyroid glands are saved, there may be stunning of the glands causing low calcium levels for several days to weeks.

- These may be managed by replacing calcium usually orally by tablets.

Other Potential Complications:

Neck Numbness:

- Some patients may experience numbness around the thyroid surgery scar after their operation. This usually subsides with time.

Swallowing Difficulties:

- Mild swallowing difficulties may occur usually pain-related improves with analgesics

Wound related issues:

- Swelling around the wound may be seen for a few days – these are usually normal after surgery.

- Wound Infections are rarely seen

- Occasionally fluid may accumulate behind the wound called a seroma. Normally subsides with time.

Thyroid Storm:

- An Extremely rare complication in patients with the overactive thyroid gland (thyrotoxic patients) undergoing surgery

- Caused by a sudden excessive amount of thyroid hormone released into the bloodstream during surgery.

Hence all thyrotoxic patients must be put on medications to achieve normal thyroxine levels prior to surgery.

Do I still need to worry about my surgery?

Thyroid Surgeries are Safe surgeries with minimal risks. Speak to your surgeon before Surgery and clarify all your doubts and concerns. Your surgeon will allay all your fears regarding the surgery.

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