Back to Medical School, November 2, 2006
Endoscopic Surgery What the GP Needs to Know
Abeezar I. Sarela MSc MS FRCS Consultant Surgeon The General Infirmary at Leeds Wharfedale General Hospital Nuffield Hospital Leeds BUPA Hospital Leeds
Laparoscopic Surgery
Minimally Invasive Surgery/Minimal Access Surgery
• Indications and patient-selection
• Advantages & disadvantages
• Common complications
• Frequent questions asked by patients
Agenda Common Laparoscopic Operations
• Repair of hiatus hernia & anti-reflux surgery • Cholecystectomy & bile duct exploration • Groin hernia repair • Incisional or para-umbilical hernia repair • Obesity (bariatric) surgery • Gastrointestinal cancer surgery
Benefits of Laparoscopic Surgery
• • • • • • • Minimal post-operative pain Day-case or only overnight hospital stay Quick return to normal activities Less impairment of pulmonary function Less immune suppression Less blood loss Minimal risk of wound infection or hernia
Gastroesophageal Reflux Disease
• Afflicts 40% of adult population p.a. • 2% consult GP
• Prescribed drugs & endoscopies: £ 600m
• Over the counter drugs: £ 100m NICE, 2005
Poor Quality of Life with GORD
80 70 60 50 40 30 20 10
64%
48%
29% 22% 25%
14%
Symptoms unbearable Interests Sleep Sex life Sport + exercise Concentrating on job
0
Figures quoted from UK respondents (n=201).
N=230 confirmed GORD patients AstraZeneca UK Data on File NEX/084/FEB2003.
GORD Predicts Oesophageal Cancer
Heartburn (>5 years duration) Odds ratios
Once-a-week Nocturnal
>20 yrs, and score >4.5*
x8 x 11
x 43.5
Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831.
GORD Treatment
• Full-dose PPI for one or two months • Recurrent symptoms: PPI at lowest dose to control symptoms, with minimal repeat prescriptions • Treatment “on demand” basis
NICE, 2005
PPI Maintenance Therapy: Limitations
• Nocturnal acid breakthrough • Twice-daily dose for severe GORD • Insufficient control of regurgitation
• ? Interaction with H.pylori • Continuing biliary-pancreatic reflux • ? Long-term (> 10 years) safety • Cost
PPI Maintenance Therapy: Limitations
• Recurrent symptoms in 20-30% of patients on regular maintenance, low-dose PPI • Full dose PPI needs to be maintained for complicated GORD (NICE, 2005) • PPIs did not eradicate need for caution and restraint (NICE, 2005) • Most patients want to dispense with need for long-term PPIs (NICE, 2005)
Anti-Reflux Surgery
NICE Guidance, 2005 Surgery is not recommended for the routine management of uncomplicated GORD, BUT individual patients whose quality of life remains significantly impaired may value this form of treatment.
Severe Oesophagitis
Mild Oesophagitis
Stricture
Necrotising Oesophagitis
Carcinoma
Barrett’s Oesophagus
Laparoscopic Anti-Reflux Surgery Indications
• Long-standing GORD – PPI dependance • Poorly controlled GORD
• PPI intolerance • Respiratory manifestations • Complications – erosive oesophagitis, stricture, Barrett’s oesophagus
• Regurgitation • Large hiatus hernia
Laparoscopic Anti-Reflux Surgery
• • • • • Keyhole (One 12mm and five 5mm incisions) Obesity is not a contra-indication Usually overnight stay Stop PPI immediately Majority have immediate, complete symptom-control • Global improvement in well-being
Anti-Reflux Surgery
Sliding Hiatus Hernia
Crural Repair
Fundoplication
Laparoscopic Anti-Reflux Surgery Post-operative Issues
• “Sloppy” diet for initial 3-4 weeks • Problematic dysphagia is rare and indicates a mechanical problem
• Need for supplementary PPI is uncommon • Is recurrent dyspepsia due to reflux? • Gaseous bloating: common side-effect
Laparoscopic Cholecystectomy
• Diagnosis: USS versus MRCP
• Increased severity of inflammation in obese individuals • Value of routine intra-operative cholangiogram: “silent” stones in 5-10% with normal USS and normal LFTs • Laparoscopic CBD exploration: quick recovery and avoids post-op ERCP
Intra-operative Recognition
Should primary repair be attempted?
Laparoscopic Cholecystectomy Post-operative Issues
• Unusually severe abdominal pain: powerful marker of bile leakage
• Prolonged recovery time: often related to inflammation and spillage
• Inflammation around umbilical incision • Exacerbation of reflux symptoms • Missed bile duct stones and delayed stricture
Laparoscopic Groin Hernia Repair
• NICE guidance (Sept. 2004) • Laparoscopic approach is preferred option
for recurrent hernia or bilateral hernias • Laparoscopic approach should be offered
for primary, unilateral hernia
Laparoscopic Groin Hernia Repair Benefits
• Keyhole (One 1.5cm & two 5mm incisions) • Minimal pain • Day-case operation • Immediate return to normal activities • Do not drive – 1 week • Do not go to the gym – 1 month • Simultaneous repair of “silent” hernias
Laparoscopic Groin Hernia Repair Surgical Anatomy
Groin Anatomy
Pre-peritoneal Mesh
Laparoscopic Groin Hernia Repair Post-operative Issues
• Common features: Bruising, Seroma • Worrying features: Haematoma, Infection • Recurrence: ? superior to open repair
Laparoscopic Ventral Hernia Repair
• Keyhole (One 12 mm & two-three 5 mm incisions)
• Avoids large incision & wound complications • Particular valuable for:
– Obese patients – Recurrent hernia
• Usually 2-3 day hospital stay • Greater security than conventional repair
• Simultaneous repair of silent defects
Laparoscopic Ventral Hernia Repair Post-operative Issues
• Prolonged-pain • Seroma • Haematoma • Infection • Uncomfortable subcutaneous suture-knots
• Missed enterotomy – rare but serious
Laparoscopic Obesity Surgery
NICE Guidance (Reviewed 2005)
Recommend for morbidly obese patients • BMI>40kg/m2 • BMI>35kg/m2 with co-morbidity If criteria are satisfied: • Age>18 years • Non-surgical measures have been tried • Understands need for long-term follow-up • No psychological or clinical contraindication
Laparoscopic Obesity Surgery
Purely restrictive operation: Laparoscopic adjustable gastric banding
Laparoscopic Obesity Surgery
Restrictive and Malabsorptive Operation: Laparoscopic Roux-en-Y gastric bypass
CHOICE
• Results are highly surgeon-dependent • Best results reported from high-volume,
high-quality centres • Expertise and technology • Particularly important to offer prompt, highquality service for problems or failures