Role of Minimal Access Surgery laparoscopic Surgery in the by mikesanye


									Advanced Minimal Access
Surgery (laparoscopic
Surgery) in rare case of
colovesical fistula

Dr Ramesh Agarwalla
Advanced Laparoscopic &
Bariatric surgeon
Fortis Hospitals

Examiner-Royal College of
Surgeons of Edinburgh
Surgical Tutor & Guide- DNB
Surgery & Surgical
Philosophy of early/mid 20th century surgeons
                           Those maestros

      Anesthesia
      Muscle relaxation
      Bio medical technology – not fully

   Hence The Need For               BIG INCISIONS
   Desire to Improve

Surgeons                    Technology

    Minimal Invasive Surgery
  •Precise diagnosis and management .
  •Less/no pain.
  •Faster recuperation.
  •Wonderful cosmesis.
  •Less expensive.
     The Ball Set Rolling
     1901 - George Kelling   1st Laparoscopy

     1987 – Philip Mouret    1st Laparoscopic Cholecystectomy

The Ball Has Never Stopped
Laparoscopic Surgery / Minimal Access Surgery

• 1st documented laparoscopic cholecystectomy in the world ---
  Philip Mouret,France,1987

• 1st documented laparoscopic cholecystectomy in India---Prof
  T E Udwadia,Mumbai,1990

• 1st laparoscopic cholecystectomy at Fortis hospital (formerly
                    At Fortis Hospitals

• Silent active minimal access surgery / laparoscopic surgery
  programme since 1992

• 1st dedicated minimal access unit in Eastern India

• Performing wide spectrum of surgical procedures by

• More than 15000 procedures
           Benefits of Minimal Access Surgery
•   Less pain

•   Reduced hospital stay

•   Early return to normal life

•   Less wound infection & dehiscence

•   Better cosmesis

• Poor vision

• Cause cardiovascular compromise

• Incomplete operation

• Not suitable in patient’s with previous surgery

• Suitable in simple cases only
             Laparoscopic basket

• Gallbladder stones

• Appendix

• Hernia
                Laparoscopic basket

• Commonly done procedures

• Expertise for the same is now available at many places.
      Advanced laparoscopic procedures.
• Horizons have expanded and more of other surgical procedures are being
  done laparoscopically
• These advanced procedures need special expertise and wide array of
• Special expertise and equipment is available in few select centres
• Now we can perform almost every abdominal surgery laparoscopically
• To name a few, operation on liver, pancreas, adrenal glands, small and
   large intestine can be conducted laparoscopically

• Effective both for benign and malignant conditions
Advanced minimal access surgery (laparoscopic

• Awareness is less

• Few dedicated centers In the country

• Fortis is one such dedicated centre
          Experienced surgical team
          state of art equipment
             Advanced minimal access surgery
                 (laparoscopic surgery)
 Entering its 2nd decade of practice
    The 1st report in the literature was in 1990
    Numerous advantages when compared
    with open procedures
              – Less post operative pain
              – Less ileus
              – Reduced perioperative immuno-suppression
              – Decreased hospital stay
              – Improved cosmesis
              – Earlier return to normal activity
Conventional surgery
                            Patient profile:
Mr Tapan Kumar Biswas, 38 years old male

Symptoms: recurrent abdominal pain,
            difficulty in passing urine,
            noticed there was stool matter in the urine
            passing urine through his anal opening

Clinical condition :was very ill, had urinary infection, fever,
                   unable to eat ,had severe pain in the abdomen
                    weighed only 27kgs
                             Patient profile
Investigations: ultrasound, CT scan revealed an abnormal
              communication between the urinary bladder and the
               intestine (colovesical fistula) due to Crohn’s disease
Treatment: initially medical to improve his general condition to
           withstand surgery
           would not be able to survive open surgery
           laparoscopic excision of fistula, repair of the urinary bladder
           and the intestine
Post operative period: was walking 24hrs after surgery
                      eating after 48 hours
                      passing urine normally after 7 days
                          Crohn’s disease

• Common in North America, Northern Europe, Uncommon disease in India
• Slightly more common in females
• Common between the ages of 15 and 40 years
• Cause not known
• Affects small and large intestine
• Chronic inflammation of the intestine causing ulcerations in the intestines
• Presents with abdominal pain, diarrhoea, fever, loss of weight, anaemia
• Complications like intraabdominal abscess and internal fistula
               Tapan Kumar Biswas ,38 years

• On 3rd Post op day following lap assisted excision of colovesical fistula
              Tapan Kumar Biswas ,38 years
•   On 3rd Post op day following lap assisted excision of colovesical fistula

• Future is BRIGHT

• Our endeavor is :
    > Increase awareness of the benefits to medical &
       non medical fraternity
    >Establish structured training & include it in
      Postgraduate curriculum
    >Benefits should reach the common man
• Being poor is neither a stigma nor a reason for despair ; it
  is a state of existence at a particular moment in a
  country’s history
• Patients in developing country have as much reason to
  receive benefits of reduced pain, & early return to family
  & work
• Advantages are greater in a developing country where
  demand for hospital beds is greater, health insurance
  cover nonexistent & early return to work a financial
Further advancements:

• Needloscopy

• Computer based Surgery

• Robotic & Tele Surgery

• PAST- Big Surgeons make Big incisions

• PRESENT- Big Surgeons make holes

• FUTURE- Big Surgeons do nothing; Robots do all

• Never stop LISTENING

• Never stop LEARNING

• Never stop TEACHING
How do you want
your patient to be
Questions ??

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