Advanced Minimal Access Surgery (laparoscopic Surgery) in rare case of colovesical fistula Dr Ramesh Agarwalla MS,FRCS(Edin) Advanced Laparoscopic & Bariatric surgeon Fortis Hospitals Examiner-Royal College of Surgeons of Edinburgh Surgical Tutor & Guide- DNB Surgery & Surgical Gastroenterology Philosophy of early/mid 20th century surgeons Those maestros limitations Anesthesia Muscle relaxation Bio medical technology – not fully developed. Hence The Need For BIG INCISIONS Desire to Improve Surgeons Technology Minimal Invasive Surgery Goal •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 Wockhardt)---1992 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 laparoscopy • 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 Myths • 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 equipment. • 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 surgery) • 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 LAPAROSCOPIC SURGERY • 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 LAPAROSCOPIC SURGERY • 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 necessity LAPAROSCOPIC SURGERY Further advancements: • Needloscopy • Computer based Surgery • Robotic & Tele Surgery LAPAROSCOPIC SURGERY • PAST- Big Surgeons make Big incisions • PRESENT- Big Surgeons make holes • FUTURE- Big Surgeons do nothing; Robots do all LAPAROSCOPIC SURGERY • Never stop LISTENING • Never stop LEARNING • Never stop TEACHING How do you want your patient to be ………..? 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