Endoscopic SurgeryWhat the GP Needs to Know

Abeezar I. Sarela MSc MS FRCSConsultant Surgeon

The General Infirmary at Leeds Wharfedale General Hospital

Nuffield Hospital LeedsBUPA Hospital Leeds

Back to Medical School, November 2, 2006

Laparoscopic SurgeryMinimally Invasive Surgery/Minimal Access Surgery

• Indications and patient-selection

• Advantages & disadvantages

• Common complications

• Frequent questions asked by patients

AgendaCommon 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

Figures quoted from UK respondents (n=201).

64%

22%

48%

14%

25%29%

% o

f pati

ents

AstraZeneca UK Data on File NEX/084/FEB2003.

0

10

20

30

40

50

60

70

80

Symptomsunbearable

Interests Sleep Sex life Sport +exercise

Concentratingon job

Poor Quality of Life with GORD

N=230 confirmed GORD patients

GORD Predicts Oesophageal Cancer

Lagergren J et al. N Engl J Med 1999; 340 (11): 825-831.

Heartburn (>5 years duration) Odds ratios

Once-a-week x 8

Nocturnal x 11

>20 yrs, and score >4.5* x 43.5

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 SurgeryNICE 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.

Mild Oesophagitis

Severe Oesophagitis

Necrotising Oesophagitis

Stricture

Barrett’s Oesophagus

Carcinoma

Laparoscopic Anti-Reflux SurgeryIndications

• 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 SurgeryPost-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 CholecystectomyPost-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 RepairBenefits

• 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 RepairSurgical Anatomy

Groin Anatomy Pre-peritoneal Mesh

Laparoscopic Groin Hernia RepairPost-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 RepairPost-operative Issues

• Prolonged-pain

• Seroma

• Haematoma

• Infection

• Uncomfortable subcutaneous suture-knots

• Missed enterotomy – rare but serious

Laparoscopic Obesity SurgeryNICE Guidance (Reviewed 2005)

Recommend for morbidly obese patients• BMI>40kg/m2

• BMI>35kg/m2 with co-morbidityIf criteria are satisfied:• Age>18 years• Non-surgical measures have been tried• Understands need for long-term follow-up• No psychological or clinical contra-

indication

Laparoscopic Obesity Surgery

Purely restrictive operation:

Laparoscopic adjustable gastric banding

Laparoscopic Obesity Surgery

Restrictive and Malabsorptive Operation:

Laparoscopic Roux-en-Y gastric bypass

• Results are highly surgeon-dependent

• Best results reported from high-volume,

high-quality centres

• Expertise and technology

• Particularly important to offer prompt, high-

quality service for problems or failures

CHOICE