1. 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 Back to Medical School, November 2, 2006

2. Laparoscopic Surgery Minimally Invasive Surgery/Minimal Access Surgery Indications and patient-selection Advantages & disadvantages Common complications Frequent questions asked by patients

3. 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

4. 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

5. Gastroesophageal Reflux Disease Afflicts 40% of adult population p.a. 2% consult GP Prescribed drugs & endoscopies: £ 600m Over the counter drugs: £ 100m NICE, 2005

6. Figures quoted from UK respondents (n=201). 64% 22% 48% 14% 25% 29% % of patients AstraZeneca UK Data on File NEX/084/FEB2003. 0 10 20 30 40 50 60 70 80 Symptoms unbearable InterestsSleepSex lifeSport + exercise Concentrating on job Poor Quality of Life with GORD N=230 confirmed GORD patients

7. 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-weekx 8 Nocturnalx 11 >20 yrs, and score >4.5*x 43.5

8. 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

9. 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

10. 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)

11. 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.

12. Mild Oesophagitis Severe Oesophagitis

13. Necrotising Oesophagitis Stricture

14. Barrett’s Oesophagus Carcinoma

15. 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

16. 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

17. Anti-Reflux Surgery Sliding Hiatus Hernia Crural Repair Fundoplication

18. 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

19. 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

20. Intra-operative Recognition Should primary repair be attempted?

21. 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

22. 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

23. 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

24. Laparoscopic Groin Hernia Repair Surgical Anatomy Groin Anatomy Pre-peritoneal Mesh

25. Laparoscopic Groin Hernia Repair Post-operative Issues Common features: Bruising, Seroma Worrying features: Haematoma, Infection Recurrence: ? superior to open repair

26. 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

27. Laparoscopic Ventral Hernia Repair Post-operative Issues Prolonged-pain Seroma Haematoma Infection Uncomfortable subcutaneous suture-knots Missed enterotomy – rare but serious

28. Laparoscopic Obesity Surgery NICE Guidance (Reviewed 2005) Recommend for morbidly obese patients BMI>40kg/m 2 BMI>35kg/m 2 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 contra- indication

29. Laparoscopic Obesity Surgery Purely restrictive operation: Laparoscopic adjustable gastric banding

30. Laparoscopic Obesity Surgery Restrictive and Malabsorptive Operation: Laparoscopic Roux-en-Y gastric bypass

31. 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