This document discusses the surgical management of gastroesophageal reflux disease (GERD). It begins by defining GERD and explaining that it is caused by a defective lower esophageal sphincter. While proton pump inhibitors are usually prescribed, they do not address the underlying cause. Surgical fundoplication procedures like Nissen and Toupet fundoplication are discussed in detail, as they significantly reduce acid exposure and improve quality of life compared to medical management. Complications, indications, contraindications and follow up are also outlined. The document provides a comprehensive overview of the surgical treatment of GERD.
Case Presentation on Perforated Duodenal Ulcerksaigowtham
a case study in the department of general medicine surgery which was collected in the month of November 2019 and studied analyzed with SOAP format and submitted
This document discusses various procedures for treating hemorrhoids, including Barron's banding, open and closed hemorrhoidectomy, stapled hemorrhoidectomy, and transanal hemorrhoidal dearterialization (THD). Barron's banding is used for first and second degree hemorrhoids as an office procedure under local anesthesia. Open hemorrhoidectomy involves making a V-cut to dissect and remove third degree hemorrhoids, while closed hemorrhoidectomy uses an elliptical incision and ligation. Stapled hemorrhoidectomy uses a circular stapler to remove hemorrhoidal tissue. THD involves identifying and ligating the hemorrhoidal arteries through the anus to reduce blood
Surgical treatment for peptic ulcer diseaseBashir BnYunus
This document discusses surgical treatments for peptic ulcer disease. It outlines relevant anatomy and physiology, classifications of PUD, indications for surgery, and various surgical options including vagotomy, gastrectomy, Graham's omental patch, and suture ligation of the gastroduodenal artery. Complications are also reviewed. The prognosis is generally satisfactory with operative procedures, though complications can include bleeding, leakage, obstruction, and recurrent ulceration. Delayed treatment increases morbidity and mortality risks.
Gastroesophageal Reflux Disease and Antireflux SurgeryHassan s1
this presentation describes the pathophysiology and presentation of gastroesophageal reflux disease. it also discusses the medical and surgical management of gastroesophageal reflux disease.. what makes this presentation unique is that it explains the short and long term effects of antireflux surgery and patient's satisfaction with this surgery with references.
This document provides information on haemorrhoids (also known as hemorrhoids), including:
- Anatomy of the anal canal and haemorrhoidal tissue
- Epidemiology of symptomatic haemorrhoids, affecting around 4.4% of the global population
- Common causes like straining, pregnancy, obesity, and familial tendency
- Grading of internal haemorrhoids from first to fourth degree based on degree of prolapse
- Treatment options like rubber band ligation, sclerotherapy, excisional or stapled haemorrhoidectomy depending on severity
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
Case Presentation on Perforated Duodenal Ulcerksaigowtham
a case study in the department of general medicine surgery which was collected in the month of November 2019 and studied analyzed with SOAP format and submitted
This document discusses various procedures for treating hemorrhoids, including Barron's banding, open and closed hemorrhoidectomy, stapled hemorrhoidectomy, and transanal hemorrhoidal dearterialization (THD). Barron's banding is used for first and second degree hemorrhoids as an office procedure under local anesthesia. Open hemorrhoidectomy involves making a V-cut to dissect and remove third degree hemorrhoids, while closed hemorrhoidectomy uses an elliptical incision and ligation. Stapled hemorrhoidectomy uses a circular stapler to remove hemorrhoidal tissue. THD involves identifying and ligating the hemorrhoidal arteries through the anus to reduce blood
Surgical treatment for peptic ulcer diseaseBashir BnYunus
This document discusses surgical treatments for peptic ulcer disease. It outlines relevant anatomy and physiology, classifications of PUD, indications for surgery, and various surgical options including vagotomy, gastrectomy, Graham's omental patch, and suture ligation of the gastroduodenal artery. Complications are also reviewed. The prognosis is generally satisfactory with operative procedures, though complications can include bleeding, leakage, obstruction, and recurrent ulceration. Delayed treatment increases morbidity and mortality risks.
Gastroesophageal Reflux Disease and Antireflux SurgeryHassan s1
this presentation describes the pathophysiology and presentation of gastroesophageal reflux disease. it also discusses the medical and surgical management of gastroesophageal reflux disease.. what makes this presentation unique is that it explains the short and long term effects of antireflux surgery and patient's satisfaction with this surgery with references.
This document provides information on haemorrhoids (also known as hemorrhoids), including:
- Anatomy of the anal canal and haemorrhoidal tissue
- Epidemiology of symptomatic haemorrhoids, affecting around 4.4% of the global population
- Common causes like straining, pregnancy, obesity, and familial tendency
- Grading of internal haemorrhoids from first to fourth degree based on degree of prolapse
- Treatment options like rubber band ligation, sclerotherapy, excisional or stapled haemorrhoidectomy depending on severity
Ventral hernia is protrusion of peritoneal sac through anterior abdominal wall defects except Groin hernias. In this presentation I have discussed Epigastric, Umbilical, Para umbilical, Incisional, Spigelian and Lumbar hernias.
Component seperation technique for the repair of very large ventral hernias nikhilameerchetty
Includes all the ventral hernia repairs with the loss of domain and the various methods of component separation technique with their success rate for their repair ,few videos showing the methods of repair in addition to the latest techniques of repair .
The document discusses surgical meshes and methods of fixation for hernia repair. It covers biologic and synthetic meshes and factors that influence hernia occurrence. Direct closure of hernias has a high recurrence rate of around 50%, which is reduced to around 5-18% when meshes are used. Long stitch lengths during closure are associated with higher rates of surgical site infection and hernia recurrence compared to short stitch lengths. Polypropylene meshes allow for tissue ingrowth but can cause complications like chronic infection, fistulas and erosion over time. Other synthetic mesh options discussed include ePTFE meshes.
1) A 30-year-old man presented with right testicular swelling without pain or urinary symptoms. Examination found an enlarged right testis without tenderness or transillumination.
2) The document provides guidance on evaluating scrotal swellings, including asking about onset/progression, site, associated symptoms, and examination of the testis and epididymis.
3) Common causes of scrotal swelling discussed are hydrocele, epididymal cyst, and varicocele. Hydrocele is fluid between the testis layers, epididymal cyst is a fluid sac in the epididymis, and varicocele is dilated spermatic veins.
Laparoscopy involves using small incisions and a camera to visualize the inside of the abdomen. It has several advantages over open surgery such as less pain, shorter hospital stays, and quicker recovery times. Some of the key equipment used in laparoscopy include rod lens systems and fiber optic cables for optics, trocars for abdominal access, and insufflators to inflate the abdomen with gas. Potential risks include injuries from trocars or pneumoperitoneum as well as effects of the pneumoperitoneum on respiratory and renal systems. Common procedures now performed laparoscopically include cholecystectomy, appendisectomy, hernia repair, and some cancer staging.
Acute abdomen is an abdominal emergency that requires prompt evaluation and treatment. Patients often present in the evening with sudden onset abdominal pain within the last 24 hours. A thorough history and physical exam are important to determine the cause, which can include appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated ulcer, bowel obstruction, mesenteric ischemia, or ruptured abdominal aortic aneurysm. Diagnostic testing may include bloodwork, imaging studies like ultrasound or CT scan, and surgery if indicated by the condition. Proper diagnosis and management are needed to prevent complications.
our study and experiences we thus conclude that the stapler haemorrhoidopexy is simple and safe procedure. It is a minimally invasive procedure and it is less associated with post-operative pain bleeding and prolapse. It can be done as the day care surgery.
This document discusses esophageal motility disorders. It begins with the anatomy of the esophagus, including its three parts (cervical, thoracic, abdominal) and normal narrowings. It then covers the physiology of peristalsis and swallowing. The main types of esophageal motility disorders are described - achalasia (failure of LES to relax), spastic disorders like DES and nutcracker esophagus, and presbyoesophagus in elderly patients. Diagnostic tests like manometry and scintigraphy transit tests are also summarized.
A general introduction to employment of utilities of meshes as surgical implant. Relevant biomaterial engineering basis are highlighted in context of current limitations of mesh-tissue integration and areas of ongoing translational scientific research.
Haemorrhoids are vascular cushions in the anal canal that can become swollen and engorged with blood due to increased pressure in the anal veins, common symptoms include bleeding, pain, itching and bulging during bowel movements, and treatment ranges from lifestyle and diet changes to minimally invasive procedures like rubber band ligation or injection sclerotherapy to surgery.
1. Typhoid fever, caused by Salmonella Typhi, commonly involves the abdomen and can lead to serious surgical complications if left untreated. The small intestine is frequently affected, with perforations in the ileum being common from the third or fourth week of illness.
2. Other abdominal organs like the gallbladder, liver, spleen and pancreas can also be impacted, such as gallbladder perforation or pancreatic abscesses. Neurological issues occasionally arise as well.
3. Early diagnosis of abdominal complications through awareness of clinical signs is important to provide prompt surgical treatment, like laparotomy, and thereby reduce high morbidity and mortality risks. Exteriorization of the intestine is often the best approach for severely se
This document provides information on hemorrhoids, including definitions, anatomy, causes, symptoms, diagnosis, and treatment options. It defines hemorrhoids as dilated veins in the anal canal and discusses four main theories for their formation. Conservative treatments like diet changes, medication, and hot baths are recommended initially. More advanced options include sclerotherapy, which involves injecting chemicals to scar hemorrhoidal tissue, and rubber band ligation to cut off blood supply to hemorrhoids. The document provides detailed descriptions of techniques for both procedures.
Cholecystitis is inflammation of the gallbladder that is usually caused by gallstones blocking the cystic duct. It presents with pain in the right upper abdomen that is initially intermittent but becomes constant and severe. Symptoms also include fever, nausea, vomiting, and diarrhea. Diagnosis is usually made based on symptoms and confirmed with ultrasound or CT scan showing gallbladder wall thickening and inflammation. Treatment involves antibiotics, pain medication, and fluid resuscitation to control symptoms prior to definitive treatment with laparoscopic surgery to remove the inflamed gallbladder.
Gastric outlet obstruction is caused by benign or malignant diseases that obstruct gastric emptying. Common benign causes include peptic ulcer disease while pancreatic cancer is a frequent malignant cause. Patients experience nausea, vomiting and weight loss. Diagnosis involves distinguishing functional from mechanical causes and identifying the underlying etiology. Treatment focuses on rehydration and correcting metabolic abnormalities as well as addressing the mechanical obstruction through endoscopic or surgical interventions.
This document discusses benign disorders of the esophagus, focusing on GERD (gastroesophageal reflux disease). It covers the epidemiology, pathophysiology, symptoms, diagnostic tests and treatment options for GERD. Regarding treatment, lifestyle modifications and medications like antacids, H2 blockers, and proton pump inhibitors are discussed as first-line options. Endoscopic treatments and anti-reflux surgery are also mentioned.
The document discusses properties that surgeons should consider when choosing a mesh for hernia repair. Ideal meshes are lightweight, with large pores to reduce foreign body reaction and chronic pain. Monofilament meshes have the lowest risk of infection. For intraperitoneal placement, composite meshes may reduce adhesions by providing an absorbable surface. Overall, lightweight polypropylene or polyester meshes are generally suitable in most contexts by balancing strength, flexibility and biocompatibility.
This document discusses acute peritonitis, including:
- Peritonitis is defined as inflammation of the peritoneum and can be localized or generalized. It is usually caused by bacterial infection entering through the gastrointestinal tract or other sources.
- Symptoms depend on whether it is localized or diffuse. Localized peritonitis causes pain specific to the affected organ, while diffuse peritonitis causes generalized abdominal pain and tenderness.
- Treatment involves antibiotics, fluid resuscitation, and sometimes surgery to address the underlying cause and drain any abscesses. Outcomes depend on several factors but mortality is around 10% with prompt treatment. Complications can include shock, bowel obstruction, and residual infections.
A presentation catering to the public, covers the basic anatomy, cause, manifestations and treatment options available to treat this very common condition. Special attention given to highlight laser hemorrhoidoplasty - one of the newer modalities currently available to surgeons to treat hemorrhoids. Session ended with a simple demonstration mimicking the procedure on models.
1. Acute appendicitis is caused by obstruction of the appendix lumen, leading to increased intraluminal pressure, edema, and bacterial invasion.
2. The classic presentation includes initially vague periumbilical pain that later localizes to the right lower quadrant, accompanied by anorexia, nausea, and low-grade fever.
3. On examination, tenderness is elicited over McBurney's point with guarding and rebound tenderness. Diagnosis is suggested by clinical scoring systems and confirmed by ultrasound or CT scan showing a thick-walled, inflamed appendix.
The document discusses typhoid ileal perforation, a common surgical complication of typhoid fever. It presents information on the epidemiology, pathogenesis, clinical features, investigations, treatment, and prognosis. Typhoid ileal perforation remains problematic in developing countries due to poor sanitation and is associated with significant morbidity and mortality. The definitive treatment is surgical intervention to repair perforations and prevent further contamination. Proper resuscitation, antibiotic therapy, and postoperative management are important for reducing complications and improving outcomes.
This document provides an overview of minimal access surgery (MAS). It defines MAS as applying modern technology to minimize surgical trauma without compromising exposure or safety. The history of MAS is traced from early laparoscopic procedures in the 1900s to developments like natural orifice transluminal endoscopic surgery (NOTES) and single incision laparoscopic surgery (SILS) more recently. The advantages of MAS include reduced pain, wounds, and recovery time compared to open surgery. Potential complications include injuries and those related to pneumoperitoneum such as arrhythmias. A variety of endoscopic, laparoscopic, and catheter-based minimal access procedures across several specialties are described in the document.
Peritonitis is inflammation of the peritoneum that can be caused by infection or chemical irritation. It is classified anatomically, etiologically, and clinically. Patients present with abdominal pain, nausea, fever and tenderness. Diagnosis involves labs, imaging, and fluid analysis. Treatment depends on severity but generally includes antibiotics, IV fluids, drainage, and sometimes surgery. Complications can be systemic like shock or organ failure, or abdominal like abscesses. Prognosis depends on factors like age, severity score, and development of tertiary peritonitis.
GERD is caused by pathological reflux of gastric or duodenal contents into the esophagus past the lower esophageal sphincter. It is the most common upper GI condition in western countries. Diagnosis involves endoscopy, pH monitoring, and manometry. Treatment includes lifestyle changes, proton pump inhibitors, fundoplication surgery, and newer endoscopic procedures. Complications may include esophagitis, stricture, Barrett's esophagus, and adenocarcinoma if left untreated.
The document discusses surgical meshes and methods of fixation for hernia repair. It covers biologic and synthetic meshes and factors that influence hernia occurrence. Direct closure of hernias has a high recurrence rate of around 50%, which is reduced to around 5-18% when meshes are used. Long stitch lengths during closure are associated with higher rates of surgical site infection and hernia recurrence compared to short stitch lengths. Polypropylene meshes allow for tissue ingrowth but can cause complications like chronic infection, fistulas and erosion over time. Other synthetic mesh options discussed include ePTFE meshes.
1) A 30-year-old man presented with right testicular swelling without pain or urinary symptoms. Examination found an enlarged right testis without tenderness or transillumination.
2) The document provides guidance on evaluating scrotal swellings, including asking about onset/progression, site, associated symptoms, and examination of the testis and epididymis.
3) Common causes of scrotal swelling discussed are hydrocele, epididymal cyst, and varicocele. Hydrocele is fluid between the testis layers, epididymal cyst is a fluid sac in the epididymis, and varicocele is dilated spermatic veins.
Laparoscopy involves using small incisions and a camera to visualize the inside of the abdomen. It has several advantages over open surgery such as less pain, shorter hospital stays, and quicker recovery times. Some of the key equipment used in laparoscopy include rod lens systems and fiber optic cables for optics, trocars for abdominal access, and insufflators to inflate the abdomen with gas. Potential risks include injuries from trocars or pneumoperitoneum as well as effects of the pneumoperitoneum on respiratory and renal systems. Common procedures now performed laparoscopically include cholecystectomy, appendisectomy, hernia repair, and some cancer staging.
Acute abdomen is an abdominal emergency that requires prompt evaluation and treatment. Patients often present in the evening with sudden onset abdominal pain within the last 24 hours. A thorough history and physical exam are important to determine the cause, which can include appendicitis, cholecystitis, pancreatitis, diverticulitis, perforated ulcer, bowel obstruction, mesenteric ischemia, or ruptured abdominal aortic aneurysm. Diagnostic testing may include bloodwork, imaging studies like ultrasound or CT scan, and surgery if indicated by the condition. Proper diagnosis and management are needed to prevent complications.
our study and experiences we thus conclude that the stapler haemorrhoidopexy is simple and safe procedure. It is a minimally invasive procedure and it is less associated with post-operative pain bleeding and prolapse. It can be done as the day care surgery.
This document discusses esophageal motility disorders. It begins with the anatomy of the esophagus, including its three parts (cervical, thoracic, abdominal) and normal narrowings. It then covers the physiology of peristalsis and swallowing. The main types of esophageal motility disorders are described - achalasia (failure of LES to relax), spastic disorders like DES and nutcracker esophagus, and presbyoesophagus in elderly patients. Diagnostic tests like manometry and scintigraphy transit tests are also summarized.
A general introduction to employment of utilities of meshes as surgical implant. Relevant biomaterial engineering basis are highlighted in context of current limitations of mesh-tissue integration and areas of ongoing translational scientific research.
Haemorrhoids are vascular cushions in the anal canal that can become swollen and engorged with blood due to increased pressure in the anal veins, common symptoms include bleeding, pain, itching and bulging during bowel movements, and treatment ranges from lifestyle and diet changes to minimally invasive procedures like rubber band ligation or injection sclerotherapy to surgery.
1. Typhoid fever, caused by Salmonella Typhi, commonly involves the abdomen and can lead to serious surgical complications if left untreated. The small intestine is frequently affected, with perforations in the ileum being common from the third or fourth week of illness.
2. Other abdominal organs like the gallbladder, liver, spleen and pancreas can also be impacted, such as gallbladder perforation or pancreatic abscesses. Neurological issues occasionally arise as well.
3. Early diagnosis of abdominal complications through awareness of clinical signs is important to provide prompt surgical treatment, like laparotomy, and thereby reduce high morbidity and mortality risks. Exteriorization of the intestine is often the best approach for severely se
This document provides information on hemorrhoids, including definitions, anatomy, causes, symptoms, diagnosis, and treatment options. It defines hemorrhoids as dilated veins in the anal canal and discusses four main theories for their formation. Conservative treatments like diet changes, medication, and hot baths are recommended initially. More advanced options include sclerotherapy, which involves injecting chemicals to scar hemorrhoidal tissue, and rubber band ligation to cut off blood supply to hemorrhoids. The document provides detailed descriptions of techniques for both procedures.
Cholecystitis is inflammation of the gallbladder that is usually caused by gallstones blocking the cystic duct. It presents with pain in the right upper abdomen that is initially intermittent but becomes constant and severe. Symptoms also include fever, nausea, vomiting, and diarrhea. Diagnosis is usually made based on symptoms and confirmed with ultrasound or CT scan showing gallbladder wall thickening and inflammation. Treatment involves antibiotics, pain medication, and fluid resuscitation to control symptoms prior to definitive treatment with laparoscopic surgery to remove the inflamed gallbladder.
Gastric outlet obstruction is caused by benign or malignant diseases that obstruct gastric emptying. Common benign causes include peptic ulcer disease while pancreatic cancer is a frequent malignant cause. Patients experience nausea, vomiting and weight loss. Diagnosis involves distinguishing functional from mechanical causes and identifying the underlying etiology. Treatment focuses on rehydration and correcting metabolic abnormalities as well as addressing the mechanical obstruction through endoscopic or surgical interventions.
This document discusses benign disorders of the esophagus, focusing on GERD (gastroesophageal reflux disease). It covers the epidemiology, pathophysiology, symptoms, diagnostic tests and treatment options for GERD. Regarding treatment, lifestyle modifications and medications like antacids, H2 blockers, and proton pump inhibitors are discussed as first-line options. Endoscopic treatments and anti-reflux surgery are also mentioned.
The document discusses properties that surgeons should consider when choosing a mesh for hernia repair. Ideal meshes are lightweight, with large pores to reduce foreign body reaction and chronic pain. Monofilament meshes have the lowest risk of infection. For intraperitoneal placement, composite meshes may reduce adhesions by providing an absorbable surface. Overall, lightweight polypropylene or polyester meshes are generally suitable in most contexts by balancing strength, flexibility and biocompatibility.
This document discusses acute peritonitis, including:
- Peritonitis is defined as inflammation of the peritoneum and can be localized or generalized. It is usually caused by bacterial infection entering through the gastrointestinal tract or other sources.
- Symptoms depend on whether it is localized or diffuse. Localized peritonitis causes pain specific to the affected organ, while diffuse peritonitis causes generalized abdominal pain and tenderness.
- Treatment involves antibiotics, fluid resuscitation, and sometimes surgery to address the underlying cause and drain any abscesses. Outcomes depend on several factors but mortality is around 10% with prompt treatment. Complications can include shock, bowel obstruction, and residual infections.
A presentation catering to the public, covers the basic anatomy, cause, manifestations and treatment options available to treat this very common condition. Special attention given to highlight laser hemorrhoidoplasty - one of the newer modalities currently available to surgeons to treat hemorrhoids. Session ended with a simple demonstration mimicking the procedure on models.
1. Acute appendicitis is caused by obstruction of the appendix lumen, leading to increased intraluminal pressure, edema, and bacterial invasion.
2. The classic presentation includes initially vague periumbilical pain that later localizes to the right lower quadrant, accompanied by anorexia, nausea, and low-grade fever.
3. On examination, tenderness is elicited over McBurney's point with guarding and rebound tenderness. Diagnosis is suggested by clinical scoring systems and confirmed by ultrasound or CT scan showing a thick-walled, inflamed appendix.
The document discusses typhoid ileal perforation, a common surgical complication of typhoid fever. It presents information on the epidemiology, pathogenesis, clinical features, investigations, treatment, and prognosis. Typhoid ileal perforation remains problematic in developing countries due to poor sanitation and is associated with significant morbidity and mortality. The definitive treatment is surgical intervention to repair perforations and prevent further contamination. Proper resuscitation, antibiotic therapy, and postoperative management are important for reducing complications and improving outcomes.
This document provides an overview of minimal access surgery (MAS). It defines MAS as applying modern technology to minimize surgical trauma without compromising exposure or safety. The history of MAS is traced from early laparoscopic procedures in the 1900s to developments like natural orifice transluminal endoscopic surgery (NOTES) and single incision laparoscopic surgery (SILS) more recently. The advantages of MAS include reduced pain, wounds, and recovery time compared to open surgery. Potential complications include injuries and those related to pneumoperitoneum such as arrhythmias. A variety of endoscopic, laparoscopic, and catheter-based minimal access procedures across several specialties are described in the document.
Peritonitis is inflammation of the peritoneum that can be caused by infection or chemical irritation. It is classified anatomically, etiologically, and clinically. Patients present with abdominal pain, nausea, fever and tenderness. Diagnosis involves labs, imaging, and fluid analysis. Treatment depends on severity but generally includes antibiotics, IV fluids, drainage, and sometimes surgery. Complications can be systemic like shock or organ failure, or abdominal like abscesses. Prognosis depends on factors like age, severity score, and development of tertiary peritonitis.
GERD is caused by pathological reflux of gastric or duodenal contents into the esophagus past the lower esophageal sphincter. It is the most common upper GI condition in western countries. Diagnosis involves endoscopy, pH monitoring, and manometry. Treatment includes lifestyle changes, proton pump inhibitors, fundoplication surgery, and newer endoscopic procedures. Complications may include esophagitis, stricture, Barrett's esophagus, and adenocarcinoma if left untreated.
1) Gastroesophageal reflux disease (GERD) occurs when stomach contents back up into the esophagus or beyond, causing troublesome symptoms or complications.
2) Diagnosis is confirmed by endoscopic findings of erosive esophagitis or positive pH monitoring, showing abnormal acid exposure in the esophagus.
3) Treatment involves lifestyle changes and medication. Surgery is considered for patients with severe, refractory GERD or complications like strictures. The most common anti-reflux surgery is laparoscopic Nissen fundoplication, which has high success rates but risks dysphagia.
Approach, indications and surgical management of gerd 2Shambhavi Sharma
GERD is diagnosed clinically or with endoscopy and pH monitoring. Surgical options include laparoscopic Nissen fundoplication, which is the gold standard for treating failed medical management, complications, or large hiatal hernias. Complications include dysphagia, which can be reduced using a partial fundoplication or short wrap. Newer minimally invasive options include the LINX device and endoscopic fundoplication but long-term data is still emerging. Revisional surgery is an option for failed initial antireflux procedures.
Minimally invasive surgeries such as laparoscopic Nissen fundoplication can be used to treat gastroesophageal reflux disease (GERD). The laparoscopic procedure involves making several small incisions and using instruments and a camera to reconstruct the esophageal hiatus and wrap the gastric fundus around the lower esophagus. This restores the anti-reflux barrier. The procedure takes several hours and has a low risk of complications. Patients typically recover within a few weeks with some short-term difficulty swallowing. The fundoplication creates a new sphincter to prevent reflux and symptoms in most patients long-term.
APD complications and surgical management.pptxNartMood
This document discusses acid peptic disease and its complications including perforation. It defines acid peptic disease and lists its types and complications. Perforated peptic ulcer is described in detail, including its epidemiology, clinical features, diagnosis, and management through surgery, peritoneal lavage, and postoperative care. Conservative treatment is also discussed. Other complications like bleeding and their long term sequelae are mentioned.
- Achalasia is a rare esophageal motility disorder caused by the loss of inhibitory ganglion cells in the esophagus. This results in failure of the lower esophageal sphincter to relax during swallowing.
- Symptoms include dysphagia, regurgitation, and chest pain. Over time the esophagus dilates and food can pool, leading to complications.
- Diagnosis involves endoscopy, barium swallow, and high-resolution manometry showing failure of the LES to relax. Treatment aims to reduce LES pressure and includes medications, botulinum toxin injection, pneumatic dilation, Heller's myotomy, and occasionally surgery. Newer treatments like peroral end
1. A 60-year-old female presents with chest pain below her sternum that radiates to her left shoulder. The pain is worsened after eating spicy foods and is relieved with omeprazole.
2. She likely has gastroesophageal reflux disease exacerbated by a hiatal hernia, allowing stomach contents to enter her esophagus.
3. Surgical repair of symptomatic hiatal hernias can effectively address her symptoms through approaches like fundoplication to reduce reflux.
The document discusses hiatal hernia, which occurs when part of the stomach bulges through an opening in the diaphragm. It outlines the causes, symptoms, diagnosis through imaging and endoscopy, differential diagnosis, and treatment options including medication, surgery to repair the diaphragm and prevent reflux, and post-operative care. The prognosis is generally good if the hernia is repaired and complications like aspiration pneumonia are managed.
GERD ~It is most common common benign conditions of stomach and esophagusJayaPrakash78548
GERD ~Gastroesophageal reflux (GER) occurs when intragastric pressure is greater than the high-pressure zone of the distal esophagus. This can develop under two conditions
1.)the LES resting pressure is too low (i.e., hypotensive LES).
2.the LES with normal resting pressure inappropriately relaxes in the absence of peristaltic contraction of the esophagus (i.e., spontaneous LES relaxation)
~ Not all GER is pathologic—in fact, it is a normal physiologic process that occurs even in the setting of a normal LES.
~Heartburn, regurgitation, and water brash are the three typical esophageal symptoms of GERD.
~Heartburn and regurgitation are the most common presenting symptoms. Heartburn is specific to GERD and described as an epigastric or retrosternal caustic or stinging sensation.
~it does not radiate to the back and is not described as a pressure sensation
~ Regurgitation of gastric contents to the oropharynx and mouth can produce a sour taste that patients will describe as either acid or bile. This phenomenon is referred to as water brash.
•Esophageal impedance monitoring identifies episodes of nonacid reflux
•Impedance catheters use electrodes placed at 1-cm intervals to detect changes in the resistance to flow of an electrical current (i.e., impedance)
•Impedance increases in the presence of air and decreases in the presence of a liquid bolus
•pH-impedance catheters can determine the direction of movement of esophageal acid exposures
~frequent drinking of water
~posture of sitting lean forward with their lungs inflated to vital capacity
~ This maneuver flattens the diaphragm, narrows the anteroposterior diameter of the hiatus, and increases the LES pressure to counteract GER.
~yellowing of teeth
~injected oropharyngeal mucosa
Both peptic strictures and LA class C and D esophagitis can be considered pathognomonic for GERD
patients found to have LA class A and B esophagitis should undergo pH testing to confirm abnormal distal esophageal acid exposure.
Endoscopic evaluation should also include an assessment of the GEJ flap valve
In hiatus hernia craniocaudal and lateral dimensions are measured
•immediate side effects of ppi are rare but long term usage causes side effects
•long term side effects of ppi are
1)loss of bone density
2)risk of fracture, dementia, myocardial infarction
3)micronutrient (magnesium, iron, B-12) deficiencies
4)Clostridioides difficile infection
5)kidney disease
• judicious prescription of PPIs for well-established indications is prudent.
•operative technique (LARS)
1)short gastric vessel ligation and mobilisation of gastric fundus
2)left crus dissection by incision at phrenoesophageal ligament
3)right crura dissection
4) The esophagus is mobilized in the posterior mediastinum to obtain a minimum of 3 cm of intra abdominal esophagus
5)fundoplocation is done
If an anterior fundoplication is to be performed (e.g., Thal or Dor), there is no need to disea
This document discusses surgical approaches for treating GERD. It outlines the pathophysiology of GERD and indications for surgery. The principles of anti-reflux surgery involve restoring the intra-abdominal esophagus length, increasing the angle of His, and reducing the esophageal opening diameter. Surgical approaches include laparoscopic, open transthoracic, and transabdominal procedures. Common procedures discussed are Nissen's fundoplication, Belsey Mark IV, Toupet, and Hill's procedure. Laparoscopic surgery is now the standard approach due to its benefits over open surgeries.
This document provides an overview of dysphagia (difficulty swallowing). It defines dysphagia and discusses its two main types: oropharyngeal dysphagia, which involves difficulty initiating swallowing, and esophageal dysphagia, which involves food feeling hindered in the esophagus. Common causes, diagnostic tools, and treatment options are described for both types. The gold standard tests are videofluoroscopic swallowing study for oropharyngeal dysphagia and endoscopy for esophageal dysphagia. Treatments include diet modification, swallowing therapy, and surgery in some cases.
Metro Curing Story-Hernia Treatment by Laparoscopic Surgery Vansh Pundit
High clinical suspicion with early intervention in RICHTER'S hernia can prevent gangrene of the intestine.
Diagnostic laparoscopy (to assess the bowel) with Laparoscopic Inguinal Hernia repair is a safe and feasible minimally invasive surgical approach with early recovery
This document provides an overview of gastric perforation. It begins with an introduction defining gastric perforation and noting the decrease in incidence due to treatment of H. pylori and acid hypersecretion. It then covers the anatomy of the stomach, etiologies of perforation including peptic ulcer disease, signs and symptoms, investigations like abdominal x-rays, and surgical management including repair techniques like omentoplasty and reconstructions like Billroth procedures. Post-operative complications are also discussed such as leakage, strictures, and syndromes. The role of vagotomy and drainage procedures is reviewed.
GASTRIC DILATATION AND VOLVULUS IN DOGS.pptxdrswathibodha
Gastric dilatation and volvulus (GDV), also known as bloat, occurs when a dog's stomach enlarges with gas or fluid and rotates on its axis. It can cause shock and organ damage due to reduced blood flow. Risk factors include age, breed, eating habits. Diagnosis is made via x-rays showing abnormal stomach positioning. Treatment involves stabilizing the patient, decompressing the stomach, surgically correcting the rotation, and attaching the stomach to the abdominal wall to prevent future twisting (gastropexy). Post-operative care focuses on monitoring for arrhythmias and providing supportive care like IV fluids and antibiotics.
This document discusses hypertrophic pyloric stenosis, which causes projectile vomiting in infants. It is caused by muscle thickening around the pylorus, narrowing the gastric outlet. Risk factors include being male, firstborn, and certain ethnicities/blood types. While the exact cause is unknown, genetic and environmental factors play a role. Diagnosis involves physical exam and ultrasound finding thickened pyloric muscles. Treatment is pyloromyotomy surgery to divide the thickened muscles. Complications can include perforation or incomplete treatment of symptoms.
This document discusses endoscopic management of obesity, known as endobariatrics. It can be used as primary therapy, bridging therapy before surgery, or revisional therapy after surgery. Primary endoscopic therapies include intragastric balloons, tissue apposition techniques, and nutrient diverting therapies. Secondary endoscopic therapies include transoral outlet reduction, revision obesity surgery procedures, and argon plasma coagulation. Several studies on intragastric balloons and other primary therapies show promising results with 20-50% excess weight loss. Endobariatrics aims to bridge the gap between medical and surgical obesity treatment.
Malignant bowel obstruction is caused by luminal narrowing of the small or large bowel due to metastatic cancer. The most common primary cancers are colorectal, ovarian, breast, and melanoma. Treatment aims to relieve symptoms like nausea, vomiting, and pain through non-surgical means if possible, including octreotide, opioids, antiemetics, and stenting. Surgery is considered for partial obstructions but has risks. The goal is palliation to improve quality of life rather than cure.
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2. Introduction
• GERD is a common and chronic GI disorder.
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus .
• It is a mechanical disorder caused by a
defective lower esophageal sphincter (LES), a
gastric emptying disorder, or failed esophageal
peristalsis.
3. Introduction
• Patients with GERD are routinely prescribed PPIs.
• PPIs suppress normal acid production in the
stomach to increase the PH. This is effective for
healing esophagitis and heartburn, but less
effective for regurgitation and the non-acidic
symptoms of GERD.
• PPIs do not address the reason that reflux occurs,
i.e., a dysfunctional LES.
• In GERD, the LES is prone to abnormal opening
due to gastric distension, transient relaxation, or
hypotensive resting tone.
4. Medical vs Surgical Rx
• Fundoplication results in significantly less acid
exposure and significantly increased LES
pressure
• Fundoplication has demonstrated improved
QOL compared to that of medically treated
patients and is associated with high patient
satisfaction rates
• Cost differences: controversial
5. Aim of treatment
• Prevention of reflux without limiting the
dynamic nature of the LES to open for gastric
venting or swallowing.
6. Indications
• Objectively proven GERD
• Failed medical Rx (heartburn, severe
regurgitation not controlled with acid
suppression, or medication side effects)
• Patient opt for surgery despite successful
medical management (quality of life
considerations, lifelong need for medication
intake, cost of medications, etc.)
7. Indications
• Presence of complications of GERD (e.g.,
Barrett’s esophagus, esophagitis, peptic
stricture)
• Extra-esophageal manifestations (asthma,
hoarseness, cough, chest pain, aspiration)
• The development of a stricture represents
failed medical Rx: strictures are often
associated with a structurally defective
sphincter and loss of esophageal contractility
9. Preoperative evaluation
• Aim: To select the appropriate reflux patients for
surgical treatment in order to optimize outcomes.
• Counselling: for complications of treatment
• Typical symptoms (heartburn and/or regurgitation)
which have responded, at least partly, to PPI therapy,
will generally do well following surgery; patients with
atypical symptoms have a less predictable response.
• Objective signs of GERD: flexible OGD for any “mucosal
break”(an area of slough or erythema clearly
demarcated from adjacent normal-appearing mucosa )-
a reliable indicator of reflux esophagitis; BE, strictures,
masses; biopsy
10. Preoperative evaluation
• In the absence of endoscopic evidence of reflux, the
current gold-standard objective test to diagnose GERD is
the 24-hour ambulatory esophageal pH-metry
• 48-hour esophageal pH-monitoring: No additional benefit.
• Esophageal manometry: evaluates the strenght of the
propulsive force of the body of the esophagus to propel a
bolus of food through a newly reconstructed valve.
• With normal peristaltic contractions, consider 360° Nissen
FP (or a partial FP) though depends on patient and surgeon
preferences.
• With peristalsis absent, consider a partial FP (rule out
achalasia).
11. Preoperative evaluation
• Barium swallow:
• for better delineation of the anatomy.
• helpful in patients with motility disorders
• large hiatal hernias who have a shortened
esophagus, or for revision surgery after previous
antireflux surgery.
• Anatomic shortening may compromise the ability
to perform an adequate repair without tension,
and that this can lead to an increased incidence
of breakdown or thoracic displacement of the
repair.
12. Adjunct studies
• Video esophagography: structure (strictures,
masses, hiatal hernia, foreshortened esophagus,
diverticula) and function (reflux)
• CT scan of the chest and abdomen, small bowel
follow-through, gastric emptying study, and
colonoscopy
• Hiatal hernia: Lung function tests because of
compromised lung function and thorough cardiac
evaluation because of overlapping symptoms
13. Principles of Antireflux Surgery
• Aim: To safely create a new antireflux valve at the GEJ,
while preserving ability to swallow normally and belch.
Creates a flap valve which prevents regurgitation of
gastric contents into the esophagus due to an increase
in the pressure of the DES region.
The length of the reconstructed valve should be at
least 3 cm. This not only augments sphincter
characteristics in patients in whom they are reduced
before surgery, but prevents unfolding of a normal
sphincter in response to gastric distention
14. Principles of Surgical Therapy
• A laparoscopic approach is now used routinely in all patients
undergoing primary antireflux surgery.
• Some surgeons advocate the use of a single antireflux procedure for
all patients, whereas others advocate a tailored approach.
• Laparoscopic Nissen fundoplication as the procedure of choice for a
primary antireflux repair in all patients with normal or near normal
esophageal motility, and partial fundoplication for those with poor
esophageal body motility.
• Others, based on the good longer term outcomes reported
following partial fundoplication, advocate the routine use of a
partial fundoplication procedure, thereby avoiding any concerns
about constructing a fundoplication in individuals with poor
esophageal motility.
15. The ideal fundoplication
• A loose wrap
• Maintains the position of the gastric fundus close to the distal intra-
abdominal esophagus, in a flap valve arrangement
• An adequate length of the DES in the positive-pressure
environment of the abdomen by a method that ensures its
response to changes in intra-abdominal pressure.
• The reconstructed cardia should be able to relax on deglutition.
• Should not increase the resistance of the relaxed sphincter to a
level that exceeds the peristaltic power of the body of the
esophagus.
• Placed in the abdomen without undue tension, and maintained by
approximating the crura of the diaphragm above the repair
16. Primary Antireflux Repairs
• Nissen Fundoplication.
• The most common antireflux procedure.
• Previously done via an open abdominal or a chest
incision, now routinely undertaken laparoscopically.
• Originally a 360° fundoplication around the lower
esophagus for a distance of 4 to 5 cm, without division
of the short gastric blood vessels.
• Modification: only the gastric fundus used to envelop
the esophagus around a large (50 to 60F) bougie,
limiting the length of the fundoplication to 1 to 2 cm,
and dividing the short gastric vessels
17. Nissen fundoplication
• The patient is placed with the head elevated
approximately 30° in the modified lithotomy
position.
• The surgeon stands between the patient’s
legs, and the procedure is completed using
five abdominal ports.
• The gastrohepatic ligament is incised until the
phrenoesophageal ligament is visualized
18. Nissen fundoplication
• Opening of the phrenoesophageal ligament in a
left to right fashion and preservation of the
hepatic branch of the anterior vagus nerve
• The circumference of the diaphragmatic hiatus is
dissected and the esophagus is mobilized to allow
about 3 cm of intraabdominal esophagus by
careful dissection of the anterior and posterior
soft tissues within the hiatus with great care to
preserve both vagus nerves and the peritoneal
lining along the crura.
19. Nissen fundoplication
• The esophagus is held anterior and to the left and crural
closure posteriorly with interrupted non-absorbable
sutures.
• Following complete fundal mobilization, tension-free FP is
constructed either with or without division of the short
gastric blood vessels, according to surgeon preference.
• The posterior wall of the fundus is brought behind the
esophagus to the right side, and the anterior wall of the
fundus is brought anterior to the esophagus creating a 1.5
to 2-cm wrap with the most distal suture incorporating the
anterior muscular wall of the esophagus
• 50 to 60F bougie placement at the time of wrap
construction
21. Posterior Partial Fundoplication
• An alternative to the Nissen procedure developed to minimize the
risk of postFP side effects: dysphagia, inability to belch, and
flatulence.
• Commonest approach - a posterior partial or Toupet fundoplication.
• Some surgeons use this type of procedure for all patients
presenting for antireflux surgery.
• Others apply a tailored approach in which a partial fundoplication is
constructed in patients with impaired esophageal motility, in which
the propulsive force of the esophagus is thought to be insufficient
to overcome the outflow obstruction of a complete fundoplication.
• The Toupet posterior partial FP is a 270° gastric FP around the distal
4 cm of esophagus. It is usually stabilized by anchoring the wrap
posteriorly to the hiatal rim.
23. Anterior Partial Fundoplication
• An alternative approach to partial fundoplication.
• Following posterior hiatal repair, the anterior fundus is rolled over
the front of the esophagus and sutured to the hiatal rim and the
esophageal wall.
• Division of the short gastric vessels is never needed.
• Various degrees of anterior partial fundoplication have been
described—90°, 120°, 180°.
• The anterior 180° partial fundoplication provides a more robust FP
and achieves an excellent longer term outcome in approximately
90% of patients at follow-up of at least 10 years.
• With this procedure the fundus and esophagus are sutured to the
right side of the hiatal rim to create a flap valve at the
gastroesophageal junction, and to stabilize a 3-4 cm length of intra-
abdominal esophagus.
25. Collis Gastroplasty (PGT)
• When a shortened esophagus is encountered,
many surgeons choose to add an esophageal
lengthening procedure before fundoplication,
to reduce the tension on the gastro-
esophageal junction, believing this will
minimize the risk of failure due to
postoperative hiatus hernia.
27. Outcome after Fundoplication
• Relieves typical reflux symptoms (heartburn,
regurgitation, and dysphagia) in more than
90% of patients at follow-up intervals
averaging 2 to 3 years and 80% to 90% of
patients 5 years or more following surgery.
28. Postop Complication
• Dysphagia: Common. Generally resolves within 3
months, but can take up to 12 months.
Permanent in 5% of individuals following Nissen
fundoplication to require dietary modification
• Inability to belch & vomit: usually temporary (
first 3 to 6 months), but 80%-90% resolves by 12
months follow-up.
• Hyperflatulence: related to increased air
swallowing reflux disease, aggravated by the
inability to belch.
• Rx failure.
29. Recent advances
• Adding bulk to the LES
• tightening the sphincter (by plication/
radiofrequency ablation)
• Robotic surgery
30. Recent advances
• Sphincter augmentation with LINX system: use of
a flexible and expandable device that creates
resistance to abnormal opening of the sphincter.
Ease of removal.
• Complications:
Dysphagia: usually mild
Chest pain from suspected esophageal spasm.
Treated with sublingual nitroglycerin
inability to belch or vomit
Device erosion or migration: Not documented
35. Follow up
• Post op complications
• Complications of GERD (BE) postop: Seattle
protocol. Surveillance at regular intervals
because regression is rare
36. American Gastroenterological
Association Guidelines for Surveillance
After FP For BE
• VARIABLE SCORE
• Age >75 years 1
• Tachycardia (>100 beats/min) 1
• Leukocytosis (>10,000 white blood cells/mL) 1
• Pleural effusion 1
• Fever (>38.5° C) 2
• Noncontained leak (barium swallow or CT scan) 2
• Respiratory compromise (respiratory rate >30, increasing
oxygen requirement, or mechanical ventilation) 2
• Time to diagnosis >24 hours 2
• Presence of cancer 3
• Hypotension 3
37. PROGNOSIS
• Technique employed
Ant vs Post vs Nissen
Length
Short gastric vessel division
• For Barrett’s Esophagus
Presence of dysplasia
Degree of dysplasia
Length of BE segment
38. Conclusion
• GERD is the failure of the antireflux barrier,
allowing abnormal reflux of gastric contents
into the esophagus.
• Surgical management is more beneficial than
medical Rx in patients with typical symptoms
due to the added reflux control.
• Follow up is mandatory in patients with BE.
PPIs- proton pump inhibitors
LES – lower oesophageal sphincter
QOL – quality of life
Barrett’s CLE is commonly associated with a severe structural defect of the LES and often poor contractility of the esophageal body. Patients with BE are at risk of the development of an adenocarcinoma. Barrett’s esophagus should be considered to be evidence that the
patient has gastroesophageal reflux, and progression to antireflux surgery is indicated for the treatment of reflux symptoms, not cancer progression.
Rx - treatment
The important variables are:
the total time with pH < 4 as recorded by a probe placed 5 cm above the LES, and a
composite score comprised of the following 6 variables:
1. total esophageal acid exposure time
2. upright acid exposure time
3. supine acid exposure time,
4. number of episodes of reflux,
5. number of reflux episodes lasting more than 5 minutes and
6. the duration of the longest reflux episode
FP - fundoplication
esophageal shortening is present when a barium swallow X-ray identifies a sliding hiatal hernia that will not reduce in the upright position, or that measures more than 5 cm in length at endoscopy. When identified these surgeons usually undertake add a gastroplasty to the antireflux procedure. Opponents claim that esophageal shortening is overdiagnosed and rarely seen, and that the morbidity of adding a gastroplasty outweighs any benefits. These surgeons would recommend a standard antireflux procedure in all patients undergoing primary surgery.
Following a Nissen fundoplication the expected increase is to a level twice the resting gastric pressure (i.e., 12 mmHg for a gastric pressure of 6 mmHg). The extent of the pressure rise is often less following a partial fundoplication
Experience and randomized studies have shown that both the Nissen fundoplication and various partial fundoplication procedures are all effective and durable antireflux repairs, and generate an excellent outcome in approximately 90% of patients at longer term follow-up.
The efficacy of this relies on the close relationship between the fundus and the esophagus, not the “tightness” of the wrap.
2. The permanent restoration of 2 or more cm of abdominal esophagus ensures the preservation
of the relationship between the fundus and the esophagus. All of the popular antireflux procedures increase the length of the sphincter exposed to abdominal pressure by an average of at least 1 cm.
2. In normal swallowing, a vagally mediated relaxation of the distal esophageal sphincter and the gastric fundus occurs. The relaxation lasts for approximately 10 seconds and is followed by a rapid recovery to the former tonicity. To ensure relaxation of the sphincter, three factors are important: (a) Only the fundus of the stomach should be used to buttress the sphincter, because it is known to relax in concert with the sphincter; (b) the gastric wrap should be properly placed around the sphincter and not incorporate a portion of the stomach or be placed around the stomach itself, because the body of the stomach does not relax with swallowing; and (c) damage to the vagal nerves during dissection of the thoracic esophagus should be avoided because it may result in failure of the sphincter to relax.
4. The resistance of the relaxed sphincter depends on the degree, length, and diameter of the gastric fundic wrap, and on the variation in intra-abdominal pressure. A 360° gastric wrap should be no longer than 2 cm and constructed over a large (50 to 60F) bougie. This will ensure that the relaxed sphincter will have an adequate diameter with minimal resistance. A bougie is not necessary when constructing a partial wrap.
5. Leaving the fundoplication in the thorax converts a sliding hernia into a PEH, with all the complications associated with that condition. Maintaining the repair in the abdomen under tension predisposes to an increased incidence of recurrence. How common this problem is encountered is disputed, with some surgeons advocating lengthening the esophagus by gastroplasty and constructing a partial fundoplication, and others claiming that this issue is now rarely encountered.
*Rudolf Nissen
Technique: 1. Hiatal dissection and preservation of both vagi along their entire length
2. Circumferential esophageal mobilization
3. Hiatal closure, usually posterior to the esophagus
4. Creation of a short and floppy fundoplication over an esophageal dilator
If the vessels are divided, the upper one third of the greater curvature is mobilized by sequentially dissecting and divided these vessels, commencing distally and working proximally.
The fundoplication does not cover the anterior surface of the esophagus, and is stabilized by suturing the fundus to the side of the esophagus, and posteriorly to the right hiatal pillar.
This entails using a stapler to divide the cardia and upper stomach, parallel to the lesser curvature of the stomach, thereby creating a gastric tube in continuity with the esophagus, and effectively lengthening the esophagus by several centimeters. Following gastroplasty a fundoplication is constructed, with the highest suture is placed on the native esophagus when constructing a Nissen fundoplication.