Procedures

Whilst minor degrees of gastro-oesophageal reflux are common in the general population, the majority of patients can be managed effectively with a combination of medications and lifestyle changes. People who continue to have reflux symptoms and or conditions secondary to reflux despite maximal medical therapy maybe candidates for anti-reflux surgery.

There are also some patients who find it difficult to remember to take their medications or who would rather not take medications for the rest of their lives. If suitable these patients maybe candidates for anti-reflux surgery. Some patients have an associated hernia of their stomach into the chest, known as a Hiatus hernia, which is repaired at the same time as the anti-reflux operation.

The aim of anti-reflux surgery is to restore the barrier or valve between the stomach and the oesophagus. This is normally achieved by wrapping the top of the stomach (the fundus) around the lower part of the oesophagus. If the stomach is wrapped completely around the stomach this is known as a Nissen fundoplication. There are variations of this where the stomach is only partially wrapped either across the front (anterior fundoplication) or behind the oesophagus (Toupet).

Partial wraps are used where there is concern over the motor function of the oesophagus, which can potentially lead to swallowing difficulties if a full wrap is performed. Prior to surgery patients will generally undergo testing of the motor function of the oesophagus (oesophageal manometry) to identify patients where this maybe an issue.

Following anti-reflux surgery swelling associated with the surgery results in a temporary degree of swallowing difficulties in virtually all patients. Because of this swelling patients will need to modify their diet towards softer and pureed foods for the first 6 weeks following their surgery.

It is important to realise that in most patients swallowing difficulties are temporary and that in the long run most patients can tolerate a normal diet. It is also worth remembering that many patients who have swallowing difficulties prior to surgery actually have much improved swallowing once their reflux is controlled. More detailed dietary advice will be supplied prior to discharge.

In the early 1990s cholecystectomy became one of the first common general surgical operations to be performed laparoscopically. At the time it was a major advancement, and despite some skeptics at the time, has become the Gold Standard for treatment of gallstone related disease.

It is now performed by most general surgeons and is one of the best examples of how a laparoscopic approach can reduce post operative pain, hospital stay and recovery compared to its open equivalent. Most patients will have 4 small incisions, and spend one night in hospital. Recovery is quick with most patients being able to return to work after a week. There is one instance where a patient had there gallbladder removed laparoscopically and ran a marathon the following week.

Most patients want to know what will happen to them without there gallbladder and why we don't just remove the stones. The gallbladders main function is to store and concentrate bile produced in the liver.

Bile aids in digestion by acting as a detergent which breaks down fat particles so they can be absorbed. Without a gallbladder about a third of patients may have mild indigestion if they eat food with a lot of fat in it, especially if they eat large quantities quickly. If the surgeon was to just remove the stones and leave the gallbladder in place then many patients would form more stones and end up with the same problem they had in the first place.

As we can survive happily without a gallbladder save for some intolerance to fat which is not necessary a bad thing it is much better to remove the gallbladder. Generally it would be said that laparoscopic cholecystectomy is a very safe procedure in the hands of an experienced laparoscopic surgeon. Specific risks will be discussed with you prior to surgery.

Technically it is possible to repair virtually any hernia by a laparoscopic approach, whether this is always necessary and can be justified or beneficial is not always true. There is certainly no advantage in repairing small umbilical hernias laparoscopically, and some large inguinal and ventral hernias are technically impossible to repair by a laparoscopic approach.

On the other hand there are several situations such as recurrent hernias or where there is more than one hernia where a laparoscopic approach is considered the best or gold standard in hernia repair.

The biggest advantage for a laparoscopic approach over traditional open surgery is in postoperative pain and recovery. When considering the long term results of hernia repair of any hernia type patients should consider two things, what is the chance that the hernia will come back (recurrence rate) and, what is the chance of being left with chronic pain. Certainly for incisional hernia's, recurrence rates and chronic pain in most studies are lower in laparoscopic repairs than open approaches. A laparoscopic approach will often pick up incisional hernias that an open approach will often miss and hence reduce recurrence rates.

The biggest debate is that of first up unilateral inguinal hernia. There are many studies which show exceptional results from a laparoscopic approach with low recurrence rates fast recovery and low rates of chronic pain. When laparoscopic inguinal hernia repair is compared with open surgery there is certainly a significant advantage in terms of post- operative pain and more importantly in the rate of chronic pain. In terms of recurrence there have been several studies which did show higher recurrence rates in patients having a laparoscopic repair versus an open repair.

However when the same studies looked at the results of experienced laparoscopic surgeon's the recurrence rates were the same as the open approach. The moral of the story is that if you are going to have a laparoscopic repair, you should insure that it is being performed by someone who is well trained and experienced in laparoscopic hernia repair.

In terms of patients who have inguinal hernia's on both sides there is little debate that a laparoscopic approach is far better give that both sides can be done through the same incision's. The other major indication for a laparoscopic approach is those patients who have already had an open repair which has recurred. By using the laparoscopic approach the surgeon can avoid the scar tissue from the previous surgery and better visualize the hernia. The benefits for both recurrent and bilateral hernias have been well proven in major clinical trials.

In Australia people and realistically most Doctors tend to equate obesity surgery with laparoscopic gastric banding because by far it is the most common operation performed in Australia with approximately 5000 bands being inserted in the last year alone. When we look at the world however by far the most common operation is laparoscopic gastric bypass, with over 140,000 operations performed in the USA alone in 2005. Other operations currently being performed include the Bilio-pancreatic diversion procedure and the latest procedure, laparoscopic sleeve gastrectomy. The reality is that all of these operations do produce effective weight loss (although to varying degrees), they all have their advantages and disadvantages, but they probably all have their place.

Traditionally surgeons have classified operations into those that work by restricting the amount of food and hence calories consumed such as gastric banding, and those that cause malabsorption of food such as Bilio-pancreatic diversion. Laparscopic gastric bypass combines both restriction and an element of malabsorption although this is mild. More recently research has revealed that some operations such as laparoscopic sleeve gastrectomy and laparoscopic gastric bypass also alter hormones involved in appetite control. These changes mean that patients can better control their diets and lose weight without feeling like they are starving to death and are probably as important as restriction and malabsorption components.

No matter what any surgeon might tell you there is not one single perfect procedure, but nor should their be as obesity embraces a wide range of patients, and certainly a super obese 300kg patient with a BMI of 80 and multiple obesity related diseases is completely different from a relatively fit 110kg patient with a BMI of 35.

Different patients need different operations and this is perhaps best evident in the best European centres where at least 3 and sometimes even 4 different types of operations are commonly performed by the surgeons operating there.

Professor Cadiere who performed the first laparoscopic gastric band in 1992 is probably the best example of this. Professor Cadiere at the Clinic of Digestive Surgery in Belgium currently performs laparoscopic gastric banding, laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, and the duodenal switch procedure.

Deciding which procedure is best for an individual patient is a complex process, but includes assessment of a patients dietary pattern, their obesity related diseases and risks, as well as patient wishes. Patients need to understand the advantages and disadvantages of varying procedures and the reasons why a certain procedure maybe a better fit for them in the long-term.

When performed laparoscopically gastric bypass is one of the most technically challenging operations and demands skills that most general surgeons do not possess. Not surprisingly when performed by inexperienced surgeons the complication rates from laparoscopic gastric bypass are higher than those for laparoscopic gastric banding and hence perhaps wisely the reluctance for many surgeons to attempt such surgery laparoscopically.

During his training Mr France was fortunate enough to be involved in over 100 open gastric bypass operations with Mr Phillip Game, an Adelaide surgeon who has performed over 400 gastric bypass procedures. Seeing Mr Game's excellent results and its obvious place in obesity surgery Mr France traveled to the USA where he spent 12 months in a laparoscopic fellowship. During this time he was trained by experienced surgeons in the art of laparoscopic gastric bypass and in doing so became one of the first surgeons in Australia to be formally trained in laparoscopic gastric bypass.

Another recent advance is 2-stage surgery for those patients who are at most risk of developing post-operative complications from any obesity procedure. These patients often have multiple life threatening diseases associated with obesity and also tend to be those who are classified as being super obese.

For high-risk patients Mr France prefers to initially perform a sleeve gastrectomy as a first step to allow patients to lose weight and hence reduce the risks a second stage gastric bypass. This approach has been proven in clinical trials to reduce complication rates whilst ultimately allowing a laparoscopic gastric bypass to be performed which many patients especially the super obese require to get effective weight loss.

Patients who have previously had a laparoscopic gastric band and had to have it removed or have not had sufficient weight loss maybe suitable for conversion to laparoscopic gastric bypass. This again maybe done as a staged procedure especially if the band is being removed at the same time.

Generally most patients will be asked to go on a pre-operative diet.

See Obesity Surgery FAQ.

Advantages

• Effective and reliable weight loss
• Average of 65 to 70% excess weight loss out to 10 years.
• Performed laparoscopically
• Fast recovery and short hospital stay
• No foreign body
• Intensive follow-up not required

Disadvantages

• Involves alteration of gastro-intestinal tract and joining of bowel
• Small risk of leakage

We have been performing laparoscopic sleeve gastrectomy for over 8 years now and with around 1400 patients and as such have one of the biggest series in the world. With this large experience we have been able to achieve excellent outcomes in terms of weight loss whilst maintaining a very low complication rate.

Generally most patients will be asked to go on a pre-operative diet.

See Obesity Surgery FAQ.

Was the most common procedure in Australia but has lost popularity in the last few years with roughly only 25% of bands being inserted compared with 3-4 years ago. The operation involves placing a band around the top most part of the stomach to effectively create a small pouch.

Outflow from the pouch is controlled by the internal diameter of the band, which can be adjusted by adding fluid to a reservoir, which sits under the skin. Adding fluid effectively tightens the band and this needs to be done in small increments so as not to cause obstruction to food. The band works by restricting the amount of food that can be eaten and also by creating a sense of fullness when only a small amount of food is eaten.

The biggest advantage of the procedure is that it doesn't require any adjustments to the normal anatomy of the gastro-intestinal tract and it doesn't require any part of the stomach or bowel to be removed. Because of this immediate post operative complications are greatly reduced and hence it is the safest of all the obesity procedures. The reduction in short-term complications needs to be weighed up against medium term complications such as the band slipping or eroding through the stomach.

The type of foods that can be eaten is also greatly reduced compared to other procedures and some patients may even vomit if they eat the wrong foods. Because of this some patients eventually do not tolerate the band and request that it be removed. Between patients who do not tolerate their bands plus band related complications such as slippage, and erosion around 20 - 30% of bands that are placed are removed within 10 years of the initial surgery. If a band is removed patients should consider conversion to another procedure as reversal of surgery in most patients ultimately leads to weight regain.

Generally most patients will be asked to go on a pre-operative diet.

See Obesity Surgery FAQ.