Gynecomastia is the enlargement of breast tissue in males, typically caused by an imbalance in hormones estrogen and testosterone.  It is a benign condition, that is it is non-cancerous, and it can affect either both the breasts or one breast.  It can also be seen as a lump in the breast and could be tender to touch. It is common during puberty due to fluctuation of hormone levels, but it can also affect men of all ages.  Enlarged breasts during puberty usually resolves without treatment within 6 months to 2 years.

Obesity can also cause enlargement in breasts in men due to excess fat tissue getting deposited in the breasts.  This is termed as Pseudogynecomastia.

Treatment options

Circumareolar mastectomy is performed for removing the tissue lump. The breast tissue is removed surgically, but the nipple, areola and the overlying skin are preserved and is done through an incision circling the areola.

Liposuction is also performed for gynecomastia.  In liposuction, excess fat from the breast is removed through small incisions using a device for suctioning.

Talk by Dr. R. Padmakumar on Gynecomastia

What is the cause of Gynecomastia?

It is caused by an imbalance of estrogen and testosterone hormones, means the amount of testosterone drops compared to estrogen.  Testosterone is the hormone that is responsible for muscle mass and body hair, while estrogen results in the growth of breasts being a hormone of females.

Medical conditions such as thyroid disorders, liver failure or cirrhosis, or kidney failure can also contribute to fluctuating hormone levels.  It can also be caused by side effects of some medications or substance use. Excessive use of steroids in gym goers is leading to gynecomastia in young adults in recent times.

Can Gynecomastia go away on its own?

Gynecomastia during puberty usually resolves within 6 months to 12 years without treatment.

Is Gynecomastia a serious problem?

Not, it is not a serious problem, but it can be treated for cosmetic reasons as it can cause psychological distress and low self esteem especially in youngsters.

Can it be cancer?

Need to evaluate with USG breast to exclude cancer when it appears in more than 40 years age group.

Stages of Gynecomastia

It can be classified into four stages or grades depending on the severity.

• Grade 1:  Small growth of the breast without excess skin
• Grade 2:  Moderate growth of the breast without excess skin
• Grade 3:  Moderate growth of the breast with excess skin
• Grade 4:  Significant growth of the breast with excess skin

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The treatment for cancer typically includes chemotherapy, radiation therapy, and/or surgery. Surgical management of cancer may be essential to prevent metastasis.

Dr. R. Padmakumar performs different cancer surgeries:

1. Thyroid Cancer, Papillary Thyroid Carcinoma – Thyroidectomy for Thyroid cancer
2. Stomach Cancer Surgery
3. Colorectal Cancer Surgery
4. Colon Cancer / Intestinal Cancer – Colectomy, Laparoscopic Abdominoperineal resection (APR), Anterior Resection without colostomy
5. Breast Cancer – Mastectomy, Lumpectomy, Axillary Dissection, Breast Reconstruction Surgery
6. Chest Cancer – Thoracoscopy
7. Soft Tissue Sarcomas
8. Cervical Cancer Surgery – Radical hysterectomy
9. Ovarian cancer – Hysterectomy, Bilateral salpingo-oophorectomy, omentectomy, Lymph node clearance.
10. Esophageal Cancer Surgery
11. Uterine Cancer – Radical Hysterectomy
12. Anal Cancer
13. Endometrial Cancer – Radical Hysterectomy
14. Gallbladder Cancer

Endoscopies performed to detect Cancer

Thyroidectomy for Thyroid Cancer

Thyroid cancer can be of different types:  Medullary thyroid cancer, anaplastic thyroid cancer, papillary thyroid cancer, follicular thyroid cancer, Hurthle cell cancer.  Surgery to remove the thyroid is the most common treatment for thyroid cancers.  It is also termed thyroidectomy.  Depending on the type and stage of the thyroid cancer, it may be necessary to remove the entire thyroid gland (total thyroidectomy) or part of it (hemithyroidectomy). 

Thyroidectomy can be performed as Open, Endoscopic, or Robotic.  In Endoscopic Thyroidectomy, small incisions are made at the axilla, and the thyroid is removed through these small incisions.  Parathyroid tumors can also be removed by endoscopic method.  Robotic Thyroidectomy involves the aid of robots in carrying out the procedure.  In Open Thyroidectomy, the thyroid is removed by making a large incision at the neck. 

Radical neck dissection is performed for surgical control of metastatic neck disease.  This can also be performed endoscopically. In case of lymph node metastasis from thyroid cancer, cervical lymphadenectomy is the treatment choice.  Endoscopic Cervical lymphadenectomy can be performed without neck cut or neck scar.

Stomach Cancer Surgery

Laparoscopic Gastrectomy is performed to remove part of stomach affected with cancer. Laparoscopic Gastrojejunostomy is performed for stomach cancer if the tumor in the stomach obstructs food from leaving the stomach. This allows the food to leave the stomach through new bypass route.

• Keyhole cancer surgery for cancer stomach
• Stapler anastomosis to promote perfect healing
• Early resumption of activities without prolonged rest

Colon Cancer Surgery

• Colectomy
• Laparoscopic Abdominoperineal resection (APR)
• Anterior Resection without colostomy

– Avoids major trouble for patient for taking care of stoma

– Avoids Ressurgery

Advantages of Laparoscopic Surgery

• Avoids abstinence from work
• Helping early initiation of adjuvent therapy (chemotherapy, radiotherapy)
• Avoids wound related problems like pain, infection and hernia
• Better cancer clearance
• Better lymph node clearance
• Reduced recurrence.
• Significantly improve quality of life

Mastectomy (Breast Cancer Surgery)

Mastectomy is performed to remove the cancer-affected breast. Depending on the size and severity of the Breast Cancer, the surgeon may decide to proceed with any of the following surgical treatment:

• Mastectomy: Surgery to remove the complete breast
• Lumpectomy : Wide excision or removal of breast lump along with surrounding normal tissue.
• Axillary Dissection: Surgery to remove associated lymph nodes
• Reconstruction Surgery: To renovate lost breast with breast implants

There are different types of mastectomy which is performed depending on the severity of the cancer. These include:

• Total Mastectomy / Simple Mastectomy
• Double Mastectomy / Bilasteral Mastectomy
• Skin-Sparing Mastectomy /
• Nipple-Sparing Mastectomy
• Mastectomy with Breast Reconstruction
• Modified Radical mastectomy
• Radical Mastectomy
• Breast Conservation Surgery (BCS)

Thoracoscopy for Chest Cancer

• Significantly reduced pain
• Avoids major thoracotomy
• Maximum preservation of lung tissue.

Hysterectomy and Bilateral Salpingo-oophorectomy for cancers related to uterus and cervix

Radical hysterectomy, Bilateral salpingo-oophorectomy, omentectomy, Lymph node clearance are some of the surgeries performed for Cervical Cancer / Ovarian Cancer / Endometrial Cancer / Uterine Cancer.

Soft Tissue Sarcoma

Soft tissue sarcomas start in body’s soft tissues like fat, muscle, nerves, lymph, fibrous tissues, blood vessels, or deep skin tissues.  There are different types of soft tissue sarcomas like liposarcoma, angiosarcoma, etc.  Surgery is the usual treatment for soft tissue sarcomas and might include radiation therapy and chemotherapy.

Image shows Liposarcoma mass weighing 4.2 kg and 1.2 kg removed from the abdomen. Liposarcoma is a rare type of cancer and starts in the fat cells.  Liposarcoma can affect the fat cells in any body part, but mostly occurs in the limb muscles or in the abdomen. Cancer Surgery may be essential to remove these masses. There are four types of liposarcoma: Well-differentiated liposarcoma, Myxoid liposarcoma, Pleomorphic liposarcoma, Dedifferentiated liposarcoma

Department of Minimally Invasive Surgery, VPS Lakeshore Hospital, headed by Dr. R. Padmakumar, offers Cancer Surgery and comprehensive surgical care of a variety of cancers including, stomach cancer, colon cancer, breast cancer, chest cancer, soft tissue tumors etc.

The Department of Minimally Invasive Surgery (MIS) has an efficient team with vast experience in laparoscopic surgeries. Dr. R. Padmakumar is one of the few surgeons in the world performing keyhole surgery for Thyroid Cancer.

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VPS Lakeshore Obesity Clinic was inaugurated at March 4. The clinic, which aims to provide a holistic solution for obesity and related diseases, will be headed by a three-member team comprising Dr. R. Padmakumar, HOD of Minimally Invasive Surgery, Dr. Joseph K. Joseph, consultant internal medicine, diabetology and obesity, and Dr. Vivek Matthew, Consultant endocrinologist. The clinic has been equipped to carry out procedures such as Laparoscopic Sleeve Gastrectomy, gastric bypass surgery, gastric banding, gastroplasty, abdominoplasty, and liposuction along with medical therapy. Facilities such as diet and psychological counselling and exercise sessions will also be available. Composer Deepak Dev and actress Aparna Balamurali were the chief guests for the function which was presided by CEO S K Abdulla.

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Hanging abdomen with an apron is unsightly and uncomfortable for any woman. Not able to wear the dress of their choice is so depressing to anyone. The self esteem gets down with every morning seeing the self profile. But they can be happy that there is a sure way out.

Causes of hanging abdomen

Overweight or Obesity: General adiposity (excess fat) as part of increase in Body Mass Index can cause an increase in abdominal circumference. The ideal BMI is 18-23. Once it is above 23 till 27.5 it is overweight and 27.5 onwards is obesity. BMI is calculated as weight in Kg/Ht in M2 e.g. If a person has 100 kg weight and 2m height, BMI= 100kg/ 2m x 2m=25 Kg/M2

Truncal Obesity (Abdominal obesity): Increasing abdominal obesity is more dangerous than the overall increase in weight. Ideally, the abdominal circumference at umbilical level should be below 80 cm in women. The increase in BMI and abdominal circumference leads to various medical illness like Diabetes, hypertension (increase in blood pressure), dyslipedemia (increase in cholesterol), sleep apnea (breathing difficulty/ snoring with respiratory arrest), PCOS (Polycystic ovarian disease) and fatty liver. It also increase the risk of cancers of breast and ovary.

Divarication Recti (separation of muscles of abdominal wall) : This happens mainly and commonly following pregnancy when there is excessive stretch of abdominal wall muscles making it fall apart from the midline. This leads to bulging of abdomen and patient will have a state similar to pregnancy look. This is highly distressing to any woman. The abdominal bulge will be such that it projects out and comes anterior than breast level in a profile view.

Ventral Hernia : Ventral hernia muscle defect with herniation / projection of abdominal contents in to the sac formed at the muscle weakness. The intestines or omentum get trapped in this defect and can cause life threatening problems.

Sagging Fat and Skin : The lower abdominal wall fat and skin is redundant (extra) and hangs down in an unsightly manner. The skin sagging may be unrelated to the muscle weakness. The pulling down of the abdominal wall by the weight of this apron itself will be causing discomfort and muscle weakness. The disfigurement in these patients is unexplainable.

Hanging Abdomen can be Treated

Patients need to consult a surgeon who is well-versed with the problem and its corrective measures. Detailed physical examination with abdominal girth, height, weight, BMI, BP, Pulse, oxygen saturation to be checked. The co-existing problems like diabetes, hypertension, snoring, respiratory difficulty with walking, menstrual irregularities, stress incontinence and psychological problem (mainly depression).

Those who have increased BMI should be advised for weight reduction. To a good extend it is possible by diet regulations and exercise. There are some drugs available to reduce weight but it helps in reducing weight around 4-5 kg only. Those with higher BMI will be benefitted by intragastric balloon placement or by bariatric surgery of which sleeve gastrectomy is the best. Abdominal obesity also gets controlled to a great extent by these procedures.

Divarication of recti (the separation of muscle in the central abdomen), the ventral hernia and sagging skin with fat (the abdominal apron) needs tummy tuck (abdominoplasty). The exercises to tone the abdominal wall, weight reduction or application of any kind of solutions or application of slim devices like vibrators are not going to give any kind of benefit to these patients.

Abdominoplasty Procedure

Pre-hospitalization

The procedure of tummy tuck involves a pre-hospitalization checkup including blood tests. Ultrasound abdomen is performed to rule out any other surgical problem in abdomen like an ovarian cyst or gallbladder stones which can be talked at the same time. The necessary consultations will also be done with other specialists as needed.

Operation

The operation is done under anesthesia, either general or regional, so that patient will be comfortable. The incision will be made at the lowest skin crease of abdomen to give excellent cosmetic outcome. The skin and subcutaneous fat will be mobilized. The muscles which are far apart will be brought together. In case of hernia a net like material (mesh) will be used to give additional strength. The excess fat and skin will be removed and wound closed. The wound closure is also done in a careful manner with no stitches outside. This also will add to the perfect healing with very minimal scar. The scar will be completely hidden by the smallest of dress.

Post Surgery

Patient needs to be in hospital for 2-3 days and can resume normal activities after that. All kinds of job can be started within two weeks time. Wearing an abdominal binder during this period will give additional comfort.

Methods of Abdominoplasty

Tummy Tuck Before and After

Procedure Outcome

The outcomes are such great that patients get immediate results and regain self esteem. The profile changes and any modern dress will suit the person. The medical issues related to the divarication like dragging pain in abdomen and backache due to the abnormal posture and weight of ventral hernia will also get resolved. In those with higher BMI and sagging abdomen the procedure to reduce weight (sleeve gastrectomy) is done along with the tummy tuck thereby avoiding scars of the bariatric surgery and unnecessary second hospitalization. Combination of these procedures is an innovative method developed at our center to give maximal benefit for patient with superior quality of life.

Tummy Tuck for women

Women who have had several pregnancies find their muscles and skin stretched. They find this procedure useful to tighten those muscles and remove the excess belly fat. Divarication Recti (separation of muscles of the abdominal wall) commonly happens following pregnancy when the abdominal wall muscles are excessively stretched leading to a bulging of the abdomen. This can be rectified by tummy tuck surgery.

Tummy Tuck for men

Tummy Tuck can also be performed in men who has hanging abdomen.

Assessment

The psychological impact of these illness on the patient is very significant. They will be always worried about and other is depression seeing the bad body contour every day. Being not able to wear the dress they like and not able to move around comfortably also keeps them introverts and less sociable. Many jobs also demand people with normal BMI and body shapes. Even promotions are jeopardized by these abnormalities. The associated medical problems and the need for medication for the same will also be making patients uncomfortable and dissatisfied in life.

Tummy Tuck Surgery Cost in Kerala

Tummy Tuck Surgery cost in Kerala is cheap compared to Tummy Tuck Surgery cost in other parts of India. For an enquiry about the cost contact:

Tummy Tuck Surgery in India

Tummy Tuck Surgery in India is performed regularly by Dr. R. Padmakumar, one of the best Tummy Tuck Surgeon in India. He is also Dr. Padmakumar is hailed as one of the Best Bariatric Surgeon in India & UAE. He is renowned for new and improved treatment techniques and the first in the World to perform SCARLESS BARIATRIC SURGERY with Abdominoplasty.

Tummy Tuck Surgery Cost in India

Tummy Tuck Surgery cost in India is also cheap compared to other parts of the world. For an enquiry about the cost contact:

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Though these fissures or anal tears heal on its own within 4 to 6 weeks or gets better with simple treatments such as increased fiber intake or using stool softeners and topical pain relievers, in some cases these fissures can be chronic and may need surgery. 

What are the Symptoms of Anal Fissure?

• Pain during and after bowel movements, sometimes can be severe.
• Traces of red blood on the stool        
• burning or Itching or irritation around the anus
• A visible tear in the skin surrounding the anus
• A small lump of skin or skin tag on the skin near to the tear.

What causes Anal Fissure?

Common causes of the anal fissure include:

• Passing large or hard stools
• Constipation
• Straining during bowel movements
• Low blood flow to the anal area
• Chronic diarrhea
• Childbirth

Other reasons can include HIV, tuberculosis, syphilis, herpes, anal cancer

How does the doctor diagnose Anal Fissure?

The doctor examines the area around the anus and performs a digital rectal exam to diagnose an anal tears. The procedure involves using a short, lighted tube (anoscope) to investigate the anal canal. The location of anal fissure provides information about the cause of the condition. Other tests to diagnose anal fissure include:

• Flexible sigmoidoscopy
• Colonoscopy

Anal Fissure Treatment

Anal Fissure treatment options include Lateral Internal Sphincterotomy (LIS), Anal Dilatation, LASER Ablation or LASER Surgery, Medications.

Several lifestyle changes and home remedies provide relief from pain and discomfort caused by anal fissures. These include:

• Adding fiber to the diet: Fiber-rich food help keep stools soft and improve fissure healing and these include fruits, vegetables, nuts and whole grains. 
• Drink adequate fluids to prevent constipation.
• Regular exercise and physical activity: Engage in moderate physical activity, such as walking for at least 30 minutes for few days of the week. The activity promotes regular bowel movements and increases blood flow to all parts of your body.
• Avoid straining during bowel movements: Straining puts pressure on the mucous lining of the anal area and leads to the reoccurrence of fissures.
• Soaking in warm water for 10 to 20 minutes several times a day help relax the sphincter muscles and promote fissure healing.

Nonsurgical Treatment

• Nitroglycerin: Applying medication containing nitroglycerin externally helps increase the blood flow to the fissure and promote healing.
• Topical anesthetic creams (rectal fissure creams or anal tear creams) provide pain relief.
• Botox injection paralyzes the anal sphincter muscle and relaxes spasms.
• Blood pressure medications help relax the anal sphincter.

Surgical Treatment

Surgical procedure for anal fissure is known as lateral internal sphincterotomy (LIS). The procedure involves cutting a small portion of the anal sphincter muscle to reduce spasm and pain. This action promotes fissure healing and is an effective medical treatment.

Dr. R. Padmakumar and team at VPS Lakeshore Hospital are best doctors for Piles and Fissure Treatment in Kochi. Read more on Other General Surgeries

Stapled Hemorrhoidectomy

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Diet and exercise, behavior therapy, and anti-obesity drugs are the first-line treatments for obesity and overweight. But for severe obesity this has limited success and long term success is very poor. Weight loss surgery or bariatric surgery results in greater weight loss than these conventional treatments. Weight loss surgery aids in improving the quality of life and brings improvement in obesity related diseases such as diabetes mellitus, hypertension, etc.

When is Weight Loss Surgery indicated?

Weight loss surgeries have proved effective and long term studies show that these procedures cause long term weight reduction, resolution of diabetes, improvement in cardiovascular risk factors and obstructive sleep apnea, etc.

According to a medical guideline published by the American College of Physicians, Weight Loss Surgery should be considered as an option for treatment in patients with BMI of 40 kg/m2 or above, who instituted an adequate exercise and diet regimen, but failed, and also in patients presenting with obesity-related comorbid conditions.

Obesity increases the risk of many diseases and health conditions. These include: Type 2 diabetes (Diabetes Mellitus), Coronary heart disease, Hypertension (High blood pressure), Cancers (endometrial, breast, and colon), Dyslipidemia (for example, high cholesterol), Stroke, Liver and Gallbladder disease, Obstructive Sleep Apnea and respiratory problems, Osteoarthritis, Infertility, Asthma

Frequently Asked Questions on Bariatric Surgery

What are the 4 Types of Bariatric Surgery?

Types of Weight loss Surgeries include:

•  Laparoscopic Sleeve Gastrectomy (LSG)
• Laparoscopic Gastroplasty
•  Roux-en-Y Gastric Bypass
•  Mini Gastric Bypass (MGB)

Laparoscopic Sleeve Gastrectomy – Laparoscopic Sleeve Gastrectomy is a surgical procedure for weight loss. Sleeve gastrectomy is also known as a vertical sleeve gastrectomy or gastric sleeve procedure. In this procedure, the outer margin of the stomach is removed to restrict the amount of intake of food leaving the size of the stomach to about 15% of the original size of the stomach.

Roux-en-Y Gastric Bypass – Gastric Bypass is a surgical weight loss procedure for treatment of morbid obesity. In this procedure the stomach is divided into a small upper pouch and a large lower pouch. The small intestine is then reattached to the pouch that creates a bypass for food, which results in absorption of less calories and nutrients.

Intragastric Balloon Placement for Weight Loss – Intragastric Balloon Placement involves using an endoscope to place a deflated balloon in the stomach. The balloon is then inflated to decrease the amount of intragastric space. The balloon is then left in the stomach for a period upto 6 months. Due to the restricted amount of food intake there is an average weight loss of 10-15 kg. This is highly effective in overweight people not classified as obese.

Which Bariatric Surgery is the safest?

Sleeve Gastrectomy is considered to be safer than Roux-en-Y Gastric Bypass and Mini Gastric Bypass as the anatomy is not altered in Sleeve Gastrectomy.

In Roux-en-Y Gastric Bypass, there is alteration in the anatomy as the stomach is divided into small upper pouch and large lower pouch and the small intestine is attached to the pouch (anastomosis) to create a bypass for food.  In Mini Gastric Bypass, the small intestine is connected by a single anastomosis, and thus there is an alteration in the anatomy.  Whereas in Sleeve Gastrectomy such anastomosis is not created and thus there is no alteration in the anatomy.

Gastroplasty on the other hand has the advantage of having no gastric leak.  There is less than 1% risk of Gastric leak that is possible in other bariatric procedures like Sleeve Gastrectomy or Gastric Bypass procedures and people could be afraid of such risks.    Gastric leak happens when digestive fluids leak through the staple line or incisions or anastomosis. Though Gastroplasty is considered safer than Sleeve Gastrectomy, Sleeve Gastrectomy is recommended is patients with high BMI as there is signification reduction of weight compared to Gastroplasty.  In Gastroplasty, 10 – 15 kg reduction is expected, where as in Gastrectomy or Bypass procedures there is much more significant loss of weight.

Which Bariatric Surgery is best long term?

Sleeve Gastrectomy is best long term because the portions of stomach which secretes Ghrelin and acid  in excess is removed.  Ghrelin is the hormone which is responsible for increasing appetite and cholesterol and the acid in the stomach is responsible for digesting the food.    As the part of the stomach responsible for secreting Ghrelin and acid is removed, appetite is reduced leading to less food intake.

Sleeve Gastrectomy is also considered best long term, because since there is no bypass created unlike Gastric Bypass procedures, the patient will not suffer from micronutrient deficiency.  No additional diet or vitamin supplements will be required and weight loss attained will be almost as equal to complex bypass procedures. Sleeve Gastrectomy is also best long term compared to Gastroplasty as the weight loss expected in Gastroplasty is around 10 – 15 kg, where as in Sleeve Gastrectomy there is a significant loss of weight.

Complications of Obesity

Obesity is a medical condition. Obesity occurs due to excess body fat accumulated in the body and is considered a serious medical condition due to the adverse health effect obesity has on the body. People with BMI (Body Mass Index) exceeding the normal range has much greater risk of medical issues. Medical issues include cardiovascular diseases, diabetes mellitus, OSA or obstructive sleep apnea, asthma, etc..

Obesity is a serious medical condition.  People who suffer with obesity and overweight, compared to people with normal or healthy weight, are more likely to develop a number of potentially serious health conditions.  These include:

Hypertension, also called high blood pressure. 

High Cholesterol (Dyslipidemia).

Heart disease:   High blood pressure, abnormal cholesterol levels and high sugar are risk factors for heart disease.  Obesity gives stress to the heart to send blood to all the cells of the body.

Stroke:   Stroke is a condition where the blood flow to a part of the brain stops, which causes the brain cells to die.  High Blood pressure and abnormal cholesterol levels increases the risk for stroke. 

Type 2 diabetes.   It is believed that obesity accounts for 80-85% of the risk of developing type 2 diabetes.  Obese people are 40 times more likely to develop type 2 diabetes than people with normal weight.

Gynecological and sexual problems. Obesity may lead to infertility and irregular periods in women and may cause erectile dysfunction in men.

Sleep apnea and breathing problems are more likely to develop in obese people.  Sleep apnea is a condition in which a person has one or more pauses in breathing during sleep.

Osteoarthritis.  Obesity increases the stress placed on weight-bearing joints.  This may cause damage to the cartilages.

Cancers.  Obesity might increase the risk of cancer of the cervix, uterus, endometrium, ovary, breast, rectum, colon, esophagus, liver, pancreas, gallbladder, kidney and prostate.

Digestive problems.  Obesity increases the likelihood that you’ll develop heartburn, gallbladder disease.

Fatty Liver disease.  This occurs when fat builds up in the liver.   This disease often affects people who are overweight or obese and/or diabetic patients and also in middle aged people.

Polycystic ovarian disease or PCOD.

Pregnancy:  Obese women who are pregnant is at increased risk for developing gestational diabetes, high blood pressure during pregnancy that causes problems for both mother and child.

Depression and anxiety.

Low quality of life.

Bariatric Surgery may help in lowering the risk of Stroke and Heart attack. Bariatric Surgery helps in lowering the risk of stroke and myocardial infarction (heart attack) in patients suffering with type 2 diabetes and severe obesity according to a study published in the Journal of the American Medical Association (JAMA). The study was conducted to investigate the relationship between bariatric surgery and incident macrovascular (coronary artery disease and cerebrovascular diseases) events in patients with severe obesity and type 2 diabetes. This observational study concluded that patients with type 2 diabetes and severe obesity who underwent bariatric surgery, compared to those who did not undergo surgery, bariatric surgery was associated with a lower risk of macrovascular outcomes.

Related Links

• Bariatric Surgery Gallery – Before and After
• Video Gallery
• About Bariatric Surgeon – Dr. R. Padmakumar

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A Ventral Hernia or abdominal wall hernia is an abnormal protrusion of the contents of the abdominal cavity or of preperitoneal fat through a defect or weakness in the abdominal wall.  The abdominal wall is the musculofibrous covering of the contents of the abdominal cavity.

A ventral hernia is a hernia of the abdominal wall excluding the inguinal area, the diaphragm and the pelvic area.  Abdominal wall hernias can be of congenital or acquired variety.  The latter can occur either spontaneously or after surgery. When they occur after surgery, they are called incisional hernias.  3-20% of laparotomy incisions develop ventral hernia.

Types of Ventral Hernia

Umbilical Hernia – This occurs at the umbilicus or the belly button when the intestine pushes through the umbilical ring.  It can be seen as a bulge at the area of the belly button.

Lumbar Hernia –  Lumbar hernia occurs when the bowel, omentum or preperitoneal fat herniates through a defect in the lumbar triangles.  This can be Right Lumbar Hernia or Left Lumbar Hernia

Hypogastric Hernia – This occurs in the hypogastric region.

Epigastric Hernia – An epigastric hernia occurs when the intestines protrudes through the abdominal wall muscles between the umbilicus and the chest.

Spigelian Hernia – A Spigelian hernia is a ventral hernia where the abdominal contents or peritoneum through the Spigelian fascia that is comprised of the transversus abdominis and the internal oblique aponeuroses.

Strangulated Hernia

When the intestinal tissue gets tightly caught as a bulge in the abdominal wall, then the condition is termed as strangulated ventral hernia. In this case the intestinal tissue cannot be pushed back and cuts the blood flow to the area causing the hernia contents to become ischemic due to compromised blood supply.  This requires emergency surgery.

Causes of Ventral Hernia

There are several factors that lead to the formation of ventral hernia and these include:

• Pregnancy
• Obesity
• Record of previous hernias
• Previous abdominal surgery
• Injuries to the bowel area
• Frequently lifting and pushing  of heavy objects
• Week scar tissues from previous abdominal surgery

Symptoms

Symptoms may last for weeks or months and includes:

• pain and discomfort in the abdominal area during prolonged walking, standing or lifting heavy objects
• outward bulging of skin or tissues in the abdominal area
• nausea
• vomiting
• Swelling in the bulged area

Diagnosing Ventral Hernia

The doctor performs a physical exam and asks about the symptoms. The doctor suggests various imaging test including ultrasound scan, CT scan or a MRI scan.

Ventral Hernia Repair

Ventral hernia repair is the second most common type of abdominal hernia operation (25.6% of all hernia repairs). It includes incisional hernia, epigastric hernia, umbilical hernia, lumbar hernia and spigelian hernia.

Laparoscopic Ventral Hernia Repair

Laparoscopic surgery is performing the hernia repair through keyhole incisions using a laparoscope.  A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached.

Laparoscopic Ventral Hernia Repair requires much smaller incisions than open surgery; minimal abdominal wall tissue trauma, less hematoma and seroma; wound infection is four-fold less likely to occur in patients with laparoscopic repair.  Cosmetic benefit varies from case to case (lack of long scar vs. correction of abdominal bulge and apron). Length of hospital stay after laparoscopic ventral hernia repair is found to be shorter in the majority of cases.

Laparoscopic surgery has several advantages with a faster recovery time and minimal scars. Advantages of laparoscopic hernia removal include:

• Few small incisions
• Lowers chance of infection
• Less postoperative pain
• Reduced hospital stay
• Minimal scars
• Faster recovery time

When approaching the hernia with the traditional open technique, the fascial defect is ideally repaired with a prosthetic mesh placed in an onlay/subfascial position. However, the appropriate positioning of the mesh usually involves a large incision and a fair amount of dissection, often complicated by the patient’s body habitus. The laparoscopic approach to ventral hernia repair offers a minimally invasive technique to repair these hernias.

The surgery is initiated by administering a dose of anesthesia to relax the patient and to reduce the pain and discomfort caused by the condition. The surgeon makes a small incision in the abdominal wall and inserts a laparoscope to view the internal abdominal cavity and associated organs. A laparoscope is a thin long tube that has a camera attached to its end and enables the surgeon to view enlarged images of the cavity and the organs with a monitor attached. After investigation, the surgeon makes few more incisions to insert hernia repair tools and the bulged tissues are pushed back and placed in position. Later a mesh is placed in the weak spot of the abdominal wall to prevent the possibility of reoccurrence of hernia. Later the incisions are closed and sutured.

After the surgery, meditations are administrated to reduce pain and discomfort from the surgery. The patient can leave the hospital in a day or two and are instructed not to do any heavy tasks like weight lifting. Diet rich in fiber content and adequate fluid intakes is instructed.

Videos Related to Hernia

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Spleen is an organ that functions to remove unwanted materials such as old and damaged blood cells from the blood stream and plays an important role in the body’s defense system. They contain particular white bloods cells that have the ability to destroy the bacteria that invade the body and prevents from bacterial attack. It also acts as a filter to the blood stream to keep it clean.  

Laparoscpoic splenectomy is recommended when following conditions persist in the organ:

• Ruptured spleen: multiple abdominal injuries leading to ruptured spleen. Ruptured spleen leads to internal bleeding.
• Enlarged spleen: An enlarged spleen condition (splenomegaly), can cause severe pain and discomfort.
• Blood disorder: Several blood disorders are successfully treated by laparoscpoic spelenectomy.
• Cancer: Laparoscopic Splenectomy is used to treat various cancers including chronic lymphocytic leukemia, Hodgkin’s lymphoma, non-Hodgkin’s lymphoma and hairy cell leukemia.
• Infection: An infected spleen develops pus and has to be removed by laparoscopic spelenectomy.
• Cyst or tumor:  Formation of cysts and tumors inside the spleen are removed by laparoscopic splenectomy.  

Diagnosis and treatment

Before undergoing a laparoscopic splenectomy patients are required to undergo various treatments and precautions such as:

• Blood transfusion: to ensure sufficient blood cells are present in the body.
• Vaccinations:  to prevent development of any infection after spleen removal
• Temporarily discontinue other meditations if any.
• Controlled diet

Laparoscopic splenectomy procedure

During laparoscopic splenectomy, the surgeon initiates the procedure by administering a dose of general anesthetic and monitors the blood pressure and oxygen levels during the surgery. The surgeon makes a small incision in the abdomen and inserts a laparoscope (a small tube connected with a camera) through the incision. The laparoscope enables the surgeon to view an enlarged image of the abdomen and internal organs captured by the camera attached to the end of the laparoscope and is connected to the monitor. Later more incisions are made and other surgical tools are inserted to remove the affected spleen and incisions are closed with surgical tapes. After laparoscopic splenectomy, the patients can leave the hospital in a day or two. As spleen plays a major role in defense system to fight infections and bacterial attacks, doctors recommend taking several immunizations to help improve the functioning of immune system of the body in the absence of spleen.

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