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Gallstones: New Insights Into An Old Story

Minimal Invasive Surgery

Gallstones: New Insights Into An Old Story

Although stones in gallbladder have been known to cause symptoms and complications for centuries, our understanding of its natural history and clinical associations continues to evolve till now. The gallbladder is a small, pear-shaped pouch that hangs out just under the liver. It stores a green-colored liquid known as bile, which helps in fat digestion. The liver produces approximately 500 ml to 1,000 ml of bile per day, but gallbladder concentrates it ten times and stores 30 to 50 ml of denser bile, which is best suited for fat digestion. Bile contains two important constituents, cholesterol and bilirubin. Bilirubin is a pigment formed by the breakdown of red blood cells in the liver. After meals, the gallbladder squeezes stored bile into the small intestine through a series of tubes called ducts and itself gets empty and flat.

Gallstones are a very common problem worldwide and considered to be a major affliction in modern society. They are in fact, hardened deposits of cholesterol or bilirubin or both which get supersaturated in bile whenever there is an imbalance in its composition. Thereby, there are three types of gallstones: pure cholesterol (more common in the western world), pure bilirubin/pigment stones and mixed stones. These deposits may vary in size, shape or number.

People at risk for gallstones are

  • Elderly
  • Females
  • Pregnant females
  • Obese
  • Diabetics
  • Western diet (high-fat content with more refined carbohydrates and less fiber)
  • Certain drugs like contraceptive pills, lipid-lowering agents
  • Rapid weight loss
  • Even diet extremely low in fats can increase gallstone risk as it leads to less usage of the gallbladder and prolonged stasis of bile, which may cause precipitation of cholesterol.

Natural history

In most cases, gallstones do not cause symptoms (silent stones) and go unnoticed unless incidentally detected on routine ultrasound. Only 10% and 20% will eventually become symptomatic within 5 years and 20 years of diagnosis respectively. The average risk of developing symptoms is 2.0-2.6% per year. Female gender, presence of multiple stones, and stones greater than 10 mm are associated with a higher risk of complications

Complications of gallstones

  • Gallstones usually cause symptoms when they get moved and become lodged within a duct that carries bile. It may cause inflammation/infection/rupture of gallbladder. Symptoms are abdominal pain (within an hour of eating a large meal or in the middle of the night), nausea, indigestion, or fever.
  • The blockage of the common bile duct may cause jaundice (cholangitis).
  • Inflammation of the pancreas can occur if stone happens to block the pancreatic duct (pancreatitis).
  • Rarely, a large gallstone can reach the intestine and cause blockage there with resultant gangrene and infection.
  • Gallstones, especially those larger than > 3 cm are risk factors for gallbladder cancer.

Clinical associations

Newer data suggest a broad association of gallstones with overall mortality, cardiovascular disease, gastrointestinal cancers, and non-alcoholic fatty liver disease. In fact, these associations reflect the presence of shared underlying risk factors like diabetes, obesity and insulin resistance in all the above-mentioned medical problems. So, gallstone disease is now emerging as an important marker of an increased future risk for medical comorbidities which signals for early and aggressive lifestyle modifications.

Medical and surgical management

  • Laparoscopic removal of the gallbladder is an outpatient, minimally invasive, safe procedure with a short hospital stay. Contrary to the popular belief, removal of gall bladder does not lead to any significant digestive problems. Only about 1-2% of people can have loose or greasy stools after fatty meals, and fatty foods may take a little longer time to digest. It does not lead to any vitamin deficiencies.
  • Stones impacted in major ducts are also easily amenable to removal by endoscopic measures (E.R.C.P.).
  • Medical options for the prevention and treatment of gallstones continue to evolve as well. But drug therapies have fallen out of favor because of lower efficacy and higher recurrence rates.


Minimal Invasive Surgery Urinary Problems

Stages of uterine prolapse

What is uterine prolapsed?

This is a condition that occurs in women; it occurs when the connective or muscles like ligament are weakened or damaged, allowing the uterus to fall into the vagina. A lot of women experience this as a result of childbirth, severe coughing, obesity, hormones changes after menopause, etc.

The womb is the female reproductive system. This reproductive system is located inside the pelvis, the muscles that support the bladder, bowel, and the uterus is called the pelvic floor, these muscles also keep the pelvic organ and the uterus in place. If these connective tissues or muscles are weakened or damaged, it gives room for the uterus to fall into the vagina; this condition is known as prolapse. When these structures, the bladder, urethra, bowel, rectum, uterus, and even the vagina falls out of position, without urgent treatment or surgery can lead to them prolapsing further into the vagina and as well as into the vagina opening.


The symptoms that come with this condition depends on the type of uterine prolapsed. But the most common symptom that is applied to every woman is the sensation that the structures or the tissues are out of place. A lot of women describe this sensation as something descending downward; the more severe the prolapse, the more symptoms are experienced. Specific symptoms to vaginal prolapsed include the following:

  • Constipation: This is one of the most common symptoms of the rectocele
  • Enlarged vagina: This is the finding physically seen mostly by women.
  • Bowel emptying difficulty: This symptom is also known as splinting. A woman will find it very difficult to empty her bowel.
  • Bladder emptying difficulty: This is one symptom of prolapse, where the woman finds it difficult to empty her bladder.
  • Pains: A lot of pains are felt during long-standing periods. If you experience severe pains during this period, you need to visit a medical professional to examine you.
  • Stress in urination: This is one common symptom of prolapse, there are severe stress and difficulty during urinating.

Stages of uterine prolapsed

There are 4 stages of uterine prolapse; these are as follows:

  • 1st-degree prolapse: At this stage, the uterus falls in the lower part of the
  • 2nd-degree prolapse: At the second stage, the uterus drops to the vagina opening
  • 3rd-degree prolapse: At this stage, it is called the complete prolapse, where the cervix is positioned at the uterus bottom sags into the opening of the vagina.
  • 4th-degree prolapse: At this stage, the entire uterus projects outside the vagina.

Diagnosis and treatment

When you experience the common symptoms that are listed above, you don’t have to panic, you have to visit a professional healthcare center so that you can be properly diagnosed and treated because there are reliable treatment methods that are used in treating this conditions and many women have been healed from it. Some of the treatment for uterus prolapse is listed below:

  • Vagina surgery
  • Pelvic floor exercise
  • Vaginal pessary.

The condition of uterine prolapse in women is nothing to fear about as the result of childbirth, obesity and some other factors have made a lot of ladies to have this condition, there are many ways that have been discovered to be able to solve this condition.

Advanced Urology Infertility Minimal Invasive Surgery

Symptoms of infertility in men and women

What is infertility?

This is a condition whereby someone is not being able to get pregnant, despite the fact that you try to get pregnant by having unprotected sex for about a year or above. In the United States alone, there is about 10 to 15 percent of infertile couples. The case of infertility may arise from your partner, yourself, or both parties involved. There is absolutely nothing to worry about as there are proven therapies that can improve your chances of getting pregnant, all you have to do is to get a reliable and professional healthcare provider and get your problem solved.


The only symptom of infertility is not able to get pregnant. Some obvious symptoms may not occur. Most times, in women, they will experience menstrual pains and irregular monthly periods. A man with infertility condition will experience hormonal problems like sexual function, change in the growth of hair.

When is the right time to see a doctor?

In most cases, you don’t have to see a doctor for not being able to give birth, until you have tried to for at least a year and see no positive result. Women should see a doctor when they are:

  • At the age of 35 and have tried to get pregnant for at least 6 months or more.
  • At the age of 40 and above.
  • Have a painful periods
  • Irregular/ absent periods
  • Have infertility problem
  • Have done cancer treatment before
  • If you had some miscarriages before
  • Diagnosed with pelvic inflammation.

Causes of infertility in men

Some major causes of infertility in men today are:

  • Low sperm production: For a woman to be able to get pregnant, the man must be able to produce quality sperm, the inability of the man to do so will result in infertility. Health problems can affect the quality of sperm that is needed to get a woman pregnant, such as gonorrhea, diabetes, varicocele, etc.
  • A problem in sperm delivery: This can cause infertility when there is a problem delivering the sperm, like early ejaculation, a blockage in the testicles, reproductive organ injury.
  • Certain environmental problems: The kind of environment that men expose themselves to can affect fertility, such as frequent heat exposure can affect sperm production, smoking, marijuana, drinking of alcohol, etc.
  • The danger caused by cancer: Some damages that are incurred in the treatment of cancer such as chemotherapy and radiation can lead to low sperm production.

Causes of infertility in women

Some things that can affect fertility in women are as follows:

  • Disorder in ovulation: This can affect the release of an egg from the ovary.
  • Blockage of the fallopian tube: This is caused by a medical condition known as salpingitis, which is the inflammation of the fallopian tube.
  • Uterine abnormality: This arises from abnormalities with the shape of the uterus, cervix, or polyps.
  • Cancer and treatment: The treatment from cancer can affect fertility in women.
  • Ovarian insufficiency: This is when a woman experiences early menopause before getting to the age of 40.

Diagnosis and treatment
When you are facing this condition just to visit a doctor and make them understand your problem, they will recommend ways to improve your chance of getting pregnant. Treatment of infertility in men and women includes:

  • Medications
  • Surgery
  • Lifestyle changes
  • Retrieval of sperm
  • Ovulation stimulation with fertility drugs
  • Insemination

There are methods that are used medically to treat this condition, make sure you find a trusted and professional doctor to examine you when you have tried to get pregnant in six months and above.

Minimal Invasive Surgery Urinary Problems

Ovarian Cysts – Types, Causes & Treatment Options

An ovarian cyst is a health condition whereby the ovaries contain a fluid-like jelly. While multiple types of ovarian cysts exist, it is imperative to note that each type has a distinct cause. Some people do not realize that they have ovarian cysts, as they may not experience any symptoms. On the other hand, there exist people who may experience some slight symptoms like stomach bloating, pain in the lower back as well as the abdomen. Ovarian cysts are not usually harmful but it may be fatal and painful if the cyst opens up.

Types of ovarian cysts

  • Functional cysts: Exists as either follicular or corpus luteum cyst and grows as follicles on the ovaries. The ability of these follicles to release estrogen and progesterone hormones influences ovulation.
  • Dermoid cysts: This type of cyst develops from the embryonic cells and are hardly cancerous. They may contain tissue like skin or hair.
  • Cystadenomas: Cystadenomas develops on the surface of an ovary and has the potential of filling up with water or mucous-like fluid.
  • Endometriomas: Develop following the growth of uterine endometrial cells outside the uterus and causes some tissue to attach to the ovary, forming a growth.

Causes of ovarian cysts

There are multiple types of ovarian cysts, including the very common functional cysts that develop following the menstrual cycle. The name is owed to the fact that it normally forms on a monthly basis and exists as a follicular cyst or a corpus luteum cyst.

  • Hormonal problems: If a woman exhibits hormonal problems, then they are likely to develop ovarian cysts. These hormonal challenges include the consumption of Clomiphene, which is commonly referred to as the Clomid (a fertility drug) as a means to induce ovulation.
  • An acute infection in the pelvic: In the event that a woman has a serious pelvic infection, then it spreads to the ovaries, this person will most definitely develop ovarian cysts.
  • Endometriosis: This is a condition that results in the growth of the uterine endometrial cells outside the uterus. Potentially, some tissue will attach to the ovary, forming a growth.
  • Pregnancy: Upon ovulation and the formation of a cyst, this cyst is preserved by the conditions that come with being pregnant.

Treatment options

The intervention for treating ovarian cysts is dependent on the age of the patient, the type of cyst, its size, and the symptoms manifested.

  • Surgery: This approach is only applicable for a large cyst that is growing and progresses across the second and third menstrual cycles. This approach is also applicable if the cyst is causing pain.
  • Hormonal contraceptives: These include birth control pills meant to prevent the cysts from redeveloping. It is important to note that contraceptives do not reduce an existing cyst.
  • Watchful waiting: This approach is opted for as a means to establish whether the cyst disappears after some time. It applies to simple cysts that are small and fluid-filled.


The potential for cysts to recur if the individual has had a previous incident is significant.

Hernia Repair Minimal Invasive Surgery

Hernia Repair – Types and Treatments

The hernia is when fatty tissue or an organ squeezes through a weak spot or hole in the adjoining muscle or tissue.  When there is more pressure on an existing weak muscle or tissue, like obesity, heavy lifting, persistent coughing, constipation, etc., it pushes an organ or a tissue into the weak spot resulting in a hernia.

Hernia types

Based on the place of occurrence, the hernia is classified into the fullowing types

  • In the inner groin region referred to as inguinal
  • In the outer groin or upper thigh region called femoral
  • Incisional when it happens through an incision or a scar in the abdomen
  • Along the ventral wall or general abdominal region referred to as ventral
  • At the belly button called umbilical
  • Hiatal, when it happens along the diaphragm/ upper stomach region, inside the abdomen.

There are also three classifications of Hernia made based on the nature of hernia namely,

  • Reducible hernia where it can be pushed back into the original position.
  • Irreducible hernia where the organ cannot be pushed back.
  • Strangulated where the organ is completely stuck inside the hernia with no supply of blood.

Hernia repair types

The procedure in which the displaced tissues are placed again in their rightful position is called Hernia repair. It is a very common procedure done to deal with the hernia and is quite safe.

There are two types of Hernia repair surgeries performed,

  • Herniorrhaphy: The oldest method of surgery performed to remove a hernia; this method involves a long incision made on the spot of hernia directly after which a cut is made to access it. This is also referred to as tissue repair surgery for a hernia. The tissues and the organs are replaced in their original position, followed by the removal of the hernia sac. The opening in the muscle or tissue which caused the hernia to protrude is then stitched close to prevent further recurrence. The wound is then sterilized before stitching it closed.
  • Hernioplasty: This is referred to as the mesh repair, where the muscle opening causing the hernia is not shut but is rather covered with a sterile mesh. The mesh is either made of animal tissue or polypropylene or similar flexible plastics. Small cuts are made around the tissue with the hole, and the mesh is stitched onto the healthy tissues around the weak spot. This helps the weak tissues to grow with the mesh as a foundation to hold onto. This is also a repair that is classified as tension-free repair.

Both the above surgeries can be done laparoscopically. There are also open repair surgeries for hernia, predominantly done for inguinal, small, and infected or strangulated hernias.

Your surgeon might, however, want to watch the hernia and ensure that it doesn’t grow or cause problems based on which he/she might recommend a surgical procedure. Since hernias have higher chances of recurring, mesh repair is often suggested to strengthen the repair.

Minimal Invasive Surgery

A Complete Guide to Minimal Access Surgery

Minimal access surgery also known as laparoscopic surgery or keyhole surgery is a modern technique of surgical treatment where a small incision is used to operate instead of large cuts. From small cuts, we refer to keyhole-sized incisions that allow surgeons to insert a telescope like an apparatus inside the human body to diagnose or treat a prevailing medical condition. When traditionally operated, the surgeon needs to make large cuts on the human body in order to view inside and operate. However, minimal access surgery allows surgeons to have a clear and better view of the insides of a human body through digitally transmitted images from a video camera, inserted inside the body. The camera acts like a surgeon’s vision during the surgery and allows performing a critical operation, efficiently.

Different types of minimal access surgeries:

When minimal access surgery is performed in the abdominal area of a patient, it is known as laparoscopy. On the other hand, when the technology is used to operate on joints it is known as arthroscopy, and when on the chest the procedure is named as thoracoscopy.

Let us have a better understanding of different types of minimal access surgical treatments:

  • Laparoscopy: One of the most common minimally invasive surgery is Laparoscopy. In this surgery, a video camera mounted on a telescopic instrument is inserted inside the abdominal range of the human body. This video camera transmits live images of the inside of the human body to a monitor, which the surgeon utilizes to proceed with the procedure. Laparoscopy is the procedure when the operation is performed in the abdomen area.
  • Arthroscopy: Another important keyhole surgery, Arthroscopy is used for examining and treating damage or other complications to the joints. The apparatus used for the procedure is known as an arthroscope, which is an endoscope device that is inserted inside the human body at the joints to get a view of the inside with minimal invasion.
  • Thoracoscopy: Thoracoscopy is a procedure that is used to examine and identify the problems in the lung region. Usually, doctors perform Thoracoscopy to check the pleural lining of the lungs and the surface of the lungs. Like other minimally invasive methods, a thoracoscope is introduced into the chest cavity through a minimal incision to identify signs of pleural mesothelioma such as inflammation, pleural plaques, and pleural thickening.

Minimal access or laparoscopic surgery: condition & treatments

Minimal Access Surgeries are one of the best ways to treat a range of medical conditions. It is recommended by the experts because of the successful results it has to offer. The most common health conditions & treatments where minimal access surgery is recommended include:

  • Gall Bladder Surgery
  • Hernia Repair
  • Anorectal conditions
  • Appendix Surgery
  • Intestinal Obstruction
  • Thyroid and Parathyroid glands
  • Solid Organ Surgery

Depending upon the condition of the patient and the extent of the condition the surgeon may recommend a minimally invasive procedure for the treatment. The success rate of Minimal Access Surgery is way higher than that of traditional surgeries along with many other exclusive benefits.

Advantages of minimal access surgery

The advantages of Minimal Access Surgery are over and above the benefits of conventional surgery. It can be broadly classified under two heads.

Benefits for the patient

The biggest advantage of Minimal Access Surgery is in an aspect of Cosmesis. The patient does not have to deal with large wounds and then scars in case of a minimally invasive procedure. Also, because the size of the wound is minimal, the healing time for the surgery is minimal too. The patient can gain back movement within a week or even less. As the patients get their mobility back, they get a physiological boost for early recovery.

To summarize, the benefits of minimal access surgery for patients include:

  • Lesser pain
  • Early recovery
  • Quick cosmesis
  • Short hospital stay and expenses
  • Lesser complications
  • Better results
  • Quick return to normal life

Benefits for the doctor

All the advantages of minimal access surgery for doctors also have favorable outcomes for the patients as they are the primary party getting affected by the treatment. The benefits include the large and magnified view of the inside of the body. In the case of cancer like diseases wherein the problem has expanded beyond treatment, the doctors can always have a visual examination
Any problem related to large incisions such as infection or pain in scars and hernia formation is limited in minimal access surgery.

Common myths about minimal access surgery

There are certain myths about the surgical procedure which do not have any scientific base and support. These myths include:

  • Minimal invasive surgery is an incomplete procedure and there are always chances of reoccurrence – This is not true as the results of conventional surgery as well as minimal access surgery is almost the same, in fact, better.
  • The complication rate is higher – Certainly not, when performed by a qualified surgeon, minimally invasive methods are least complicated.
  • An expensive procedure – There is only a small difference between the cost of conventional surgeries and the cost of minimally invasive surgery.
  • All the surgery can be performed utilizing the minimally invasive method. – No, not all surgeries can be performed utilizing the MAS technique. However, thanks to modern technology the expanse of MAS is rising and more and more procedures can be now done utilizing the minimally invasive surgery techniques.


Minimal Invasive Surgery

Rare Endocrine Tumour Removal Surgery

One rare case of the endocrine tumour has been operated at RG Stone And Super Speciality Hospital on 12-May-2010 by Dr. HS Jolly. An old female, Karamjeet Kaur, aged 60 yrs, r/o distt. Jallandhar came to the hospital on 10-May-2010 with the complaint of one big mass in the upper abdomen. She was suffering from this disease for three years and had constant distress in the abdomen with heaviness after meals along with other digestion troubles. Upon clinical examination and investigation, she found to have one tumour arising from the head of the pancreas. After full preparation she was operated upon by Dr. HS Jolly, Chief Laparoscopic & Endoscopic Surgeon at RG Stone & Super Speciality Hospital.

After opening the abdomen, one mass with big blood vessels surrounding vital structures was found. Tumour of more than 12 cm. X 12 cm. in dimension removed carefully without any damage to surrounding structures.

The patient recovered well after such marathon surgery and has been discharged in a healthy condition. At the time of discharge, she was not feeling any distress and any other related problems.

Microscopic examination of tumour suggested it as an endocrine tumour from the pancreatic head region and such type of tumour with that big dimension is rare to be found in the medical literature.

Advanced Urology Minimal Invasive Surgery

Five Months Old Baby Operated Successfully with Holmium Laser

Baby Manvi, a 5 months old female child was having a rare congenital anomaly of her left Kidney. There were two kidneys on her left side (called duplex kidney), both of which were opening separately in her urinary bladder, but the problem was that one of these two kidneys was having blockade of its ureter due to a condition called ureterocele (the dilated lower part of the ureter which blocks its own passage). A big ureterocele was obstructing the passage of the urinary bladder.

Dr. Anand Sehgal, Chief Urologist at RG stone & Super Specialty Hospital, Ludhiana performed this difficult surgery with the help of the holmium laser and a very small telescope on Thursday, 11th Feb 2010. This operation was done without any incision on the skin, with the help of laser, the dilated lower end of the blocked ureter was opened.

The baby was fine after 3 hours of surgery taking her mother’s feed and was discharged from the hospital on Friday. (within 36 hrs of admission)

Duplex Kidney is a very rare congenital anomaly. This defect occurs during the development of the kidney while the baby is in the mother’s womb.

Previously this condition used to remain undiagnosed until the child grew up and the disease had caused complications. Thanks to the ultrasound modality which now helps us to diagnose this condition even before the baby is formed and timely action can be taken to preserve the kidney from further damage. Such highly advanced procedure requires a combination of modern technology and the exclusive skill of the surgeon.

The facility of such advanced urological procedures is available in very few centres in India.

Minimal Invasive Surgery

New Era of Laparoscopy

Conventionally cholecystectomy is done by laparoscopy by putting four holes over the abdomen. As the surgical field is evolving and technologies are becoming advanced day by day, especially in laparoscopic surgery, now this surgery can be performed by putting a single incision over the abdomen.

Recently, this operation has been performed successfully for the very first time in Punjab at RG Stone And Super Speciality Hospital. The patient was a young lady and was distressed with gall stone problems for a long and was planning to do this operation in the least possible invasive way. As per the plan, the procedure went smoothly by a single hole over the abdomen and the patient was being discharged the next day. The surgery was a success with a single scar, hence cosmetically superior with minimal need for medications and with no chance of pain in the long run at other scar sites.

The dawn of a new era of laparoscopy has been started and minimally invasive surgery has become more minimal. In the above single port cholecystostomy, state of the art imported instruments was used. After putting a single incision over the abdomen; the flexible port was inserted and through the port miniature camera and miniature instruments were used to perform the surgery.

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