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December 21, 2017


Family of Shantha a sixty year old lady was devastated when she was diagnosed to have a pancreatic head tumor. Fortunately, on CT scans she had an early tumor with no evidence of spread elsewhere. Although medically found fit, the complex nature of operation – ‘Whipple Procedure’, possible complications and possibility of prolonged stay provided little comfort. She was referred to me and after careful scrutiny of her reports I suggested a laparoscopic (key hole surgery) Whipple procedure. The course of stay in hospital, undergoing laparoscopic Whipple Procedure came as a pleasant surprise for the patient and family who were feared at the outset about the formidable nature of the operation. She recovered well and was discharged from the hospital on the sixth postoperative day.


The goals of lesser pain, shorter hospital stay and early return to productivity have inspired the believers in minimal access surgery to extend the horizons of laparoscopic surgery. The line between extending the benefits of laparoscopic surgery and questionable advantages with this approach is difficult to draw in complex procedures because of the lack of extensive peer reviewed literature as in the case of ‘laparoscopic Whipple Pancreaticoduodenectomy (LPD).

In a recent surgical meeting a senior surgeon commented that ‘the true benefit for patients with minimal access surgery is when the morbidity with the incision (surgical cut) is obviously more than that of the excision’. The corollary would be that there is less benefit in procedures where the morbidity of excision is more than that of the incision as with LPD.


Till a decade before my work in laparoscopy was limited to removal of a gall bladder, appendix, fundoplication or occasionally a spleen. However, with increasing experience and a desire to extend the benefits of key hole surgery to patients undergoing other gastrointestinal procedures I spent several hours training on the endo-trainer, spent several hours with experts in the country and abroad, on several occasions had the good fortune to join in for operations with them. By the year 2008, most of my foregut (food pipe, stomach) and colorectal work was laparoscopic. The collective experience from having done distal gastric resections, common duct explorations, distal pancreatic resections, choledochal cyst excisions and hepaticojejunostomies and proximal jejunal resections gave me the confidence to proceed to performing my first LPD in 2010.


I have been very selective about patients chosen for LPD selecting mainly with periampullary tumors or cystic neoplasms of pancreas. Patients with serious comorbidities, carcinoma head, previous upper abdominal surgery were excluded. Also in the initial two years patients with an aberrant or replaced right hepatic artery were excluded. To put things in perspective out of forty odd Whipple procedures in the last three years fourteen were done laparoscopically. In the first five the resection and part of reconstruction (hepaticojejunostomy) were completed laparoscopically, the specimen retrieval was done through a 8 cm midepigastric incision. Pancreaticojejunostomy and gastrojejunostomy were completed through this minilaparotomy. In the remaining the entire procedure was completed laparoscopically and specimen was retrieved through a small Pfannenstiel incision. Overall, twenty five percent of patients had morbidity. Although, I need to look at my data critically comparing short term and long term outcomes with the open and the laparoscopic approach, with LPD, I did see most patients recovering faster, having lesser pain, having fewer wound complications and starting adjuvant treatment earlier. In the subgroup of patients with LPD experiencing major morbidity such as bleeding or a Grade B or Grade C pancreatic fistula this benefit was clearly absent. Considering major morbidity was seen in 25% of patients, it would be safe to say that seven out of ten patients undergoing a LPD would have better short term outcomes than the open approach.

LPD is technically feasible for a surgeon with advanced laparoscopic skills with team work from assistant surgeons, anesthetists, scrub nurses and technicians. Also, the procedure requires high definition laparoscopic camera, HD monitors, vessel sealing devices and endostaplers. I am sure with increasing experience, improving technology more centres would adopt LPD as standard of practice in the near future.

Dr G Srikanth, MCh is a Senior GI, HPB & Advanced Laparoscopic Surgeon from Bangalore, Managing Director of Sahasra Hospitals and Visiting Surgeon at Gleneagles Global Hospital, Bangalore. He is certified Consultant Surgeon by Dubai Health Authority (DHA), Offering services at Medeor Hospital 24/7 and Aster Hospital, Dubai.

Anterior view, angled to the left hand side, of the gastrointestinal system in a male torso.

Geetha (name changed) was suffering from ulcerative colitis for nearly eight years. She responded well to medical treatment for the initial five years but had frequent relapses of the disease since.

She had been on prolonged course of mesalamine, steroids, immune modulator drugs, Humira etc. Despite best efforts to control the disease with medications, she needed frequent hospital visits and her symptoms of loose stools with blood continued unabated.  A senior medical gastroenterologist for surgery referred her after best efforts to treat her with all available medical options failed. Her quality of life was seriously compromised and she was in tears during her first out patient consultation for surgery. After two sessions of detailed counseling regarding surgery and preoperative evaluation she underwent a ‘restorative procto-colectomy’ a procedure wherein the entire large intestine was removed and a reservoir (pouch) for stool was constructed from the last one foot of small intestine and connected to the anal canal. The operation removed the entire diseased portion and the pouch performs the function of the large intestine. She made a smooth recovery from surgery and three months after surgery she is glad that her normal life is restored.  The most satisfying part for her was that the operation was performed laparoscopically (key hole) and she made a much faster recovery than she expected.


Surgery is required in about ten percent of patients with Ulcerative colitis. The clear indications for surgery would be

  • Non-responders to medical treatment
  • Need for prolonged steroids and related complications
  • Complications of disease – intestinal obstruction, perforation, development of cancer
  • Precursor of cancer detected during long term screening (one out of ten patients with ulcerative colitis stands the risk of developing cancer in the large intestine)


Patients fear surgery for several reasons and the foremost concern with this operation is the perceived need to have a permanent stoma (motion outlet from abdomen wall). Current surgical treatment avoids need for a permanent stoma in nearly all patients. In the last decade I have been performing this entire operation laparoscopically giving the advantages of lesser pain and early recovery, and this has increased the acceptance of the operation by patients, Dr Srikanth said. A temporary stoma may be required for few weeks during recovery from surgery. Risks from surgery are comprehensively evaluated during preoperative workup of patients.


Ulcerative Colitis – At a glance

  • Typical symptoms would be loose stools with mucus and blood. Fever, weakness, decreased appetite, joint pains, etc may be present in 15-20% patients
  • Diagnosis is established by colonoscopy and biopsy
  • Majority (90 %)of patients can be treated with medical therapy and avoid surgery
  • Patients not responding to medical therapy or requiring steroids for longer than six months and/or complications of the disease and medications, must have an expert surgical consultation
  • Surgical expertise is not available in many centres in the city under one roof. This may cause delay in referral with persistent medical treatment with steroids, immune modulators, the prolonged use of which can have serious side effects and drains the patient of their finances to the extent that they are left in a hopeless situation and in no position to explore the surgical option.

There are some areas of the body which are not only sensitive but of extreme importance. The bowel activity of the body determines the happiness and satisfaction quotient. Any problem in that area disturbs the peace of mind and makes one highly apprehensive.

WhatsApp Image 2017-11-28 at 11.32.57

Fistula in anal is one such issue. Usually there is a prodrome when an abscess forms and it drains outside. Most of the times the fistula is small and superficial but in about 25 percent of patients it can be a high in comparison to the muscles of control.


The treatment of a high anal fistula that too with multiple external opening is highly complex. The main aim is to preserve the control while making a bowel movement and not damaging the muscles and nerves in the area, at the same time avoiding a recurrence of the fistula. It is very difficult balancing act. Several new procedures have been demonstrated in the last few years, like laser treatment, video assisted anal fistula treatment and radiofrequency ablation.

But the success of treatment depends on the judicious use of technology and experience of the surgeon. Adequate investigations and a profound patience on behalf of the patient is a “Must”. People get influence and swayed by the promises of simplistic treatment offered by use of new technology. The provision of laser is just a means. The principles of treatment do not change. The pain and recovery time has to be minimized. “Do no harm” is the motto.


Testimonial of one of our patient who had the problem for 1 year and had 3-4 interventions done starting with VAAFT and then seton and then mucosal advancement flap with complete healing in the area. “all that glitters are not gold”. Prudence is a must.

36 year old female patient presented with pain I the right shoulder. Her last child was 5 year of age and she had no findings on the ultrasound done at the time of the pregnancy. She also had palpitations for which she went to the internist who referred her to a cardiologist. She had some changes in the ECG and then she underwent an echocardiography. The echo showed some external pressure on the heart. She did an ultrasound of the abdomen with showed a large cyst in the liver.



She was examined and evaluated by number of doctors and surgeons who gave her multiple opinions. Some advised against surgery, some suggested an endoscopy, and some advised an internal drainage.

Patient was finally seen by the team of surgeons of ’lap surgery”. The counseling was done and explained about various probabilities. She underwent a laparoscopic surgery. The cyst was containing 3.8 liters of fluid. The cyst was removed completely although it was adherent to some of the major blood vessels around the liver. The reason was to ensure that the recurrence of the cystic collection does not take place.


The patient recovered well and was discharged on 4th day.

Cystic lesions of the liver can be a simple cyst, hydatid cyst or a benign tumour of the bile duct known as a cystadenoma. The symptoms are usually of pressure and space occupying lesion. Sometimes the cyst may rupture when it is thin walled. The hydatid cyst is progressively enlarging and can become infected or rupture into the lungs of adjoining structures. Complete removal of cyst is a priority. In occasional circumstances partial deroofing of the cyst can be done.



My experience with Granulomatous Mastitis changed the way how I look at life right now.  It all started a year ago, 2016. The painful experience started as a lump on the right breast that would not go away. I went to the Gynaecologist and she just had me take anti inflammatory medicines. After a month the lump came back and I consulted a different gynaecologist this time and suggested that I go for ultrasound. They referred me to a different surgeon back then. I did all the tests, MRI, FNA Biopsy, etc.   I decided to agree on the surgeon’s suggestion to remove the lump even though it was benign and had no signs that it was cancer.

I was afraid I would develop breast cancer as my grandmother had it and died from it. The mass taken from my right breast was tested for bacteria, and acid fast bacilli for tuberculosis, all tests that was done to me returned negative. No bacteria, No Tuberculosis, nothing inside my breasts. Thought the pain and horror of lump excision will be over after the operation. Two months after, I developed fever and my breasts are red, super sore and painful. I had developed breast abscess on the left breast (the breast which was not operated on).

The experience on this new developed condition is more painful than the lump excision I had before. The current surgeon I was consulting with suggested I have breast incision and drainage. After a month or two of going to the same surgeon, he suggested I transfer to Rheumatology department as I have to take steroids to get well as my breasts are not closing on its own like it is supposed to. The Rheumatologist suggested I take 40mg of steroids which I did not agree with as the steroids had adverse effects on other parts of my body and I still plan to have a baby after my son. This started my quest to find a new doctor. I have seen a few doctors asking for advice on my condition and all suggested I take Steroids as the Rheumatologist suggested. After all hope of finding a specialist who has experience on my condition is almost lost, I tried to find in Google the keywords “Abu Dhabi Doctor Granulomatous Mastitis”. Lo and Behold, the Name of Dr. Ritu came in the search with her website and I tried contacting her via Whatsapp. She was out of the country back then. When she came back, she agreed to see me.

That started the journey to healing for me. She is the only doctor who explained what really happened to my breasts. She is very accommodating to think that my health card was not covering ACDS last year. After 2 months of taking a low dose of steroid, only 5mg compared to what was the rheumatologist was suggesting which 40mg, my breasts started to heal is.  It was a slow healing process but it never got worse than it was before. Until now, I am consulting Dr. Ritu every three months to check and both breasts are closed now for about a month or two. Dr. Ritu is the only doctor I think who has experience with Granulomatous mastitis here in Abu Dhabi. If you have similar case, I think consulting her would be the best option.

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