Digestive & Reflux Surgery

Anti-Reflux Surgery (GERD)

If you suffer from heartburn, we may recommend robotic anti-reflux surgery to treat the condition technically referred to as gastroesophageal reflux disease, or GERD.

What is GERD?

Although “heartburn” is used to describe a variety of digestive problems, in medical terms it is a symptom of gastroesophageal reflux disease. Stomach acids reflux, or back up, from the stomach into the esophagus. Heartburn is a harsh, burning sensation between your ribs or just below your neck, which may radiate through the chest into the throat. Many adults experience it at least once a month. Other symptoms may include vomiting, difficulty swallowing, and chronic coughing or wheezing.

What causes it?

At the lower end of the esophagus is a small ring of muscle called the lower esophageal sphincter (LES), which acts like a one-way valve. Normally it closes immediately after swallowing to prevent stomach juices from backing up. GERD occurs when the LES does not function properly, allowing acid to flow back and burn the lower esophagus. This irritates and inflames the esophagus, and eventually may damage it.

Some people are born with a naturally weak sphincter. For others, fatty and spicy foods, certain medications, tight clothing, smoking, alcohol, vigorous exercise, or changes in body position such as bending over or lying down may cause the LES to relax. A hiatal hernia may be present in many patients who suffer from GERD.

How GERD is treated

GERD is generally treated in three progressive steps.

Lifestyle changes

In many cases, changing your diet and taking over-the-counter antacids can reduce how often and how harshly symptoms occur. Losing weight, reducing or eliminating smoking and alcohol, and altering eating and sleeping patterns can also help.

Drug therapy

If symptoms persist, drug therapy may be required. Antacids neutralize stomach acids, and over-the-counter medications reduce the amount of acid produced. Prescription drugs may be more effective at healing irritation of the esophagus and relieving symptoms.

Surgery

Patients who do not respond well to lifestyle changes or medications, or who continually require medication to control symptoms, will either have to live with the condition or undergo a surgical procedure. Surgery is very effective in treating GERD.

How robotic anti-reflux surgery is performed

Robotic anti-reflux surgery — commonly referred to as a Nissen fundoplication — reinforces the valve between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus, much the way a bun wraps around a hot dog. Surgeons use incisions of a quarter to a half inch to enter the abdomen through cannulas. A laparoscope connected to a tiny video camera gives a magnified view of your internal organs on a monitor, and the entire operation is performed inside the abdomen after it is expanded with gas.

Advantages and recovery

• Reduced postoperative pain
• Shorter hospital stay
• Faster return to work
• Improved cosmetic result

Most patients stay in the hospital the night of surgery and may require additional days. Post-operative pain is generally mild, though some patients need prescription pain medication. Anti-reflux medication is usually not required after surgery. We typically modify your diet afterward to mostly liquids and soft-textured foods — this is discussed in detail at your consultation. Schedule a follow-up appointment within two weeks after your operation.

Gallbladder Removal (Cholecystectomy)

Gallbladder removal is one of the most commonly performed surgical procedures in New Jersey and the United States. Today it is performed laparoscopically. The medical name for the procedure is a laparoscopic cholecystectomy.

What does the gallbladder do?

The gallbladder is a pear-shaped organ that rests beneath the right side of the liver. Its main purpose is to collect and concentrate bile, a digestive liquid produced by the liver, which is released after eating to aid digestion. Removal of the gallbladder is not associated with any impairment of digestion in most people.

What causes gallbladder problems?

Gallbladder problems are usually caused by gallstones — small hard masses consisting primarily of cholesterol and bile salts that form in the gallbladder or bile duct. It is uncertain why some people form them, and there is no known way to prevent them. These stones may block the flow of bile out of the gallbladder, causing it to swell and resulting in sharp abdominal pain, vomiting, indigestion and occasionally fever. If a stone blocks the common bile duct, jaundice — a yellowing of the skin — can occur.

Ultrasound is most commonly used to find gallstones; in more complex cases other imaging may be used. Gallstones do not go away on their own. Some can be temporarily managed with drugs or dietary changes such as reducing fat intake, but this has a low short-term success rate, and symptoms will eventually continue unless the gallbladder is removed. Surgical removal is the time-honored and safest treatment of gallbladder disease.

How the operation is performed

Under general anesthesia, the surgeon enters the abdomen through a cannula in the area of the belly button. A laparoscope connected to a special camera is inserted, giving a magnified view of your internal organs on a television screen. Other cannulas allow the surgeon to delicately separate the gallbladder from its attachments and remove it through one of the openings. In selected patients an x-ray called a cholangiogram is performed to identify stones in the bile channels or to confirm that structures have been correctly identified. If stones are found in the common bile duct, they may be removed with a special scope or through a second minimally invasive procedure later. The small incisions are then closed with a stitch or two or with surgical tape.

Advantages of the laparoscopic approach

• Rather than a five- to seven-inch incision, the operation requires only four small openings — and for most patients we now perform it through a single tiny incision.
• Minimal post-operative pain for most patients
• Faster recovery than open gallbladder surgery
• Most patients go home the same day and return to normal activities quickly

Virtually all patients are candidates. Our surgeons are able to perform laparoscopic gallbladder removal even for patients who have had multiple previous abdominal surgeries, with an extremely low conversion rate to open surgery.

Recovery

Gallbladder removal is a major abdominal operation and a certain amount of postoperative pain occurs; nausea and vomiting are not uncommon. The vast majority of patients leave the hospital the same day once they can tolerate a diet. A small percentage stay overnight due to nausea and vomiting from the anesthetic, and occasionally patients with a significant pre-existing medical condition require overnight monitoring.

Walking is encouraged. You may shower the day after the operation, and dressings are removed four to five days after surgery. Most patients return to normal activities within a week, including driving, walking up stairs, light lifting and working — those with desk jobs usually return in a few days, while those doing manual labor or heavy lifting may need longer. Patients who have the open procedure usually resume normal activities in four to six weeks. Make an appointment within two weeks following your operation.

Single-Incision Robotic Gallbladder Surgery

When medicine and dietary changes do not help with symptoms related to the gallbladder, robotic gallbladder surgery may be recommended. Removing the gallbladder robotically can control or eliminate severe symptoms — and the gallbladder is an organ you can live without.

How it differs

da Vinci cholecystectomy is performed using the da Vinci Surgical System, a surgical platform that provides 3D high-definition vision of your anatomy, with patented instruments that offer a range of motion far beyond the abilities of the human hand. Unlike traditional robotic surgery, single-incision robotic cholecystectomy allows for a single incision at the belly button, through which the diseased gallbladder is removed.

During the procedure the surgeon sits at a console viewing 3D high-definition video while using controls below the display to move robotic arms with attached surgical instruments.

Potential benefits

• Minimal scarring
• Less pain
• Less bleeding
• Faster recovery and a shorter hospital stay

Robotic Heller Myotomy (Achalasia)

If your doctor recommends surgery to treat achalasia, you may be a candidate for da Vinci robotic Heller myotomy.

What is achalasia?

Achalasia is a disorder in which the lower esophageal sphincter fails to relax properly, making it difficult for food and liquids to reach the stomach. A Heller myotomy is a surgical procedure in which the muscles of the lower esophageal sphincter are cut, allowing food and liquids to pass.

How the operation is performed

Under general anesthesia, five or six small incisions are made in the abdominal wall and robotic instruments are inserted. The myotomy is a lengthwise cut along the esophagus, starting above the sphincter and extending a little way down onto the stomach. The esophagus is made of several layers, and the myotomy cuts only through the outside muscle layers that are squeezing it shut, leaving the inner mucosal layer intact.

Food can easily pass downward after the myotomy, but stomach acid can also more easily reflux upward. For that reason this surgery is often combined with a partial fundoplication to reduce the incidence of post-operative acid reflux.

Potential benefits over open and laparoscopic surgery

• Lower risk of esophageal tears (perforations)
• Fewer complications
• Safer and more precise

Recovery

After robotic surgery, most patients can take clear liquids later the same day, start a soft diet within two to three days, and return to a normal diet after about a month. The typical hospital stay is two to three days, and many patients can return to work after two weeks. If the surgery is performed open instead, patients may need a month off work. Heavy lifting is typically restricted for six weeks or more.

The Heller myotomy is a long-term treatment and many patients require no further treatment. Some will eventually need pneumatic dilation, a repeat myotomy, or an esophagectomy. It is important to monitor changes in the shape and function of the esophagus with an annual timed barium swallow; regular endoscopy may also be useful, since reflux may damage the esophagus over time.

Though this surgery does not correct the underlying cause and does not completely eliminate achalasia symptoms, the vast majority of patients find it greatly improves their ability to eat and drink. It is considered the definitive treatment for achalasia.

Stomach & Duodenal Ulcer Surgery

Our surgeons have extensive experience in the surgical management of ulcers of the stomach and duodenum, and in laparoscopic and robotic surgery for stomach tumors.

What ulcers are, and when they need surgery

Ulcers are erosions or wounds of the inner lining of the stomach and duodenum. They can be shallow or very deep, and can erode into blood vessels causing internal bleeding. Alternatively, ulcers can erode completely through the wall of the stomach or duodenum, causing a hole that allows acid, stomach contents and bacteria to leak into the abdominal cavity — causing dangerous infection and peritonitis. Emergency surgery is required to treat these complications. Less commonly, ulcers fail to heal with medication and surgery is required.

Perforated ulcers

Unsuspected ulcers can continue to erode the lining and wall of the stomach and duodenum, causing life-threatening perforations. This results in peritonitis, in which caustic stomach acid and enzymes cause massive inflammation of the abdominal cavity and its organs, leading to potentially lethal sepsis. Laparoscopic surgery requires highly skilled and experienced surgeons to provide this life-saving treatment. Our surgeons are frequently called upon to perform emergency laparoscopic surgery to repair and patch perforations caused by ulcers.

Bleeding or hemorrhaging ulcers

Ulcers of the stomach and, more commonly, the duodenum can erode into blood vessels causing internal bleeding. Bleeding can frequently be stopped by a gastroenterologist using an endoscope passed through the mouth to cauterize or clip the bleeding vessel. Occasionally massively bleeding ulcers cannot be stopped endoscopically, or bleeding recurs after several attempts. These cases require surgical intervention. In selected patients, laparoscopic surgery can stop the bleeding by either cutting out the ulcer or suturing the bleeding vessel.

Gastric outlet obstruction

Under certain circumstances the outflow of the stomach can become blocked by either tumors or scar tissue, causing food to back up, with vomiting and malnutrition. Laparoscopic and robotic surgery can treat this by removing the blockage or bypassing it.

Non-healing ulcers

On rare occasions ulcers fail to heal with medication, and laparoscopic surgery is used to remove the ulcer and surgically reduce acid production to allow healing and prevent future ulcers. This can involve removing the portion of the stomach involved in stimulating acid production, cutting the nerves that stimulate it, or both. These techniques have a very high degree of success.

Tumors of the stomach

Both malignant and benign tumors of the stomach can be treated and cured with laparoscopic and robotic surgery. Cancers treated this way include adenocarcinoma, GIST (gastrointestinal stromal tumors) and carcinoid tumors. Benign tumors include polyps and leiomyomas. For stomach cancer specifically, see robotic gastrectomy.

Appendectomy

Appendicitis is the most common abdominal emergency requiring surgery, and removal of the appendix is one of the operations most suited to a minimally invasive approach.

A laparoscopic appendectomy removes the inflamed appendix through a few small incisions rather than a single open one, and in selected cases we perform it through a single incision robotically — a technique our practice was the first in the tri-state area to perform.