As has been discussed under the section on reflux disease, heartburn and reflux is very common from time to time. The majority of people will experience a little bit of reflux from time to time and even those who have frequent reflux usually have their symptoms controlled with simple dietary measures and/or regular medication. A small number of people will continue to have symptoms despite maximal medical treatment or may have symptoms that are not suitable for control with medical treatment, or may not wish to take tablets on a long term basis. These people may be candidates for a laparoscopic fundoplication.

The aim of anti-reflux surgery is to restore normal anatomy, for example, ensuring you have a portion of your oesophagus below the diaphragm and also to reinforce the natural valve at the end of the oesophagus. This valve is reinforced by wrapping part of the stomach around the oesophagus. There are various different ways of doing this; these operations are known as the Nissen, the Toupet, or the anterior fundoplication. All of these operations have been shown to work well and produce good long term results. The type of operation used is usually down to surgeon preference.

Prior to surgery, patients require appropriate investigation and this will include an endoscopy, pH studies and also possibly a barium swallow. This is because it is important to establish that your symptoms are caused by reflux. There is nothing worse than having an operation and being no better.

With anti-reflux surgery, you are exchanging one set of symptoms, for example, heartburn or volume reflux symptoms such as coughing, choking or asthma type symptoms, for post-surgical symptoms such as a feeling of bloating and excessive flatulence. With anti-reflux surgery, you are exchanging a valve at the bottom of the oesophagus that can relax and tighten, for a fixed valve which does not relax and tighten.

This fixed valve has to be tight enough to stop your reflux otherwise you will get no benefit from your surgery. In return, you can experience difficulty in being able to vomit. Also, we all swallow some air as we eat, and usually get rid of this air by burping. After a fundoplication this can be difficult so the air has to escape in other ways and ultimately will end up coming out the other end as flatulence.

Therefore when deciding if anti-reflux surgery is appropriate for you, you have to decide whether your quality of life with reflux is such that you would prefer to live with these other operation dependent lifestyle issues. Nevertheless I have to say that the vast majority of my patients who proceed with anti-reflux surgery have not expressed any regrets.

It is now technically possible to repair virtually any hernia by a laparoscopic approach. There continues to be some debate in surgical circles as to whether a laparoscopic repair is the appropriate type of surgery for certain types of hernia. Generally, I like to repair hernias laparoscopically wherever possible.

The greatest advantage of laparoscopic surgery is a reduction in post-operative pain and a more rapid return to normal activities. All hernia repairs are now carried out using the insertion of a prosthetic mesh. The meshes used are one of two types; either polypropylene or polyester. Polyester meshes have been used in Europe for some time but have only recently been introduced to Australia. Polyester meshes have certain characteristics that make them better for hernia repair. They are easy to handle from the surgeon’s point of view and they are less likely to shrink. I therefore use polyester mesh for all of my hernia repairs.

Inguinal or groin hernias can be repaired laparoscopically with a couple of different techniques. The most common technique in Australia is the laparoscopic extraperitoneal repair (TEP repair) whereas in Europe they have tended to favour the intra-abdominal repair (TAP repair). The TEP repair is technically more demanding but avoids the risks of entering the abdominal cavity. Because the TEP repair is technically more difficult, historically the recurrence rates have been higher than open hernia repair, but with the introduction of new mesh materials and changes in surgical technique, the long term results are now as good as – if not better – than open inguinal hernia repair. However it should be emphasised that TEP inguinal hernia repair should be performed by an experienced laparoscopic surgeon with appropriate training in the technique. TEP inguinal hernia repair is not possible in some patients, particularly men who have had prostate surgery, and in these circumstances a TAP type repair offers an appropriate laparoscopic alternative.

Laparoscopic hernia repair would be considered the gold standard operation for recurrent groin hernias and also for patients with bilateral groin hernias. Up to 25% of patients with a unilateral groin hernia have a hernia on the other side when examined and investigated.

A new and exciting area of laparoscopic hernia repair has been laparoscopic repair of umbilical and incisional hernias. These types of repair allow the hernia defect to be examined from the inside and as is often the case with incisional hernias, other smaller hernias which are not clinically apparent, are seen laparoscopically. This allows a mesh of appropriate size to be placed to cover both the main defect and also the smaller defects which, if untreated, would eventually present as recurrent incisional hernias in years to come. Laparoscopically repair of incisional hernias avoids the need for major abdominal incisions leading to faster patient recovery and less post-operative pain. Laparoscopic repair of these types of hernias does require the use of special non-adherent mesh that can be placed inside the abdominal cavity. Laparoscopic repair of incisional hernias has been shown to have a lower recurrence rate and lower infection rate than the more traditional open operation.

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The first laparoscopic cholecystectomy was performed by French surgeon Philippe Mouret in 1987. Since then it has gone on to become one of the most commonly performed general surgical operations.

The operation is performed using a laparoscope (telescopic camera) and three 5mm operating ports. The majority of patients stay in hospital overnight and go home the following day. I have performed a number of day case laparoscopic cholecystectomies and this is perfectly acceptable if the patient has an appropriate level of care at home. The majority of patients are able to return to work after about a week.

In addition to removing the gall bladder laparoscopically, it is also possible to laparoscopically remove gallstones that have escaped from the gall bladder and have lodged within the biliary system. These gallstones can produce symptoms such as jaundice or recurrent infection. In a small percentage of patients, these stones are detected as incidental findings during their laparoscopic cholecystectomy.

Evidence suggests that the majority of these stones will pass spontaneously without causing any difficulties. While it is possible to remove these stones laparoscopically, in some cases this is not technically possible or may not be advisable for other reasons, in which case I may recommend a procedure such as an ERCP in the post-operative phase. In this procedure, a camera is passed down through the stomach to the bottom end of the bile duct and the gallstones are removed under x-ray control. This is usually performed as either a day case or an overnight stay and involves some sedation but not a full general anaesthetic.

The colon is the last part of the gastro-intestinal tract and its main function is to remove fluid and electrolytes from intestinal content to form a semi solid bowel motion, which is stored in the last part of the colon, until it can be evacuated at an appropriate time.

The colon which is around 1 meter long is predominantly fixed to the outermost parts of the abdominal cavity winding its way from the lower right side of the abdomen up into the upper portions and then across to the left before descending down into the pelvis where it becomes the rectum.

Because the colon is not located at one particular point in the abdominal cavity to remove all or even part of the bowel requires access to a large part of the abdominal cavity and hence by traditional techniques requires a large incision or cut which may extend all the way from just below the breast bone to just above pelvis. Laparoscopic surgery generally allows access to the entire colon through multiple small incisions and by using special laparoscopic instruments all or part of the colon maybe removed and reconnected.

The 2 main diseases affecting the colon, which may necessitate its surgical removal, are bowel cancer and diverticular disease. Both of these diseases may be diagnosed on colonoscopy, when it is performed to investigate symptoms such as abdominal pain, change in bowel habit or if blood is passed at the time of a bowel motion.

Colonoscopy is also performed when an individual is at risk of developing bowel cancer such as when there is a strong family history of bowel cancer or if the patient is known to have polyps. Most cancers develop from polyps and whilst most polyps can be removed at the time of colonoscopy, occasionally when they are very large the patient may have to have part of the bowel removed.

Diverticular disease, which is quite common especially as people get older for the most part, does not cause patients much problem. Rarely does it require removal of the bowel unless secondary complications such as narrowing or severe infection occur. Fortunately these complications are not common.

Surgically removing the bowel is known as a colectomy. Most of the time the bowel can be rejoined which is known as an anastomosis, there are however some situations where there is a high risk that the join may leak and part of the bowel may have to be brought out onto the abdomen as a stoma. Often if a stoma has to be performed it is only temporary and can be reversed by a second operation at a later date. If you are going to have any bowel surgery it is important that you and your surgeon discuss these risks before your operation. Our practice certainly considers this important. It should be noted that the risk of leaking from an anastomosis or having a stoma are not related to whether the procedure is performed by traditional open or laparoscopic techniques and this has been proven in many studies.

Not all patients are suitable for a laparoscopic approach because of factors such as adhesions from previous surgery or infection, large or advanced bowel cancers, or cancers located low in the pelvis. Often these factors can be identified prior to surgery but at other times they are discovered at the time of the surgery, in which case a traditional open approach may be taken. In these situations often it is possible to do part of the procedure laparoscopically and part through a small open incision. Because a small incision is virtually always required to remove the colon, sometimes a special larger port is placed through which the surgeon may place his hand but still work in a laparoscopic environment. Hand assisted surgery may allow a colectomy to be performed in some situations not suitable for a pure laparoscopic approach, it is often quicker, and carries all the same benefits of a pure laparoscopic approach.

Overall the risks of laparoscopic or open colectomy are similar. Laparoscopic colectomy has been shown however to result in less wound complications, shorter hospital stay, less pain relief requirements and a faster recovery and return to work and daily activities. More recently studies have confirmed that in terms of treating bowel cancer, outcomes from laparoscopic colectomy are equivalent to traditional open techniques when performed by experienced laparoscopic surgeons. It should be born in mind that laparoscopic colectomy is a technically challenging procedure and should only be performed by experienced and well trained laparoscopic surgeons specifically trained in laparoscopic colectomy.