Chirayu Healthcare Polyclinic & Diagnostics

Hello friends,

I am Dr. Dilip S Rajpal. I am a general and laparoscopic surgeon. I specialize in single incision laparoscopic surgery. Before single incision laparoscopic surgery, what is laparoscopic surgery? laparoscopic surgery is a minimally invasive surgery in which surgery is done exclusively through minimal holes in the abdomen ranging from 0.5 to 1 centimeter, typically around three to four holes are made and in any laparoscopic surgery we need minimum 3 holes and we need to put one camera which is connected to TV for visualization of what is going inside the abdominal cavity. Second will be to hold the tissue and third will be to cut the tissue. Now we specialize in something called single incision laparoscopy, so this is a new advanced minimally invasive surgery in which instead of three holes or four holes we do exclude this complete surgery in a single hole and that would typically from the patient's navel. Now who does this particular surgery? so this is the advanced surgery it has a long learning curve so because it is advanced and the surgeon who is doing it should have an expertise about the laparoscopic surgery, so that is a main indication of this thing.

Now what all surgeries can be done? In today, the most common surgery what can be offered is what we call SILS (single incision laparoscopic surgery). SILS cholecystectomy, a gallbladder stone disease that is the most commonest of the surgeries. Of course indication-wise we do SILS appendectomy, we do SILS diagnostic laparoscopy, SILS mesenteric lymph node biopsy. In best of the Centers it is done for any disease including that of bariatric surgeries also. Today the main advantage of this particular surgery is that the single hole in the navel and the size is hardly 2 centimeters because we take inverted stitches, patient gets a waterproof dressing, so patient has a feeling that he has never been operated, though psychologically patient doesn't have any pain per se and because there is a single hole obviously the chances of complication, wound infection, herniation everything is very low.

We use all normal conventional instruments, here again there are two parts, one is either using conventional instrument or using something called SILS port. SILS port is a disposable port which is slightly expensive and it costs around twenty thousand rupees per patient. Now we are doing by conventional surgery in which we use the normal conventional instruments so there is no extra cost burden to the patient and with the same common instruments we can complete the surgery so definitely the cost part also doesn't increase for the patient so in the same cost patient gets an added advantage of less scar.

Now it has its own disadvantages in the sense the instruments manipulation is very difficult, it has its own long learning curve because we were always taught that the instrument angulation has to be 90 degrees and has both angles and all those things we were always taught, but here all the principles are gone now, actually all the instruments are going parallel to each other so when we are doing this surgery all the instruments are fighting and cross fighting with all the instruments so it has its own learning curve that secretly that is the thing, but today in eight years of experience we have started with the simple cholecystectomy, simple gallbladder diseases and we reach the stage of accurate appendix and now in today we even manage puss in the gallbladder, empyema, mucosa of gallbladder, appendicular abscess, even gangrene of appendix and gallbladder that can be managed.

There is no restriction we put in a single hole for SILS surgery for all our patients. We do our own modification as I already said that we use all normal conventional instruments we don't use any special instruments, so it definitely doesn't increase any cost burden to the patient so the main nutshell is that SILS is advanced laparoscopic surgery and which causes very little pain, better cosmesis because small scar is there. We usually do subcuticular stitches so patient’s scar is hardly visible, no need for any suture removal we give waterproof dressings, so next patient is back to normal activity, We usually hospitalize for 36 hours and in 48 hours patient is back to normal activities, so for any such more videos you can connect to lybrate page.

Thank you.

Hello friends,

I am Dr. Dilip S Rajpal. I am a general and colorectal surgeon. Today I am going to discuss about perianal diseases. Most common symptoms of perianal diseases is usually painful defecation, bleeding PR and pus discharge from around the motion area. First of all before going anywhere I would like to highlight that not all bleeding PR are because of piles at the same time not all bleeding PR are because of cancer. Now the most important pathophysiology, any etiology of any disease related to motion area is constipation, straining at the time of motion and hard motion, three common disease what we usually see in this particular area one is fissure, one is piles and one is fistula, coming to fissure. Fissure, one of the commonest of the disease which is usually seen in very young age and common presentation is usually pain and also bleeding, basically it is a small crack in the motion area, any person who has hard motion, when he strains he finds a small cut in that particular area and because there is a cut, the muscles in that particular area they contract causing severe pain and because the muscles are contracting this wound or amal cut also fails to heal.

Now the treatment for this is medical treatment, very good appointments are available in today's date but the most important is taking care of constipation, because till the time of patient constipation is not cured or patient is having hard motion this small wound is never going to heal. The most important treatment would be laxatives and we practically stopped operating with these patients because what we do is bedside dilatation and once dilatation is done the patient is immediately pain-free and he is better applying ointments and taking medical treatment, otherwise if patient has recurrent diseases than we offer surgical treatment in the form of internal sphincterotomy. Coming to next disease called piles, now pilles is one of the most common diagnoses which patient assumes that each and every bleeding because of piles, now piles is nothing but it's mucosal prolapse so any person who strains at the time of motion some part of the anal mucosa that comes out and that is called piles, depending on the severity how much it comes out, how much its prolapses, severity are there. Now if it prolapses inside inside then something like pops then it will be a grade I or grade II, if it comes out of the motion area the patient complaint that he can feel something, but it comes and goes inside then it's usually grade III and if something comes out, but does not go inside it's usually grade IV.

As I already said the main reason is straining at the time of motion, hard motion so till the time all these things are not taken care of patient is bound to have this disease and it is never going to get cured. Treatment wise, in today’s world treatment is medical treatment in the form of laxatives, sitting in warm water because once you sit in warm water there is soothing effect, patient is better compliant, pain reduces and also the bleeding also reduces. Surgically we usually offer MIPS that is minimally invasive procedure for piles, which is done with the PPH03 stapler, with the help of the staplers complete surgery is done about the motion area, so it is definitely a pain-free surgery. Today we also do suture rectopexy, many times this staplers are quite expensive when this type of patient can not afford then we offer them suture rectopexy, surgery done completely above the motion area so hence it is painless surgery.

Other treatment options like laser treatment option nowadays is coming up in a very big way that can also be offered. All these and whatever form of treatment is offered is just to decrease the morbidity of the surgery, for recurrence patient has to take care of this, What I always tell all my patient is irrespective whether they get operated or not, whether they take Ayurvedic, homeopathic or allopathic you have to take care of your motions that till the time patients doesn't take dietary advice he is bound to have recurrence and third form of disease is fistula. Fistula is a small tunnel is formed within the motion area and outside skin which keeps on discharging pus so typical this pus discharges every 3 weekly, patient will have some pus discharge and because there is a pus discharge patient have lot of pain and he will have inflammation, he may have fever also very rarely but we need to operate that pus also, so for fistula treatment is 100% surgery.

So for all these perianal diseases the most important reason is constipation till the time patient does not take care of his diet, because these all are lifestyle diseases, diet in the form of patient should drink a lot of liquids, liquids like any form water, coconut water, Dal, soup, juice whatever you want you have fruits, vegetables, salad, all these leafy vegetables. All these leafy vegetables and salads are fibre and the more fibre you take more it will absorb the water and once it absorbs the water the motion become more and more softer this problem will decrease on its own. The non-vegetarian food, extra spicy food, cheese, chocolate should be reduced as much as possible because they all alludes more and more constipation and also patient should not strain at the time of motion, patient should pass motion as and when he feels right, don't try to control and patient motions should always be soft, if we follow this advice then patient’s motion will be soft, any motion related problem will never ever recur in his life. For any such more videos you should definitely go to lybrate page.

Thank you

Hello,

I am doctor Dilip S Rajpal. I am a practicing general and laser varicose vein surgeon. Varicose vein is one of the most common diseases which is misdiagnosed and very under diagnosed, varicose vein is a disease in which the veins of the legs become dilated and tortuous, so the patient usually neglect it thinking that it's a very common disease, it's a day-to-day activity and I'm having since childhood, my family has it, my relatives have it and we have a family history that's why the disease is grossly neglected. So people have a lot of questions like how do I inherit it? what is the complication? what is the treatment we can offer and most important is whether it causes any recurrence? so I will explain about everything.

The most important is the risk factor so definitely the aging increases because of age, because of daily wear and tear the veins become damaged and the valves become diseased. It is more common in women than in men because of hormonal issues, because of pregnancy, menopause and even OC (oral contraceptive) pills increase the incidence of varicose veins. Obesity obviously because of increased fat deposit the veins are less supported and as the veins become dilated, tortuous and hence the valves become diseased leading to varicose vein formation. Standing is being the most important reason for this thing.

Today most of the jobs are concerned for long standing that's why the incidences become more and more common So coming to familial component, almost 75% of identical twins will have varicose veins and almost 52% of non identical twins will have varicose veins. If both parents have varicose then almost 90% of the children will have varicose veins. If one of the parents is having it then 62% of women and 25% of men will have varicose veins, so the incidence is that common. Coming to the symptoms, patient usually complains of lot of visibility of veins in the legs then comes a stage of pain, then swelling, then discoloration in the legs and even ulceration. Ulceration being the most deadliest of the complication because these ulcers happen because of increase in the pressure in the veins, so these ulcers although they look very simple, but they ooze a lot and they don't heal, they refuse to heal.

We usually follow CEAP classification, which is clinically, etiological, anatomical and pathological classification. According to that we may grade the patient and according to that the treatment is offered to the patient, now before coming to the treatment I would like to highlight something on the pathophysiology because I give a lot of importance to pathophysiology because since the time patient doesn't understand how does varicose vein happen? so he is not critical and he doesn't take care of it. So varicose vein is one disease which happens only in humans because of our standing job because we stand, so anything in this world will come from above downwards because of gravity but nothing goes on below so our bodies is the one structure in this universe, where actually blood is going from below upwards so when this blood is going from below upwards and person's job is concerned with prolonged standing or family compromise as I just mentioned some of the valves become diseased now when these valves become diseased, blood actually falls down and when the blood falls Down the vein becomes dilated so initially the veins will be visible.

Slowly and steadily what happens the pressure in the brain increases and these are small superficial veins they cannot bear that much of pressure, so the veins start paining, this pain is not a typical pain as in orthopedic diseases, this pain is more of heaviness in the legs and when a patient gets up early in the morning, patient feels very comfortable because he was lying down, all the pressure in the vein decreases, but now as the day is ending patient is working throughout the day vein will become more and more tortuous so it caused a lot of pain, more so in the evening and patient feels we should do massage or something like that, slowly the pressure in the vein further increases which causes the plasma, the white part of the blood to ooze out, so leading to swelling in the legs, slowly and steadily even the red blood cell come out leading to blackish color of the legs if there is blackish discoloration, if the red cell ooze out then there is something called inflammatory mediators get released and patient has feeling of itching and patient scratches and once patients scratches, patient develops this and it never heals.

So as I told the main pathophysiology of the disease is increased pressure in the vein, so the treatment is to decrease the pressure in the vein. Now how will you do that? conservative treatment in the form of bed rest, keeping legs elevated more so in lying down position, once you do that the pressure in the vein decreases but throughout the day you cannot do that so what you can do is you are supposed to wear specially designed stockings. Nowadays very good quality, very fine elastic stockings are available we usually recommend class 2 stockings which gives a pressure almost 20-30 mmHg so once you wear the stockings the pressure in the vein decreases, so obviously the pain, swelling and another complication that also decreases, in fact the ulcer also heals, but the disease is not going to get cured, the disease is going to remain static, the disease will not get prolonged. Now coming to the surgical management, if at all in today the diagnosis is done on the basis of venous Doppler and on the basis of venous Doppler we diagnose what is the size of the saphenofemoral valve, saphenopopliteal valve, ankle perforators.

Today, we ask for even the size in millimeters what is it? because the treatment we are doing more and more non-surgical treatment in the form of endovenous laser ablation, so all that is very helpful. So one is of course, as I told you the treatment, the veins, the valves are diseased so surgically we can either cut the valves at those, we can just disconnect the superficial and the main vessels but this has to be done at multiple levels, so it is painful and this wounds itself doesn't heal because of the pressure in the vein, leg is already swollen and the pressure in the vein was already high. Now coming to endovenous laser ablation what we actually do is, we put in a small needle inside the vein, inside the needle you put in a laser fiber and completely burn out the vein from inside. This complete procedure is doppler guided, so this complete surgery in fact is done under local anesthesia, it is an OPD procedure because we do OPD procedures and patient can immediately walk down and can be resume normal activities very next day, so it causes very very less morbid than today's day. The most important treatment is to decrease the pressure in the superficial vein and that is taken care with the help of endovenous laser ablation. Coming to the recurrence part.

A lot of patients have a question regarding the recurrence now this disease is valve related disease, so any valve which is diseased we have to take care of that, so the valves which are diseased we are ablating with the help of laser we are taking care of that, but tomorrow patient is not going to change his job for a particular disease, some new ones may still get disease. Now many times both the veins i.e. long veins and soft veins, when both are diseased so in such patients we ablate both the veins the chance becomes almost nil, but if at all the one vein is diseased there is always a possibility that the patient may still develop, so in such patients, the already operated once and more than once then we recommend them to wear life long stocking otherwise the stocking is recommended only for 3 months. Now if you compare whether this is laser and open surgery the recurrence rate for both is almost the same; however, in open surgery there is a lot of morbidity, a lot of pain, suffering but in laser ablation, it is OPD procedure, can be done under local anesthesia, the patient can resume work very next day so morbidity is absolutely nil. If you want to get more information then you can go to lybrate page.

Thank you