a About us a a
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buton Transplant Surgery
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buton Liver Surgery
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buton Pancreas Surgery
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buton Gall bladder & Bile Duct Surgery
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buton Bloodless Surgery
 
Dr Ravi Shankar Dr. Ravishankar
Liver & Transplant Surgeon

Cell: 0065-91817293
Ph: +65-64790608
24hr Svc : +65-65358833
Fax : +65 64797608

Email: diddapur@yahoo.com.sg
www.liversurgery.com.sg

Specialist Surgery Singapore Pte Ltd
#02-35, Gleneagles Hospital
6 Napier Road, SINGAPORE 258500
   
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Laparoscopic Gallbladder and Bileduct Surgery
 
Benefits of laparoscopic surgery:
  Laparoscopic procedures provide many advantages to the patient over conventional open surgery. Some of the benefits of laparoscopic surgery are less discomfort & pain after the surgery, quicker recovery times, shorter hospital stays, earlier return to full activities and much smaller scars. Furthermore, there may be less internal scarring when the procedures are performed with laparoscopic surgery compared to standard open surgery.
 
Laparoscopic surgery for the gallbladder and the bile duct:
  Laparoscopic gallbladder removal has been performed in thousands of patients throughout the world and is a very safe procedure. Gallbladder removal should be performed by laparoscopic surgery when possible.

In contrast to gallbladder surgery, procedures on the bile duct are rarely performed laparoscopically by biliary surgeons since they are technically very difficult. Since the bile duct is located deep in the abdomen the incisions for open bile duct surgery are long and large. These incisions are usually associated with a lot of discomfort and require recovery period of 4 to 12 weeks. The majority of patients who undergo open surgery stay in hospital for 4 to 10 days after surgery compared to patients who undergo laparoscopic surgery and stay in hospital for 1 to 3 days after surgery.

The laparoscopic procedures performed on the biliary system are:
Laparoscopic cholecystectomy: In this procedure the gall bladder is removed by laparoscopic techniques. The usual indications for removal of the gall bladder for laparoscopic cholecystectomy include the presence of gallstones in the gall bladder and small benign tumors called gallbladder polyps.

Laparoscopic common bile duct exploration: In this procedure, stones in the bile duct are removed by laparoscopic techniques. In patients with gallstones small stones can pass from the gallbladder into the bile duct. Stones in the bile duct can cause obstruction leading to the development of jaundice and pancreatitis (inflammation of the pancreas). The treatment is removal of the gallbladder.

In many patients a stone that has passed into the bile duct is spontaneously excreted into the intestine. If a stone is found in the bile duct at the time of the gallbladder surgery then additional procedures are required to remove the stones. Stones in the bile duct can be removed at the time of the laparoscopic cholecystectomy by advanced laparoscopic techniques.

Resection of choledocal cysts: Choledocal cysts develop from abnormal dilatation of the bile duct that is usually congenital in origin. Choledocal cysts can lead to the development to of jaundice, pancreatitis and cancer in some patients if left untreated for many years.

The recommended treatment is removal of the choledochal cyst. The bile duct is then sutured to the intestine so that normal passage of bile is restored. In selected patients we offer a laparoscopic procedure for removal of the choledocal cyst.
 
Advanced Laparoscopic Hepatobiliary surgery
 
Along with routine laparoscopic surgery, Dr Ravishankar K Diddapur performs advanced laparoscopic hepatobiliary surgeries like

Laparoscopic Hepatectomy

laparoscopic deroofing of liver cysts
Laparoscopic drainage of liver abscess
Laparoscopic Radio frequency ablation in selected cases of liver tumors
Laparoscopic ultrasound and liver biopsy
Laparoscopic pancreatectomy
Minimally invasive pancreatic necrosectomy
Laparoscopic Pseudocystogastrostomy
Laparoscopic surgery for gallstone disease(Laparoscopic cholecystectomy and CBD exploration)
   

Being trained in advanced specialist surgical units in UK Dr Ravishankar K Diddapur deals with all varieties of hepatobiliary cases and performs complex surgeries. To his credit he has performed laparoscopic cholecystectomy in Jehovah’s Witness patients and also in patients with poor cardiac function with EF of 30%. He has performed similar surgeries in cirrhotic patients and in patients with gangrenous gallbladders. Has conversion rates of less than 5% and has had no bile duct injury or vascular injury over the last 4 years at NUH. He has performed the first in house laparascopic hepatectomy at NUH and also the first minimally invasive pancreatic necrosectomy at NUH, Singapore.

He performs complex major surgeries like

Gallbladder Cancer in the form of Radical cholecystectomies

Whipple’s operation – has maintained a nil 30 day mortality over the last 4 years at NUH

Distal pancreatectomy

Total pancreatectomy

Cholangiocarcinomas/Hilar Cholangiocarcinomas

Redo surgery for biliary stricture

Surgery and management of portal hypertension related problems

Surgery for intractable ascites

Re-exploration surgery for complex Hepato biliary problems
   
Diagnostic and interventional endoscopy
  An endoscope is a long fiber optic tube with a light source at its tip that can be passed through the mouth into the gastrointestinal tract. The tip of the endoscope has a small video chip that transmits images of the gastrointestinal tract to a television monitor so that the gastroenterologist can visualize the inside of the gastrointestinal tract.

During interventional endoscopy the gastroenterologist manipulates the gastrointestinal tract by instruments that are introduced through the endoscope. For example in a patient with blockage of the bile duct the gastroenterologist inserts a small tube called a stent into the bile duct to relieve the obstruction.

A number of interventional endoscopic procedures are now available for complicated pancreatic and biliary disease. A close collaboration between the interventional gastroenterologist and a pancreatic and biliary surgeon is important to provide the optimal care to the patient. A multidisciplinary team of physicians led by an experienced pancreatic and biliary physician provides optimal care to patients with complex pancreatic and biliary diseases.

An experienced pancreatic and biliary surgeon, a gastroenterologist and medical oncologists who have a focus on pancreatic and biliary cancers often jointly evaluate patients with complex pancreatic and biliary diseases for optimal treatment planning.

The types of interventional procedures performed include the following:
 
Placement of bile duct stents:
Bile duct stents are needed when the patient develops jaundice due to blockage of the bile duct. The gastroenterologist passes a plastic tube from the duodenum through the blockage into the bile duct so that the blockage in the bile duct is bypassed by the stent.
Two types of stents are available:
i) plastic stents: Plastic stents are placed to provide temporary relief of jaundice while the patient is being evaluated for surgical treatment for correction of the blockage in the bile duct or removal of the tumor, if a tumor is causing the blockage of the bile duct. ii) metal stents: Metal stents are permanent stents and are placed when the patient is not a surgical candidate. Metal stents have metal hooks that anchor into the bile duct. This significantly reduces the chances of subsequent successful surgery on the bile duct. Your gastroenterologist should not insert metal stents until you have been ruled out as a surgical candidate for your disease.
Removal of stones from the bile duct:
Gallbladder stones pass into the bile duct and cause obstructive jaundice. During ERCP if the gastroenterologist finds stones in the bile then these stones can be removed during interventional endoscopy.
Endoscopic dilatation of a bile duct stricture (blockage):
This procedure is usually performed in patients who have a benign (non-cancerous) stricture of the bile duct. Benign bile duct strictures are often secondary to injury to the bile duct after a laparoscopic or open cholecystectomy.

Endoscopic treatment is less effective than surgical treatment for bile duct strictures, however, for very short strictures this treatment can avoid a surgical procedure. If the strictures do not respond to endoscopic dilatation after several attempts then surgical treatment may be indicated.
Pancreatic duct stents :
Pancreatic duct stents are often placed in patients who have chronic pancreatitis or a condition called pancreatic divisum. The use of these stents is controversial and the results are variable. Multiple pancreatic duct stents placed over a long period of time or stents that are left in the pancreatic duct for prolong periods of time can by themselves cause chronic pancreatitis in some patients.

Pancreatic duct stents should be placed only after careful consideration of other treatment options that are available for treatment of chronic pancreatitis.
Drainage of pancreatic pseudocyst:
Pancreatic pseudocyst is a collection of fluid that is found around the pancreas after a patient develops acute or chronic pancreatitis. Pancreatic pseudocyst is a pool of pancreatic juice that has leaked from an injured pancreatic duct. Pseudocysts form when the normal healing process seals of the pancreatic juice collections around the pancreas to form localized fluid collections.

Pseudocysts are treated by draining the cyst fluid into a loop of intestine or the stomach. Endoscopic treatment is one of the options that are available for treating pseudocysts. During endoscopic treatment a stent (a small tube) is placed between the stomach or the duodenum and the cyst so that the cyst drains into the gastrointestinal tract. An alternate method is to pass a small catheter through the pancreatic duct and into the cyst if the cyst is communicating with the pancreatic duct.

Careful selection of patients is very important for treatment of pancreatic pseudocyst with endoscopic techniques. While this technique can lead to cure of the pseudocyst in some patients; severe infective complications that require complicated surgical procedures by introducing bacteria into the cyst is a significant risk of this treatment. Endoscopic procedures may also aggravate the situation by causing pancreatitis.
 
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