Tag Archives: surgery

Vertical Sleeve Gastrectomy and Gastric Lap Band Surgeries

This is a continuation to the main article about bariatric surgery .

Below is a narrated animation of Gastric Sleeve and Gastric Lap Band procedures. Click here to license this video on Alila Medical Media website.

Vertical sleeve gastrectomy (VSG)

In this procedure a cut is made vertically and the larger part of the stomach (up to 85% of its volume) is removed from the body. The remaining is closed with staples to create a “new stomach” that is now having the shape of a tube (see Fig. 1). The procedure preserves both sphincters at the two ends of the stomach and therefore has minimum effect on the functioning of the digestive process.This reduces the risk of malabsorptive complications commonly associated with intestinal bypass. The procedure is irreversible.

Click here to see an animation of VSG procedure on Alila Medical Media website where the video is also available for licensing.

Fig. 1: Vertical sleeve gastrectomy procedure. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

VSG procedure is gaining more and more popularity thanks to its simplicity and good results on initial weight loss. However, due to the lack of long-term data, it is yet to be endorsed by bariatric surgery societies and is not covered by some insurance companies.

Adjustable gastric band (Lap band)

In this procedure an inflatable silicon band is placed around the top of the stomach to create a small stomach pouch (Fig. 2). During a meal, the pouch is filled up quickly with a small amount of food and releases it slowly into the lower part of the stomach due to the restriction by the band. As the pouch is full, it gives a feeling of satiety (fullness). Slow passage of the food makes the patient feel full for a longer period of time and thus reduces the amount of food intake. The band is connected to a port placed under skin of the abdomen. Through this port, a saline solution (salt water) is injected to adjust the diameter of the band and thus making the passage between the pouch and the lower part of the stomach smaller or larger accordingly to the needs of patient.

Click here to see an animation of gastric band procedure on Alila Medical Media website where the video is also available for licensing.

Fig. 2: Adjustable lap band procedure. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

As the procedure involves no cutting or stapling of the stomach, it is minimal invasive and reversible. The surgery can be performed laparoscopically (as opposed to open surgery) through small incisions with the aid of a camera. Recovery time is significantly shortened compared to gastric bypass procedures. Also, as there is no intestinal bypass, the risks of nutritional deficiencies, dumping syndrome and other complications associated with it are significantly reduced.
In terms of weight loss efficiency, however, patients who undergo gastric lap band surgery typically lose less weight than those who have had gastric bypass procedures.

> See Gastric bypass procedures

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Bariatric surgery

Below is a narrated animation of body mass index and Roux-en-Y gastric bypass. Click here to license this video on Alila Medical Media website.

Bariatric surgery, or weight loss surgery, refers to a variety of surgical procedures for treatment of morbid obesity. Obesity is determined by Body Mass Index (BMI) which is calculated as the ratio of body weight over square of body height. The higher the BMI the higher the extend of obesity. A normal BMI is between 20 and 25. An individual is considered morbidly obese if he or she has a body mass index of 40 or more, or of 35 or more and with obesity-related health problems such as diabetes, sleep apnea or hypertension.

Weight loss is achieved by reducing the size of the stomach. Smaller stomach makes you feel full faster and therefore makes it easier to reduce the amount of food intake.

Roux en-Y Gastric bypass (RNY)

This is the most commonly performed bariatric surgical procedure and is considered the gold standard for weight loss treatment. This procedure includes two steps:
1. The stomach is divided into two part : one small pouch at the top of the stomach where it is connected to the esophagus (gastric pouch in Fig. 1) and the rest of the stomach which will be “bypassed”, the two parts are separated and stapled.
2. Rerouting of the intestine: the intestine is cut at about 45cm (18in) down from the end of the stomach. The first part of the intestine (the duodenum) will be “bypassed”. The top end of the second part (the jejunum) is pulled up and connected to the gastric pouch created in step 1. The lower end of the duodenum is reconnected to the jejunum at a lower point (Fig.1). The new configuration has a shape of an Y, hence the name of the procedure.

Click here to see a video animation of gastric bypass procedure on Alila Medical Media website where the video is also available for licensing.

Fig. 1: Roux-en-Y gastric bypass diagram. Note the passage of food and digestive juice after surgery. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

How weight loss is achieved?
Firstly, the volume of the stomach is now greatly reduced to a small pouch (usually less than 10% of the original volume) which is filled up fast after a small amount of food intake. This sends a signal to the brain that the stomach is full and generates a feeling of fullness (satiety). This helps to stop eating. Also, if eating continues, vomiting and discomfort may follow. Secondly, as the first part of the intestine (the duodenum) is bypassed, the amount of nutrition absorbed by the body is greatly reduced. In normal digestion, this is where most of the nutrition is absorbed. Malabsorption contributes to weight loss effect.

Complications
While this procedure is proven as an efficient long term weight loss treatment, it associates with significant complication risks. These include: leakage along the staple lines and surgical connections leading to infection and abscess formation; stricture and obstruction of digestive tract due to scar formation; dumping syndrome; nutritional deficiencies; and other general surgical risks due to complexity of the procedure.

Mini Gastric bypass (MGB)

This is a modification of the more common RNY procedure described above. Here are the differences: (see Fig. 2)
1. In step 1 a long tube is created instead of a pouch.
2. In step 2, the intestine is NOT cut, it is pulled up and hooked up with the new stomach tube.

Fig. 2: Mini gastric bypass diagram. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Click here to see a video animation of mini gastric bypass procedure on Alila Medical Media website where the video is also available for licensing.

This procedure is becoming more and more popular as it produces good weight loss results and is simpler than the original procedure resulting in less complication risks. Less cutting and stapling lowers the risk of leakage and infection. It also reduces the bile reflux possibility as the intestinal rerouting is set at a lower point on the stomach.

> NEXT: Gastric Sleeve and Gastric Lap Band

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GERD and Heartburn (with video)

Gastroesophageal reflux disease

This video and other animations of the digestive system are available for licensing on Alila Medical Media website. Click here!

Gastroesophageal reflux disease (GERD) or gastric reflux disease is a chronic condition where acid from the stomach flows up and damages the mucosa of the esophagus.
At the junction between the esophagus and the stomach is the lower esophageal sphincter (LES). The LES is a ring of muscle that is generally closed tight to prevent stomach acid from coming up. In normal digestion, the LES opens shortly to allow food bolus passing down to the stomach and closes back tight instantly. GERD occurs when the LES is abnormally relaxed and can not close properly (Fig. 1). Heartburn is a burning sensation in the chest associated with each regurgitation of gastric acid and is the most prominent symptom of GERD.

Fig. 1: Abnormal relaxation of the lower esophageal sphincter as cause of GERD. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Hiatus hernia is believed to be another cause of GERD. Hiatus hernia or hiatal hernia is a condition where the top portion of the stomach is pulled up forming a herniation above the diaphragm. This situation somehow compromises the esophagus – stomach barrier and facilitates acid reflux.

Fig. 2: Types of hiatal hernia. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Treatment

Treatment includes dieting and medication. Proton-pump inhibitors, which act to reduce gastric acid production, are drugs of choice. If these fail, a surgery may be recommended. In a procedure called Nissen fundoplication, the top portion of the stomach is wrapped around the lower part of esophagus and sewn into place. This way, the muscles in the wall of the stomach reinforce the closure of the esophagus. This surgical procedure is particularly recommended when hiatus hernia is present as this can be fixed at the same time. The procedure can be done with minimal invasive laparoscopic technique through small incisions with the aid of a camera.

Fig. 3: Nissen fundoplication procedure. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

> See all Digestive topics

Common knee injuries and surgical repair, part 1

Knee anatomy

The knee has three bones : the femur (the thigh bone), the tibia (the shinbone) and the patella (the kneecap). The femur and the tibia form a hinge joint. The joint is enclosed by the joint capsule at the back and on the sides, and is covered by the patella and patellar ligament in front. The knee joint is stabilized mainly by the tendons of quadriceps femoris muscle in front and semimembranosus muscle (one of the hamstrings) on the back. Strengthening these two muscles therefore helps to reduce the risk of knee injuries.

Fig.1 : Midsagittal section of the knee joint. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Apart from the regular articular cartilage that cover the end surfaces of the three bones there are two additional pads of cartilage that are unique to the knee joint : medial meniscus and lateral meniscus (Fig. 2 and Fig. 3). The menisci act as shock absorbers to cushion the joint.

Two pairs of ligaments help to stabilize the knee : collateral ligaments run along two sides of the knee (Fig. 2), and cruciate ligaments which connect the femur and tibia in the center of the joint and cross each other in the from of an X (hence the names) : anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) (Fig. 2 and Fig. 3).

Fig. 2 : Front view of the right knee (the kneecap is removed in this picture to show structures behind). Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Fig. 3 : The right knee viewed from top (femur removed to show structures underneath). Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Meniscus tear and repair

Commonly referred to as torn cartilage, torn meniscus is a common sport injury. Mild injuries maybe treated with rest, ice, compression and elevation (the RICE approach). Larger tears may require surgery. The goal of surgery is to remove the damaged tissue which is the source of irritation, pain and possibly inflammation, and attempt to induce healing. Treatments vary depending on the location of the tear. If the tear is located on the outer border of the meniscus (the red zone, see Fig. 3) where there is a good blood supply, the damaged loose tissue will be removed and sutures will be used to tight the cartilage together to facilitate self healing. If the tear is located on the inner part (the white zone, see Fig. 3) where the blood supply is poor and hence healing is unlikely, the damaged part is simply removed (partial meniscectomy) (Fig. 4).

Minimal invasive arthroscopic surgery is commonly used for meniscus repair. In case of large tears, open surgery may be required.

Click here to see an animation of arthroscopic meniscus repair on Alila Medical Media website where the video is also available for licensing.

Fig. 4 : Treatment of meniscus tear depends on its location. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

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Common shoulder injuries and surgical repair (part 2)

Rotator cuff injuries

Fig. 1 shows a group of four muscles that cover the shoulder joint. These muscles originate on the scapula and insert on the humerus: the supraspinatus, infraspinatus, subscapularis and teres minor. The tendons of theses muscles form the rotator cuff (tendons connect muscles to bones). The most common injury to the rotator cuff is the impingement of one or more of these tendons. This may happen as a result of a trauma or sport related injury but more commonly as a result of aging. The tendons may rub against the acromion (a bony extension of the scapula that hangs over the cuff) every time the person raises an arm and become irritated, inflamed and ultimately torn.

Fig. 1: Rotator cuff muscles of the right shoulder. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Below is a narrated animation of arthroscopic rotator cuff repair. Click here to license this video and/or other orthopedic videos on Alila Medical Media website.

Impingement usually develops over a period of time. Treatment includes rest, shoulder exercise, physical therapy and surgery. In most cases surgical treatment is done through an arthroscope but open surgery may be needed for larger tears. During surgery the damaged tissue is removed, source of irritation (commonly bone spurs on the acromion) is identified and removed. If there is no tear, the treatment may stop here and the surgical procedure is called shoulder debridement. In case of tear sutures will be used to tight the tendon back down to the bone (Fig.2).

Fig 2. Rotator cuff injury (1) and repair: small holes are drilled (2) into the bone of the humerus to hold small suture anchors with threads (3). The threads are attached to the tendon (4) and pulled tightly to hold the tendon to the bone (5). Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Separated shoulder

Separated shoulder is a condition affecting the “second” joint of the shoulder : the AC joint (acromioclavicular joint) between the acromion (an extension of the scapula) and the clavicle. This condition is commonly due to a direct blow to the shoulder as in a fall or sport injury. Fig. 3 shows the ligaments involved in stabilization of AC joint, injury to any of these ligament results in separated shoulder. Injuries are graded according to the extend of tears and number of ligaments involved. Grade I injury (partial tear in one of the ligament) may be treated with simple rest and ice, small tears heal themselves over time. Grade III injury where the clavicle is completely detached from the scapula requires surgery where a screw will be inserted to fix the clavicle to the coracoid process of the scapula.

Fig.3 : Shoulder separation grading. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Frozen shoulder (adhesive capsulitis)

The shoulder, like all synovial joint, has a capsule around it. The capsule encloses the two end surfaces of the bones involved in the joint and a joint cavity containing a lubricant called synovial fluid. In people with frozen shoulder condition this capsule is thicken and inflamed (Fig. 4) causing pain when they try to move an arm. The pain increases with time and the range of motion decreases, the shoulder becomes stiff or “frozen”.

Fig. 4: Frozen shoulder. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

The causes of frozen shoulder are not fully established. People with diabetes and some other diseases show increased risk for frozen shoulder. It can also be resulted from a long-term immobilization of the shoulder (for example after a shoulder surgery). Treatments include pain management and physical therapy although in some cases surgery may be necessary. A procedure called arthroscopic capsular release is usually performed to cut through the tight area of the capsule.

> See all Orthopedic topics

Common shoulder injuries and surgical repair (part 1)

Anatomy

There are three bones in the shoulder: the humerus (the bone of the upper arm), the scapula (shoulder blade) and the clavicle (collarbone). Articulations between these bones make up the shoulder joints. The main joint, commonly referred to as “the shoulder joint”, is the joint between the head of the humerus and glenoid cavity of the scapula and is called the humeroscapular or glenohumeral joint. The second joint of the shoulder is formed by the articulation between the clavicle and the acromion (extension of the scapula that forms the top of the shoulder) and is called acromioclavicular joint or AC joint. The two joints are stabilized by associated muscles and ligaments.

Fig.1: Main components of the shoulder joint. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Shoulder dislocation

Shoulder dislocation occurs when the humeral head slips out of the pocket made by glenoid cavity of the scapula (Fig. 2). This usually happens as a result of trauma (fall, sport injury,..). Dislocation can be anterior where the humerus slips to the front or posterior where it dislocates behind the normal position. Anterior dislocation is more common.

Fig.2 : Types of shoulder dislocation. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Below is a narrated animation about shoulder dislocation, bankart lesion and repair. Click here to license this video and/or other orthopaedic videos on Alila Medical Media website.

Bankart lesion and shoulder instability

The glenoid cavity has a ring of fibrocartilage tissue called the labrum around it. The labrum makes the cavity deeper and helps to keep the humeral head in place (Fig.3). During anterior shoulder dislocation, the head of the humerus may be pressed against and damages the anterior portion of the labrum. This type of labral tear is called bankart. Damaged labrum makes it easier for the humeral head to slip out of place again. This vicious cycle leads to repeated shoulder dislocation and severely damaged labrum. The condition is called shoulder instability as it feels like slipping out anytime. Treatment includes physical therapy and, in some cases, surgery for bankart repair (see below).

Click here to see an animation of bankart lesion and arthroscopic repair on Alila Medical Media website where the video is also available for licensing.

Fig. 3: Anatomy of the shoulder joint with the humerus slightly abducted to show the glenoid cavity and labrum. Types of labral lesions are shown on the right. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Bankart repair

During surgery the damaged cartilage is removed, area is cleaned, small holes are then drilled into the bone of glenoid fossa to hold small suture anchors with threads. The threads are attached to the labrum and pulled tightly to hold the labrum to the glenoid (Fig.4). Over time, the labrum will reattach to the glenoid naturally. Physical therapy will be needed to regain the shoulder range of motions and strength.

Fig.4: Steps of bankart repair surgery. See text for details. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

Bankart repair can be done with arthroscopic or open surgery. While arthroscopy is minimal invasive, open surgery maybe recommended for larger tears. In arthroscopic surgery only two or three small incisions are made, an arthroscope is inserted through one of the incision. Arthroscope is an instrument equipped with light and camera which transmits image of the joint to a computer screen. Other small tools are inserted to carry out the repair (Fig.5).

Click here to see an animation of arthroscopic bankart repair.

Fig. 5 : Arthroscopic surgery for bankart repair. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

> See all Orthopedic topics

Medical Information Illustrated

Medical and health topics fully illustrated with pictures and videos for easy understanding.

Tag Archives: surgery

Vertical Sleeve Gastrectomy and Gastric Lap Band Surgeries

Vertical sleeve gastrectomy (VSG)

Adjustable gastric band (Lap band)

Bariatric surgery

Roux en-Y Gastric bypass (RNY)

Mini Gastric bypass (MGB)

GERD and Heartburn (with video)

Gastroesophageal reflux disease

Treatment

Common knee injuries and surgical repair, part 1

Knee anatomy

Meniscus tear and repair

Common shoulder injuries and surgical repair (part 2)

Rotator cuff injuries

Separated shoulder

Frozen shoulder (adhesive capsulitis)

Common shoulder injuries and surgical repair (part 1)

Anatomy

Shoulder dislocation

Bankart lesion and shoulder instability

Bankart repair