What is obesity and severe (morbid) obesity?

What is the cause of obesity?

Is obesity a health hazard?

Obesity is not just a cosmetic issue; it is a major health problem with difficulty in walking and breathing, decreased life expectancy and quality, and a high risk of
	Type II diabetes
	High blood pressure/heart disease
	Infertility/menstrual irregularities
	Osteoarthritis of weight bearing joints
	Sleep apnoea/respiratory problems
	Gastro-oesophageal reflux/heartburn
	Depression
	Dyslipidemia (lipid metabolism abnormalities)
	Risk of breast cancer
	Intertrigo - infection in the skin folds
These can be improved or resolved with weight loss.

How to measure obesity (know your BMI)?

Who is a bariatric surgery candidate?

Bariatric surgery is considered for those people who:
	Are aged over 18 years
	Have a BMI greater than 40 or greater than 35 and have co-morbidities (e.g. hypertension, diabetes, etc.) - WHO recommendations
	Have a BMI greater than 37.5 or greater than 32.5 and have co-morbidities (e.g. hypertension, diabetes, etc.) - ASIA PACIFIC guideline recommendations
	Have tried all other methods of losing weight (diets, exercise, medication)
	Are fit enough to undergo an anaesthetic and surgery. In addition, patients should have a documented or high probability of failure of non-surgical weight-loss treatments and be well informed, motivated, and compliant.

What are the treatment options available for the morbidly obese?

What are the risks involved in weight loss surgery?

Some of the specific risks related to weight loss surgery include:
	Anastomotic leak, which is leaking from the staple line around the newly formed pouch or at any new connections that have been made, including small intestine.
	Gastric Fistula, which may occur when there is abnormal connection with the stomach, usually to other organs in the body.
	Pulmonary Embolism which is one of the most common risks or complications of any surgery is usually a blood clot that has normally formed in the legs and moved its way up, causing blockage of an artery in the lungs. It is very important to get patients out of bed quickly after surgery and moving around. In addition, anti-clotting medications are given.
	Wound infection - This is when there is a penetration of bacteria to the site of surgical incision.
	Wound seroma - the swelling at the site of surgical incision caused by fluid within the tissue.

Precautions before surgery to reduce the risks of complications?

To reduce some risk, you can do the following at least a month before surgery:
	Increase physical activity
	Dietary advice
	Lose 10% of body weight
	Quit smoking
	Quit drinking alcohol
These can not only help reduce risk but will also help optimize your recovery.
Preoperative Diet for Weight Loss Surgery Dieting before surgery can significantly shrink liver size and make operations shorter and safer. For two weeks before your operation, you should follow this diet to prepare your body for surgery. The recommended preoperative diet will consist of a prescribed amount of a high protein drink plus 1-2 regular meals.
First Week: 1 high protein drink with 2 regular meals
1000 Kcal REDUCING DIET CHART BED TEA TEA 1 cup BREAKFAST MILK 125ml (1 cup) CEREAL 20 gms (1 chap/1 slice/Dahlia) PROTEIN 30gms paneer/1 egg/1kat sprouts MID-MORNING FRUIT/SALAD 200gms/150gms LUNCH OPTIFAST 1 Glass TEA TEA 1 cup SNACK 20gms (Roasted Chana/ Dhokla/Popcorn/Bhelpuri/ Chana chat/ Digestive Biscuit) DINNER SOUP 1 Bowl CEREAL 20gms (1 chap) DAL 30gms (1kat) VEGETABLES 150gms (1kat) OIL 5gms (1 tsp) CURD 100gm (1 Kat)
Foods allowed liberally
	Raw and boiled vegetables
	Juices like fresh lemon, coconut water, soda
	Vegetable juices like tomato juices, clear soups, cucumber juice
	Skimmed or toned milk and milk products
	Refined vegetable oil for cooking
	Egg white, lean meat, chicken, fish
Foods to be avoided
	Excess of cream, butter, oil, cheese, mayonnaise, ghee
	Excess of fried foods - potato chips, puri, paratha, pakora, cutlet
	Excess of dried nuts
	Sugar, sweets, desserts
	Whole milk and its products
	Pork, ham, sausages
	Red meat, organ meat, tuna in oil
	Fruit juices
	Banana, chikku , mango, grapes
After a week replace your two meals with Optifast (i.e. Breakfast and lunch) One day preoperative: On high protein drinks and liquid only.

How much weight can I expect to lose?

Hair loss is common after weight loss surgery. Is this true?

How do you prevent sagging skin after weight loss?

Will I ever regain the weight I lose?

How many days do I have to stay in the hospital after surgery?

Is there any supplement to be used after surgery?

Should I exercise after weight loss surgery?

Diet after Bariatric Surgery

Dietary Guidelines for Post-Bariatric Surgery
After surgery it is important to follow special dietary guidelines to ensure proper healing, to obtain adequate nutrition, and to avoid complications. Because of your stomach's reduced size, the amount of food you eat at one time is very small at first. Your diet will be advanced and additional foods will be added as you tolerate each diet phase. However, keep in mind that people have varied tolerances to different foods following this type of procedure. A dietician can help you identify food intolerances, make appropriate food choices, and help you plan a balanced meal plan.
Postoperative Diet:
STAGE 1: Day One and Two
	An x-ray procedure will be performed the morning after your surgery to evaluate your new stomach and check for leaks.
	If there are no leaks, you will be cleared to start taking one ounce of water (30 ml) at room temperature each hour while awake.
	To avoid irritation of your new stomach or development of gas, you will need to: Sip slowly Not use straws Take no carbonated beverages
Clear Liquid Diet can be started from day two: Tea/Coffee, coconut water, fresh lime water salted, clear chicken broth, clear vegetable soup, lentil soup can be given in small amounts.
STAGE 2: First two weeks post operative
	This diet consists of low sugar/sugar free foods that are liquid or semi-liquid only. Low sugar diet is recommended to prevent dumping syndrome. Dumping syndrome can occur when concentrated sweets or hydrating liquids are consumed with a meal causing foods to rapidly pass into the small intestine in 10-15 minutes rather than gradually. Symptoms include rapid heartbeat, nausea, possibly diarrhoea or cold and clammy feelings.
	Remember you have a tiny "new" stomach so sip and eat liquids slowly. Plan on 30-60 minutes at each meal.
	Protein is the most important nutrient after surgery for healing. Liquid protein supplements may be substituted for a meal. The protein supplement should be sugar free with minimal carbohydrates.
6.00am Tea/Coffee 8.00am Coconut water/Fresh lime water/Milk (skimmed) 10.00am Glucerna SR (4 scoop in water)/Getrim/ Optifast 12.00 am Chicken soup/Vegetable soup/ Lentil soup 2.00pm Sweetened curd salted 4.00pm Tea/coffee 6.00pm Glucerna SR (4 scoop in water)/Getrim/Optifast 8.00pm Chicken soup/Tomato soup 10.00pm Glucerna SR (4 scoop in water)/Getrim/Optifast
STAGE 3: Third week post operative
The key to this diet phase is to increase protein levels (goal of 60-90 grams protein per day) and all food should be in liquid or pureed form. Therefore, a blender/food processor is an essential part of your meal preparation.
	Each day you will eat five times: Early breakfast Brunch Late lunch Afternoon snack Supper
	DO NOT SKIP or ADD MEALS; however, if you cannot eat the protein source with your meal then an alternative would be adding a 1 cup high protein supplement in between meals as part of your liquid intake.
8.00am Tea + Semolina porridge + Milk 10.00am Glucerna SR (2-3 scoops in milk) 12.00 am Blenderized Khichri + vegetables Curd 2.00pm Sweetened curd salted 4.00pm Tea/coffee 6.00pm Chicken soup/vegetable soup 8.00pm Blenderized Khichri Curd 10.00pm Glucerna SR
STAGE 4: Fourth week post operative
You are now ready to introduce soft food to your meal plan. The key to success will be slowly expanding the new food list.
	Continue small blended meals as in post operative diet #2. You are still avoiding fibre, to allow continued healing, and lessen the chance of obstruction.
	Introduce new soft solid food slowly.
	If nausea, pain or vomiting occurs - STOP! Take clear liquids for your next meal.
	Devote all of your attention and concentration on slow, deliberate eating.
	DO NOT DRINK and EAT at the same time. Continue to drink 6-8 cups water or sugar free liquids in between meals.
STAGE 5 One month post operative (Regular Diet)
You are now ready for regular foods.
	Add new menu items slowly to determine if you can tolerate that food, as some foods will be better tolerated than others. If you do not tolerate the food the first time, try that food a few weeks later.
	To avoid impulse eating, it is very important to eat 3 to 4 times per day and to continue to have a routine eating schedule. Constant nibbling of food or snacking will slow your weight loss and may eventually lead to weight gain. It is important not to return to poor eating habits!
	Continue to plan for meals weekly to avoid buying junk food or fast foods. Healthy foods do not need to be special; have a few easy recipes on hand or make your foods ahead of time.
	Continue to choose water or zero calorie liquids as beverage of choice as regular sweetened drinks (such as regular soda, fruit punch, fruit juice or milkshakes) can lead to weight gain. Do not drink with meals or within 30 minutes after meals.
	You should be reducing/eliminating liquid supplements as a source of nutrition; eventually, these liquids will provide too many calories in addition to solid foods. Do continue to choose a protein source at each meal. Proteins are the building blocks of health.
SAMPLE MEAL PLAN BREAKFAST 2 dairy portions (1glass of skimmed milk) 1 carbohydrate (Oats/Brown bread toast) AM SNACK 2 dairy portions (Yogurt/Buttermilk) 1 fruit LUNCH 1-2 non-veg portions (Chicken/Fish/Pulses) 1 vegetable or 1 fruit AFTERNOON SNACK 1 cup high protein drink/(Milkshakes) DINNER 1-2 portions (Chicken/Fish/Pulses) 1 vegetable or 1 carbohydrate (Brown rice/Chapati with veggies)
Long-Term Tips
It is important to make healthy food choices throughout your weight loss process to be as healthy as possible while losing weight. Healthy food and lifestyle choices are critical to maintain your weight for the long-term. These tips are recommended for people who are in the maintenance phase of weight loss.
	Eat three meals a day. Have a healthy snack only if hungry. Skipping meals does not promote weight loss and results in overeating in the long run.
	Eat lean proteins first at each meal.
	Include fruits and vegetables with meals.
	Avoid drinking fluids with meals. Fluids may force foods through your pouch too quickly. This may cause dumping syndrome in gastric bypass patients but may cause all patients to become hungry quickly and eat more food throughout the day.
	Strive to drink 6-8 cups of water daily. Artificially flavoured drinks are fine, but we recommend that you avoid carbonated beverages, even diet soda. The carbonation in diet soda may contribute to enlargement of the small pouch.
	Chew foods thoroughly. Your small pouch will not be able to physically break down foods that have not been chewed to a liquid consistency.
	Avoid problematic foods such as tough, fibrous or overcooked meats, doughy breads, pasta; rice, skins and seeds of fruits and vegetables, nuts and popcorn.
	Stop eating when you begin to feel full. It is critical that you do not eat to the point of feeling overfull. People have stretched their pouch by eating too much and have regained weight.
	Take daily vitamin and mineral supplements.
	Weigh yourself weekly. It's much easier to correct a 2 kg weight gain (physically and psychologically) than 10kg weight gain.
	Exercise: Try to get at least 30 minutes of physical activity each day. Physical activity is defined as activities in addition to normal daily activities such as work, shopping or housekeeping.

Going back to work after Bariatric Surgery

Birth Control and Pregnancy

Long-Term Follow-Up after Bariatric Surgery

Life after Bariatric Surgery - Support Groups

What is a gallbladder?

Gallbladder is a pear shaped organ present close to the liver. Its function is to store and concentrate bile juice which is produced in the liver. It does not produce bile as many people think.

What is bile?

Bile is a liquid produced by the liver which helps the body to digest fat. On eating a meal, the gallbladder pushes this bile into the common bile duct which carries it to the intestine.

What are gallstones?

Gallstones are stones which form within the gallbladder. They may vary in number and size. For management of these stones, size/shape and number is not relevant.

What causes gallstones?

The exact cause for their formation is not known, however, risk factors include :
	Gender: Women between 20 and 60 years of age are twice as likely to develop gallstones as men
	Age: Practically all age groups but more common in the 30's & 40's
	Obesity
	Excess estrogen (women on oral contraceptive pills etc.)
	Cholesterol-lowering drugs
	Diabetes
	Rapid weight loss
	Prolonged fasting
	Hereditary blood disorders
	Unknown geological factors such as gallstones are much more common in northern and eastern part of India

Who is at risk for gallstones?

	Women are more prone than men
	People in their 30's and 40's
	Overweight men and women
	People who fast frequently or lose a lot of weight quickly
	Cholesterol-lowering drugs
	Pregnant women, women on hormone therapy and women who use birth control pills for a prolonged period

What are the symptoms?

Symptoms of gallstones are severe abdominal pain often called a gallstone 'attack' (colic) because they occur suddenly. Gallstone attacks often follow fatty meals, and they may occur during the night. A typical attack can cause the following:
	Severe pain in the right upper abdomen that increases rapidly and lasts from few minutes to several hours
	Pain in the back between the shoulder blades
	Pain under the right shoulder
	Nausea or vomiting
Other symptoms of gallstones include :
	Abdominal bloating (gas formation)
	Recurring intolerance to fatty foods
	Belching
	Indigestion
People who also have the following symptoms should see a doctor right away:
	Sweating
	Chills (shivering)
	Low-grade fever
	Yellowish colour of the skin or whites of the eyes
	Clay-coloured stools
Many people with gallstones have no symptoms. These patients are said to be asymptomatic and these stones are called 'silent stones'.

What complications can these stones cause?

	Recurrent severe abdominal pain or vomiting
	Pus formation in the gallbladder (Empyema)
	Cholangitis (life threatening infection of biliary system)
	Gangrene and perforation of the gallbladder
	Acute pancreatitis (swelling of pancreas) which can have a catastrophic sequel of multi-organ failure and other serious complications
	Jaundice due to blockage of the common bile duct due to stones
	Associated with Cancer of gallbladder in the long term

What is the treatment?

Medical: Treatment of symptoms of pain with injectable or oral painkillers.
No medical therapy is available for gallstones as such which can cure the disease. Though, injectable or oral antibiotics and supportive medications are available for treating the infection.

Surgery: Surgery to remove the gallbladder (cholecystectomy) is the only way to treat gallstones. This can be done by conventional (open) method or a well established endoscopic (laparoscopic) method which is now the 'Gold Standard'.

The surgery is called Laparoscopic Cholecystectomy (Lap. Chole).
For this operation, the surgeon makes few tiny incisions in the abdomen and inserts surgical instruments and a miniature telescope with a mounted video camera into the abdomen. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. While watching the monitor, the surgeon uses the instruments to carefully separate the gallbladder from the liver, ducts and vessels. The gallbladder is then removed through one of the small incisions. Recovery usually occurs within a day in the hospital, followed by few days of rest at home.

Because the abdominal muscles are not cut during laparoscopic surgery, patients have less pain and fewer wound complications.

If the surgeon finds any difficulty in the laparoscopic procedure, the operating team may decide to switch over to open surgery. It is called 'open' surgery because the surgeon has to make a 5 to 8 inch incision in the abdomen to remove the gallbladder. Open surgery is now required in less than 0.1 percent gallbladder operations at our institute.

Why did my child get cancer?

Slippage of the stone(s) in CBD may cause pain or jaundice or both. This situation requires an endoscopy (ERCP) for removing the stone(s). This should preferably be done before surgery. However it may also be done after the operation.

How do we confirm if a stone is in the CBD?

Sometimes a stone in the CBD may not show on ultrasound, however patient may have symptoms which are indicative of the same.

In this event, the patient requires magnetic resonance cholangiopancreatogrphy (MRCP - an MRI scan) which shows the presence of stones in the common bile duct.

What is ERCP?

The surgeon may use endoscopy for removing CBD stones before gallbladder surgery. Once the endoscope is in the small intestine, the surgeon locates the affected bile duct. An instrument on the endoscope is used to cut the duct, and the stone is captured in a tiny basket and removed with the endoscope. This two-step procedure is called ERCP and EPT.

Non surgical treatment

Non surgical approaches are used only in special situations such as when a patient's condition is not fit for anaesthesia and surgery. This does not cure the patients as it only provides symptomatic relief.

Don't people need their gallbladders?

Fortunately, the gallbladder is an organ that people can live without. Losing it won't even require a change in diet. Once the gallbladder is removed, bile flows out of the liver through the hepatic ducts into the common bile duct and goes directly into the small intestine, instead of being stored in the gallbladder. Points to remember:
	Gallstones form when substances in the bile juice get precipitated
	Gallstones are common among women and people who are overweight
	Gallstone attacks often occur after eating fatty meals
	Accurate diagnosis is important because symptoms can point towards other problems, including heart attack. Diagnosis can be made in majority of the patients by simple ultrasound conducted in a fasting state
	Gallstones can cause serious problems if they become trapped in the bile ducts such as jaundice and pancreatitis
	Laparoscopic surgery to remove the gallbladder is now the 'Gold Standard' for treating gallstones
	This surgery can be done in practically all the patients including patient with a previous abdominal operation / cardiac history / asthma / diabetes etc

Can the surgery be performed as a day care procedure?

Yes, day care surgery may be performed in young and selected patients. The patient is supposed to be fasting and would be called to the operating theatre in the morning. The operation will be performed and the patient would be observed for 4-6 hours post operatively in our day care facility. The patient would normally be discharged the same afternoon. However, if the need arises, he/she could be admitted overnight as well.

What happens after admission for surgery?

The patient is normally admitted to the hospital a day prior to surgery or on the day of surgery. After admission, the patient is examined and investigations reviewed by one of the team members. Also, a member of the Anaesthesia Team would conduct the pre-anaesthetic check-up. Pre-operative investigations are performed, if needed. The patient would need to be fasting overnight or for 8 hours for the surgery but can take his regular dose of medicines with sips of water. (Please follow the instructions given by the attending staff.)

Next morning, the patient is shifted to the operating theatre about an hour or so prior to the surgery. After surgery, the patient is shifted to the recovery ward under the care and supervision of our Anaesthesia Team. The patient is observed in the recovery ward normally for 2-4 hours after surgery and then shifted back to the room. Hence, the patient may come back to the room after about 5-8 hours after he/she has left the room.

Oral diet is started with sips of water when the patient returns to the room. He/she gradually progresses to drinking all liquids on the same day of surgery. The patient is encouraged to sit up, visit the toilet and move around the same day. In fact, movements are encouraged because this causes a dramatic reduction in pain and increases the sense of well-being.

The patient is given a normal breakfast next morning and will generally be discharged from hospital after a visit by one of the team members. On discharge, a discharge summary with the advised medication is handed over to the patient along with the date for next appointment.

Post operative instructions and information

	After the operation you will be kept in the recovery room. This period may vary from few minutes to few hours. The anaesthetist decides about your shifting to room. The decision depends on many technical factors.
	You will be sleepy immediately after the operation due to sedation given during anaesthesia and during the recovery period.
	You may have some discomfort when coming out of the effect of sedation. It gradually reduces to a tolerable level within a few minutes without any pain killer. However, if necessary you may ask for pain killer injections/tablets. You should try to avoid these drugs because they produce drowsiness and you may sleep for a longer period which is not desirable.
	You may feel nauseated in the immediate post-operative period, and you may even vomit which should not cause any worry. This generally gets over after few hours.
	You are generally allowed to have sips of water immediately after the operation and liquids on day of operation. In case of vomiting the liquid intake may be stopped and restarted after 30 minutes. The liquids may include water / cold drinks / tea / coffee / milk / juices or some clear soups.
	You are allowed to have normal home cooked meals of your choice from the next morning at breakfast.
	You should have small frequent meals for few days after operation following which you can resume your normal diet gradually. This is vital because you may feel bloated and distended if the quantity of food is in large quantities at a time.
	You should try to move the limbs and can sit up immediately after operation. You should also go to the toilet on your own. There are no restrictions whatsoever for the physical movement. In fact majority of the patients will feel much better after they have started the movement. The pain also dramatically reduces once you start sitting up, moving and walking.
	There is no restriction on your physical activity. You are allowed to walk as soon as you recover from your sleep. There is no restriction on climbing of stairs, lifting weight etc. You may even drive two wheelers or car as soon as you feel fit. This infact is one of the major advantages of the laparoscopic procedure.
	You will be discharged on the same day or next day of operation unless there is some associated medical/social problems. You are advised to visit again for follow up after 2-5 days when the dressings are removed. You should avoid wetting the dressings unless they are waterproof. After the removal of dressing, you can have normal bath with soap and water.
	In very few cases there may be some bloody/whitish discharge from the wound in the post operative period. This should not bother you because it is generally harmless. You can wipe the discharge and apply band-aid so as to avoid staining the clothes. If it is more you should report to the surgeon during the next visit. Please feel free to ask any question that may come to your mind.

What is appendix?

It is a narrow, hollow muscular tube present near the junction of the small and large intestine. It has no significant function in human beings.

What do you mean by appendicitis?

It means inflammation of appendix (infection or swelling). The term acute means sudden development of the inflammatory process.

In whom does it occur the most?

It is most commonly seen in the second decade of life (adolescence), though it can occur in any age group.

What is the cause of appendicitis?

80% of cases of acute appendicitis are caused due to obstruction of lumen of appendix. The reason of obstruction could be a faecolith (i.e. hard faecal matter), worms if present in the intestines and rarely a foreign body like seeds.

What are the symptoms?

Severe pain around the navel which shifts after few hours to the right lower abdomen. Coughing and straining cause an increase in the pain. Pain is accompanied by nausea and vomiting. Less common complaints include burning on passing urine and loose stools.

How is a diagnosis of acute appendicitis made?

The clinical signs and symptoms as mentioned above, are the most important indications for reaching a diagnosis. In addition, raised total blood count confirms the diagnosis. Acute appendicitis is the commonest abdominal emergency and requires surgery.

Any special tests required?

An abdomen ultrasound may help in reaching the diagnosis in case the clinical examination and other investigations are inconclusive.

What are the complications of acute appendicitis?

Gangrene and rupture of appendix causing generalised abdominal infection, Intra Abdominal Abscess (collection of pus) and Septicaemia (generalised, severe infection in blood) leading to catastrophic life threatening consequences.

What is the treatment?

The treatment of acute appendicitis is removal of the appendix (i.e. Appendicectomy). This can be done by an open technique or laparoscopically. Laparoscopic appendicectomy is performed by making three tiny (3-5-10 mm) incisions through which the telescope and instruments are introduced and the appendix is removed. The advantage of laparoscopy over open technique is less pain, early recovery and excellent cosmetic results. Also, laparoscopically the entire abdomen and pelvis can be inspected to rule out any other pathology.

Don't we need appendix?

Hormonal Therapy is a method used to attack those cancers which depended on natural hormones to grow. If the tumor is reported as estrogen receptor or progesterone receptor positive, it is logical to think that any remaining cancer cells may continue to grow in the presence of these hormones. Hormonal therapy blocks the body's natural hormones from reaching any remaining cancer cells.

Are there any side-effects after removal of appendix?

There are no side-effects as it has no definite function in the human body. It is a useful organ for animals where it helps in digestion.

Which is a better procedure-open or laparoscopic?

Laparoscopy has the advantage of lesser post operative pain, early recovery, good cosmetic results as well as the chance to rule out any other pathology present in the same surgical sitting. This is a method of choice in well equipped institutes having a trained surgical team.

Post operative instructions and information

	After the operation you will be kept in the recovery room. This period may vary from few minutes to few hours. The anaesthetist decides about your shifting to room. The decision depends on many technical factors.
	You will be sleepy immediately after the operation due to sedation given during anaesthesia and during the recovery period.
	You may have some discomfort when coming out of the effect of sedation. It gradually reduces to a tolerable level within a few minutes without any pain killer. However, if necessary you may ask for pain killer injections/tablets. You should try to avoid these drugs because they produce drowsiness and you may sleep for a longer period which is not desirable.
	You may feel nauseated in the immediate post-operative period, and you may even vomit which should not cause any worry. This generally gets over after few hours.
	You are generally allowed to have sips of water immediately after the operation and liquids on day of operation. In case of vomiting the liquid intake may be stopped and restarted after 30 minutes. The liquids may include water / cold drinks / tea / coffee / milk / juices or some clear soups.
	You are allowed to have normal home cooked meals of your choice from the next morning at breakfast.
	You should have small frequent meals for few days after operation following which you can resume your normal diet gradually. This is vital because you may feel bloated and distended if the quantity of food is in large quantities at a time.
	You should try to move the limbs and can sit up immediately after operation. You should also go to the toilet on your own. There are no restrictions whatsoever for the physical movement. In fact majority of the patients will feel much better after they have started the movement. The pain also dramatically reduces once you start sitting up, moving and walking.
	There is no restriction on your physical activity. You are allowed to walk as soon as you recover from your sleep. There is no restriction on climbing of stairs, lifting weight etc. You may even drive two wheelers or car as soon as you feel fit. This infact is one of the major advantages of the laparoscopic procedure.
	You will be discharged on the same day or next day of operation unless there is some associated medical/social problems. You are advised to visit again for follow up after 2-5 days when the dressings are removed. You should avoid wetting the dressings unless they are waterproof. After the removal of dressing, you can have normal bath with soap and water.
	In very few cases there may be some bloody/whitish discharge from the wound in the post operative period. This should not bother you because it is generally harmless. You can wipe the discharge and apply band-aid so as to avoid staining the clothes. If it is more you should report to the surgeon during the next visit. Please feel free to ask any question that may come to your mind.

What is hernia?

It is the protrusion (bulge) of abdominal viscera through a weakened part of abdominal wall. A hernia does not get better over time, nor will it go away by itself (except very small congenital navel hernia). It always becomes bigger with time.

What are the common types?

The common types of hernias are present in the groin (inguinal), belly button (umbilical) and the site of a previous operation (incisional). There are many more types but are rare.

What are its symptoms? How can it be detected?

Hernia is easy to recognise. It appears as a bulge under the skin. This bulge may appear on standing or straining and disappear on lying down. It may or may not be painful. Discomfort may worsen at the end of the day and also while coughing and sneezing.

What is the treatment for hernia?

Surgery is the only cure for majority of hernias. There is no medical treatment for it.

When should hernia be treated?

Once detected, for best results, the hernia should be treated as early as possible. Also, early operation will prevent complications like obstruction and strangulation. When compared with large hernias, the surgical results with smaller hernias are much more satisfying.

What is strangulation of hernia?

Strangulation of hernia is a surgical emergency.
The hernia becomes very painful, does not reduce and the overlying skin becomes red. The patient will require hospitalisation and immediate surgery.

What are the types of surgery available for treating hernias?

The types of surgery available for treating hernias are:
	Laparoscopic surgery (also known as Minimal Access Surgery / Minimally Invasive Surgery / Endoscopic Surgery)
	Conventional (Open) Surgery

How is the laparoscopic / endoscopic repair for hernia performed?

Three (5-5-10 mm sized) incisions are made and cannulas placed in them. A laparoscope (a long narrow telescope) connected to a special camera is inserted through a cannula (a small hollow tube), allowing the surgeon to view the hernia and surrounding area on a video screen. Other cannulas are inserted which allow the surgeon to work 'inside'. A piece of surgical mesh is fixed over the hernia defect and held in place with small surgical staples.

What are the advantages of laparoscopic/ endoscopic surgery over
conventional surgery?

Endoscopic surgery causes much less pain and patients are mobile within hours after surgery. They are also allowed to resume all activities much earlier and can go back to work within 5-7 days. Another advantage is that both sides can be operated in the same sitting without any extra pain or stay. The cosmetic results are excellent.

Is it necessary to use the mesh in all the cases?

Yes. Now world over, there is consensus that the use of mesh is desirable in majority of patients to stengthen the wall whether surgery is done conventionally or endoscopically. Only the childhood hernias are repaired without using mesh.

Is endoscopic surgery safe?

Yes. Done by a properly trained surgeon in a well equipped centre, it is a safe surgery with excellent results.

What happens after admission for surgery?

Patients are admitted in the hospital on the day of surgery or a day prior to surgery. On admission, patients are examined and investigations reviewed by one of the team members. A member of the Anaesthesia Team conducts the pre-anaesthetic check-up. Pre-operative investigations are performed if needed. Patients need to be fasting overnight before the surgery. Next morning, he/she will be shifted to the operation theatre half an hour prior to surgery. After surgery, they are shifted to the recovery room for 2-4 hours under the care and supervision of our Anaesthesia Team for observation and then shifted back to the room. It takes about 4-8 hours before the patient comes back to his / her room.

Patient is given sips of water orally on returning to the room and progresses to drinking all liquids on the same evening as surgery. They may sit up, visit the toilet and move around for a few hours after surgery and are encouraged to do so early.

Patients are given a normal breakfast next morning and discharged from hospital after a visit by one of the team members. On discharge, a discharge summary with the advised medication is handed over to the patient.

Can the surgery be performed as a day care procedure?

Yes, day care surgery is being performed on young and fit patients.

The patient is called to the operation theatre in the morning in a fasting state of more than 8 hours. After the operation, patient is observed for 4-6 hours post operatively in the day care facility before getting discharged. In case the need arises, there is a provision for overnight admission as well.

Post operative instructions and information

	After the operation you will be kept in the recovery room. This period may vary from few minutes to few hours. The anaesthetist decides about your shifting to room. The decision depends on many technical factors.
	You will be sleepy immediately after the operation due to sedation given during anaesthesia and during the recovery period.
	You may have some discomfort when coming out of the effect of sedation. It gradually reduces to a tolerable level within a few minutes without any pain killer. However, if necessary you may ask for pain killer injections/tablets. You should try to avoid these drugs because they produce drowsiness and you may sleep for a longer period which is not desirable.
	You may feel nauseated in the immediate post-operative period, and you may even vomit which should not cause any worry. This generally gets over after few hours.
	You are generally allowed to have sips of water immediately after the operation and liquids on day of operation. In case of vomiting the liquid intake may be stopped and restarted after 30 minutes. The liquids may include water / cold drinks / tea / coffee / milk / juices or some clear soups.
	You are allowed to have normal home cooked meals of your choice from the next morning at breakfast.
	You should have small frequent meals for few days after operation following which you can resume your normal diet gradually. This is vital because you may feel bloated and distended if the quantity of food is in large quantities at a time.
	You should try to move the limbs and can sit up immediately after operation. You should also go to the toilet on your own. There are no restrictions whatsoever for the physical movement. In fact majority of the patients will feel much better after they have started the movement. The pain also dramatically reduces once you start sitting up, moving and walking.
	There is no restriction on your physical activity. You are allowed to walk as soon as you recover from your sleep. There is no restriction on climbing of stairs, lifting weight etc. You may even drive two wheelers or car as soon as you feel fit. This infact is one of the major advantages of the laparoscopic procedure.
	You will be discharged on the same day or next day of operation unless there is some associated medical/social problems. You are advised to visit again for follow up after 2-5 days when the dressings are removed. You should avoid wetting the dressings unless they are waterproof. After the removal of dressing, you can have normal bath with soap and water.
	In very few cases there may be some bloody/whitish discharge from the wound in the post operative period. This should not bother you because it is generally harmless. You can wipe the discharge and apply band-aid so as to avoid staining the clothes. If it is more you should report to the surgeon during the next visit. Please feel free to ask any question that may come to your mind.