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What is Gastroesophageal Reflux Disease (GERD)? Although “heartburn” is often used to describe a variety of digestive problems, this term more accurately describes the main symptom of gastroesophageal reflux disease (GERD). In this condition stomach acids reflux, or “back up”, from the stomach into the esophagus. Patients usually characterize heartburn as a harsh, burning sensation behind the breastbone (sternum). This pain may radiate to the back of the chest or into the throat and neck. Many adults in the United States experience heartburn at least once a month. Other symptoms of reflux include vomiting, difficulty swallowing, chronic coughing, or wheezing. What Causes GERD? When you eat, food travels from your mouth to your stomach through a tube called the esophagus. A small ring of muscle, called the lower esophageal sphincter (LES), is located at the lower end of the esophagus. The LES acts like a one-way valve, allowing food to pass through to the stomach, then closing immediately afterwards to prevent reflux of acidic stomach juices into the esophagus. Reflux occurs when the LES malfunctions and allows acid to irritate the lower esophagus. This inflames the lining of the esophagus and may eventually lead to ulceration, scarring, and narrowing of the esophagus. What Contributes to GERD? Some people are born with a naturally weak sphincter (LES). For others, however, fatty and spicy foods, certain medications, tight clothing, smoking, drinking alcohol, vigorous exercise, or changes in body position (bending over or lying down) cause the LES to relax, producing reflux. A hiatal hernia (a term erroneously used interchangeably with reflux disease) may or may not be present in patients with reflux. There are a number of people with reflux who do not have a hiatal hernia, just as there are many people with a hiatal hernia who do not reflux. How is GERD Treated? Reflux is generally treated in three progressive steps: 1.Lifestyle Changes: In many cases, changing diet, losing weight, reducing smoking and alcohol consumption, and altering eating and sleeping patterns reduce the frequency and harshness of symptoms. 2.Drug Therapy: If symptoms persist after these lifestyle changes, drug therapy may be required. Antacids such as Maalox, Riopan, and Amphogel neutralize stomach acids. Over-the-counter medications (such as Pepcid AC and Tagamet AC) reduce the amount of acid produced by the stomach. Both may be effective in relieving symptoms, but if they do not work, stronger prescription drugs may be required. This therapy needs to be discussed with your surgeon. 3.Surgery: Patients who do not improve with lifestyle changes or drug therapy, or who continually require medications to control their symptoms, are candidates for surgery. Surgery is very effective in treating GERD. However, until recently this operation required a large abdominal incision resulting in significant pain and a recovery period of six weeks or more. Now we use a laparoscope to do the procedure, avoiding the necessity of a large abdominal incision. How is Laparoscopic Anti­Reflux Surgery Performed? • Laparoscopic anti­reflux surgery (commonly referred to as Laparoscopic Nissen Fundoplication) involves reinforcing the “valve” between the esophagus and the stomach by wrapping the upper portion of the stomach around the lowest portion of the esophagus­­much the way a bun fits around a hot dog. • In a laparoscopic procedure, surgeons insert cannulas (narrow tubes) through small incisions (1/4 to 1/2 inch) to enter the abdomen. The laparoscope, which is connected to a tiny video camera, is inserted through the cannula, and gives the surgeon a clear, magnified view of the patient’s internal organs on a television screen. Instruments such as forceps and scissors are inserted through other incisions and the entire operation is performed “inside” without making a large incision. What are the Risks of Laparoscopic Anti­Reflux Surgery? Although the operation is considered safe, complications may occur, as they may occur with any operation. Complications during the operation may include: Adverse reaction to general anesthesia, bleeding, or injury to the esophagus, spleen, or the stomach. Complications after the operation may include: Infection of the wound, abdomen, or blood. What happens if the Operation Cannot were Performed Laparoscopically? In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that increase the possibility of converting to an “open” procedure include obesity, bleeding problems during the operation, or a history of prior abdominal surgery causing dense scar tissue. The decision to perform an open procedure is made by your surgeon either before or during the actual operation and is based strictly on patient safety. What are the Side Effects of this Operation? • Long-term side effects of this procedure are generally uncommon. • Some patients develop temporary difficulty swallowing immediately after the operation. This usually resolves within one to three months after surgery. Occasionally, these patients require a simple procedure to expand or dilate the esophagus (endoscopic dilation). Rarely they need another operation. • There may be a limited ability to belch or vomit following this procedure. Some patients complain of abdominal bloating. • Rarely, patients report no improvement in their symptoms. What are the Expected Results after Laparoscopic Anti­Reflux Surgery? Studies have shown that the vast majority of patients who undergo the procedure become symptom free or have significant improvement in their symptoms. The advantage of the laparoscopic approach is that it usually provides: 1. Reduced post­operative pain. 2. Shorter hospital stay. 3. A faster return to work. 4. Improved cosmetic result.

What Is A Colonoscopy? A Colonoscopy is a procedure that enables your surgeon to examine the inner lining of the rectum and colon. It is usually done in the hospital in the endoscopic procedure room. A soft, bending tube about the thickness of the index finger is gently inserted into the anus and advanced into the rectum and the colon. It is usually done as part of a routine screening for cancer, in patients with known polyps or previous polyp removal, before or after some surgeries, or to evaluate diarrhea, bleeding or colitis. What Preparation Is Required? The rectum and colon must be completely emptied of stool for the procedure to be performed. The office staff will give you a Colonoscopy Preparation instruction sheet. If you do not complete the preparation, it would be unsafe to perform the colonoscopy and the procedure will have to be rescheduled. If you are unable to take the preparation, please contact the office staff. • Prior to the procedure, you will refrain from eating, drinking and chewing after midnight on the night before your procedure unless otherwise instructed. You should refrain from smoking 24 hours before your procedure, due to the high level of carbon monoxide smoking delivers to your bloodstream. People who smoke prior to general anesthesia or sedative are more than 20 times likely to have episodes of inadequate oxygen supply to the heart (which could be interpreted as a heart attack) than non­smokers. • You should bathe or shower the night before or the morning of your procedure. • Some preoperative testing may be required depending on your medical condition. • If you take medication on a daily basis, our surgeons request that only heart and blood pressure medications be taken on the morning of your procedure with a sip of water, unless otherwise instructed. If you take aspirin, blood thinners or arthritis medication the surgeon will discuss the proper timing of discontinuing these medications before your procedure. • If you are on insulin, take half of your usual morning dose the day of the procedure, unless otherwise instructed by your doctor. Your blood sugar will be checked if needed. • If you require antibiotics prior to dental procedures instruct your surgeon, you may also require antibiotics prior to your colonoscopy. What Can Be Expected During The Colonoscopy? The procedure is usually well tolerated and rarely causes much pain. There is often a feeling of pressure, gassiness, bloating or cramping at various times during and after the procedure. You will receive a medication through an IV in your vein to help you relax and better tolerate any discomfort that you may experience. You will be lying on your side while the colonoscope is advanced through the large intestine. The lining of the colon is examined carefully while going in and while the instrument is withdrawn. The procedure usually last for 15 to 60 minutes. In rare instances if the entire colon cannot be visualized your surgeon could request a barium enema. What If The Colonoscopy Shows An Abnormality? If your surgeon sees an area that needs a more detailed evaluation, a biopsy may be obtained and submitted to a laboratory for analysis. This is done by placing a special instrument through the colon­ oscope to sample the lining of the colon. Sites of bleeding can be identified and controlled by injecting certain medications or coagulating (burning) the bleeding vessels. Biopsies do not imply that cancer is suspected, however, removal of a colon polyp is an important means of preventing colorectal cancer. Generally all polyps are removed during the colonoscopy and sent to the laboratory for analysis. The majority of polyps are benign (noncancerous), but your surgeon cannot always tell by the outer appearance alone. They can be removed by burning or by a wire loop (snare). It may take your surgeon more than one sitting to do this if there are numerous polyps or they are very large. What Happens After The Colonoscopy? • Your surgeon will explain the results to you at your follow up visit or telephone the results. • You may have some mild cramping or bloating from the air that was placed into the colon during the examination. This should quickly improve with the passage of the gas. • You will be able to eat and return to normal activities after leaving the hospital. Do not drive or operate machinery until the next day, as the sedatives given will impair your reflexes. • You will be observed after the procedure until most of the effects of sedation have worn off. • You may not remember what your surgeon told you after the examination or follow instructions.

About Your Hernia, Laparoscopic Vs. Open Repair: Laparoscopic Hernia Repair is a technique to fix a tear or hole in the abdominal wall (muscle) using small incisions, telescopes and a patch (mesh). It offers a quicker return to work and normal activities with decreased pain. Open Hernia Repair is performed with an incision over the site of the hernia. The hernia or hole in the abdominal wall is repaired with mesh or by closing the defect with sutures. What Is A Hernia? When a hernia occurs, the inside layers of the abdominal wall have weakened, resulting in a bulge or tear. Just as an inner tube pushes through a damaged tire, the inner lining (peritoneum) of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon like sac. A loop of intestine or abdominal tissue can then push into the sac. The hernia can cause severe pain and other potentially serious problems that could require emergency surgery. • both men and women can get a hernia. • you may be born with a hernia (congenital) or acquire one over time. • a hernia does not get better over time, nor will it go away by itself. The defect, or hole will stay the same size or become larger. How Do I Know If I Have A Hernia? The most common areas where a hernia can occur are in the belly button (umbilical), groin (inguinal), and the site of a previous operation site (incisional). It is usually easy to recognize a hernia. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, and strain during urination or bowel movements or during prolonged standing or sitting. • the pain may be sharp and immediate or may be a dull ache that gets worse toward the end of the day. Severe, continuous pain, redness and tenderness are signs that the hernia may be entrapped (Incarcerated) or strangulated. These symptoms should prompt you to contact your physician immediately. Why Do People Get Hernias? The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, aging, injury, an old incision, or a weakness present from birth. Anyone can get a hernia at any age. Most hernias in children are congenital. In adults hernias can be caused by a natural weakness, strain from heavy lifting, persistent coughing, or difficulty with bowel movements or urination. What Are The Treatment Options? Most hernias require a surgical procedure. These operations are now done in one of two ways: 1. The traditional approach is done from the outside through an incision in the groin or the area of the hernia. The incision will extend through the skin & fat under the skin, to allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole. This technique can be done with a local anesthetic and intravenous sedation or by using a spinal or general anesthetic. 2. The second approach is a laparoscopic hernia repair. A laparoscope (a tiny telescope) connected to a special camera is inserted through a small hollow tube (trocar) to allow the surgeon to view the hernia and surrounding tissue on a video screen. Other incisions are made that allow the surgeon to introduce instruments (forceps & scissors) to operate on the inside without making a large incision. The hernia is repaired from behind the abdominal wall. A piece of surgical mesh or screen is placed over the hernia defect and held in place with small surgical staples or by the patient’s own tissues. This operation is usually performed with general anesthesia. Is Everyone A Candidate For Laparoscopic Hernia Repair? Only after a thorough examination can your surgeon determine whether a laparoscopic hernia repair is right for you. The procedure may not be best for some patients who have had previous abdominal surgery or underlying medical conditions.

Dr. Singh is Board certified in both laparoscopic and open gallbladder surgeries. What is the Gallbladder? The gallbladder is a pear-shaped organ that rests beneath the right side of the liver. Its main purpose is to collect and concentrate a digestive fluid (bile) produced by the liver. Bile is released from the gallbladder after eating and travels through a narrow tubular channel (bile duct) into the small intestine, aiding digestion. Removal of the gallbladder is not associated with any impairment of digestion in most people. The only known side effect from removal of the gallbladder is loose bowel movements or infrequently diarrhea. This can occur in about 5% of patients and is usually transient. Rarely it is long lasting and may require medications to control. What Causes Gallbladder Problems? Gallbladder problems are usually caused by the presence of gallstones: small hard masses consisting primarily of cholesterol and bile salts that form in the gallbladder or in the bile duct. It is uncertain why some people form gallstones. There is no known means to prevent gallstones. These stones may block the flow of bile from the gallbladder, causing it to swell and resulting in sharp abdominal Pain, vomiting, indigestion, and occasionally fever. How are these Problems Found and Treated? After the patient has symptoms: Ultrasound is most commonly used to find gallstones. In a few complex cases, other X-ray tests may be used to evaluate gallbladder disease. Gallstones do not go away on their own. Some can be temporarily managed with drugs or by making dietary adjustments, such as cutting down on fat intake. This treatment has a low, short-term success rate and symptoms will usually persist until the gallbladder is removed. Surgical removal of the gallbladder is the safest, most effective treatment of gallbladder disease. How is Laparoscopic Gallbladder Removal Performed? General anesthesia is used; therefore the patient is asleep throughout the procedure. In a laparoscopic operation, surgeons insert cannulas (narrow tubes) through small incisions (1/4 to 1/2 inch) to enter the abdomen. The laparoscope, which is connected to a tiny video camera, is inserted through the cannula, and gives the surgeon a clear, magnified view of the patient’s internal organs on a television screen. Instruments such as forceps and scissors are inserted through other incisions and the entire operation is performed “inside” without making a large incision. The surgeon separates the gallbladder from its attachments then removes it through one of the incisions. An intraoperative x-ray (called a cholangiogram) or an ultrasound is sometimes performed to identify stones in the main bile duct or to insure that the main bile duct has been properly identified. If the surgeon finds one or more stones in the common bile duct, these may be removed with a special scope during the operation or may be removed later under mild sedation using a second minimally invasive procedure called an ERCP (Endoscopic Retrograde Cholangio­Pancreatography). After the gallbladder is removed, the small incisions are closed with absorbable stitches under the skin and a liquid like glue called collodion on the surface of the skin. The collodion will eventually wear off. What happens if the Operation Cannot be performed by the Laparoscopic Method? In a small number of patients (about 5%) the laparoscopic method is not feasible because of an inability to identify the anatomy adequately or handle the organs safely. Factors that may increase the possibility of converting to “open” procedure include obesity, a history of prior abdominal surgery causing dense scar tissue, bleeding problems during the operation, or intense inflammation around the gallbladder and bile ducts, obscuring the normal anatomy. The decision to convert to an open procedure is made by your surgeon during the operation and is based strictly on patient safety. What are the Complications of Laparoscopic Gallbladder Removal? Complications can occur with any operation and include bleeding, blood clots, and infection, which are uncommon with laparoscopic gallbladder removal (1% or less). An even less common, but very serious, complication is an unintended injury to the common bile duct or duodenum. This may require conversion to an open operation. Finally, bile leakage from the bile duct into the abdomen may occur and may necessitate further intervention. What are the Complications of an Open Gallbladder Removal? These are the same as for the laparoscopic operation. There is however a higher chance of pneumonia, wound infections, and clots forming in the deep veins of the leg. Of course, there is more pain after an open abdominal operation and recovery is much Longer.