General Surgery

Minimally-Invasive Surgery in Washington, D.C.

Minimally Invasive Surgery at the Medical Faculty Associates specializes in a variety of procedures and services and are committed to improving our patient's surgical experience through minimally invasive techniques. Minimally invasive surgery (MIS) is any surgical technique that does not require a large incision. This relatively new approach allows the patient to recuperate faster with less pain. Not all conditions are suitable for laparoscopic surgery. MIS or laparoscopic procedures offer many options for both the physician and the patient. Compared with traditional surgery, laparoscopic procedures offer the following advantages:

• Smaller Incisions resulting in Reduced Pain and Discomfort
• Minimal Scarring
• Greater Surgical Precision
• Less Trauma
• Fewer Complications
• Less Blood Loss and a Decreased need for Blood Transfusions
• Reduced Risk of Infection
• Shorter Hospital Stays
• Faster recoveries

Overview of Minimally Invasive or Laparoscopic Surgery

The MIS surgeons specialize in minimally invasive or laparoscopic surgical techniques that utilize small incisions to perform advanced gastrointestinal surgery. These incisions are typically less than one inch. Since smaller incisions are used, patients experience a faster recovery and less pain. All of the MIS surgeons are experienced with these evolving techniques. Many of the surgeons utilize emerging technologies such as robotics, state of the art imaging, and innovative equipment. All of these technologies allow the MIS staff to stay on the cutting edge of medical and surgical advances in order to provide outstanding patient care. Along with excellent clinical outcomes, the MIS staff cultivates a research environment to explore basic science and industry related products to enhance patient care in the future.

Many surgical techniques now fall under minimally invasive surgery:

• Laparoscopy - a technique that uses a tube with a light and a camera lens at the end (laparoscope) to examine organs and check for abnormalities. Laparoscopy is often used during surgery to look inside the body and avoid making large incisions. Tissue samples may also be taken for examination and testing.
• Endoscopy - a technique that uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of the digestive tract. Tissue samples from inside the digestive tract may also be taken or biopsied for examination.

Achalasia Surgery

Achalasia is a medical condition that affects the esophagus and lower esophageal sphincter (LES). The esophagus is a muscular tube that contracts and propels food from the mouth down to the stomach. The LES is a one way valve that relaxes and allows food to pass from the esophagus into the stomach. The LES prevents reflux of stomach acid back into the esophagus also. In achalasia, the LES fails to relax, and the muscles of the esophagus do not propel food from the mouth to the stomach. This results in dysphagia (feeling of food or liquid getting “stuck”), weight loss, and regurgitation. Over time, the esophagus dilates and may be associated with chronic cough or wheezing. The cause of achalasia remains unknown.

Procedure

The advantages of a laparoscopic Heller myotomy include a smaller incision, less pain, shorter hospital stay, lower chance of future hernia formation, and earlier return to work and normal activities.

The most durable and effective treatment for achalasia is surgery. Endoscopic treatments such as balloon dilatation and injection of botulinum toxin are transient and usually reserved for patients who are not surgical candidates. Surgery for achalasia involves dividing the muscle fibers of the LES. This is performed laparoscopically with 5 small incisions (all < 1 inch), as opposed to the “open” surgery which may require a 10-12 inch incision. A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The muscle fibers of the LES are divided. This procedure is a Heller Myotomy and allows food to pass through the LES and into the stomach. After the Heller Myotomy is performed, a valve must be surgically recreated at the LES in order to prevent reflux of harmful stomach acids back into the esophagus. This is accomplished with a fundoplication. A fundoplication is a wrap of stomach that is gently placed around the lower portion of the esophagus. Two different types of fundoplication are performed including a Toupet or a Dor Fundoplication.

Advantages of the Procedure

Previously, a Heller myotomy was completed through the chest and required a lengthy recovery in the hospital with a tube to drain the chest. Currently, the laparoscopic approach does not require a chest tube and provides a quick recovery with decreased pain.

Recovery

A liquid diet is started the day after surgery and advanced to a soft diet as tolerated. Patients will need to continue on soft foods for approximately 2-4 weeks after surgery. Most patients spend one night in the hospital and are discharged home the next day. Most patients return to work in less than one week depending on the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.

Adrenal Gland Removal

Removing Adrenal Tumors in Washington, DC

The adrenal glands are small organs located just above each kidney. Each gland is approximately the size of a walnut and triangular in shape. The adrenal glands produce hormones that control many bodily functions such as, blood pressure, electrolytes, and the “fight or flight” reaction to stress. Some of the hormones produced by the adrenal gland include aldosterone, cortisol, epinephrine, and norepinephrine. Diseases of the adrenal gland include adrenal masses or adrenal tumors that secrete excess hormones. An aldosteronoma and pheochromocytoma are examples of adrenal tumors. Adrenal masses that produce excess cortisol result in a condition called Cushing's syndrome. Some adrenal masses or tumors are non-functional (do not secrete hormones) and are found on x-rays obtained to evaluate another problem.

Procedure

An adrenalectomy or removal of the adrenal gland can be performed laparoscopically. A laparoscopic adrenalectomy is performed through 4 small incisions (all < 1 inch) instead of a large incision or the “open” approach which may require a large 10-12 inch incision. A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The adrenal gland is dissected away from the kidney and the arteries and vein are clipped and divided.

Advantages of the Procedure

The advantages of a laparoscopic adrenalectomy include a smaller incision, less pain, a shorter hospital stay, a faster recovery, less wound complications, and a lower chance of future hernias.

Recovery

The majority of patients return home the day after surgery. Most patients return to work in approximately one week depending on the physical requirements of their occupation. Patients return two weeks after surgery for routine follow-up with their surgeon.

Anti-Reflux (GERD) Surgery

Gastroesophageal Reflux Disease (GERD) is a medical condition associated with acid reflux, heartburn, regurgitation, abdominal pain, coughing, bloating, and dysphagia (difficulty swallowing). Normally, food is swallowed and travels down the esophagus, a muscular tube that connects the mouth to the stomach. The food passes through a one way valve called the Lower Esophageal Sphincter (LES) into the stomach. The LES allows food to pass into the stomach and then closes to prevent the food from refluxing back into the esophagus. The majority of patients with GERD have a dysfunctional LES. The exact cause of this dysfunction is unknown. Chronic exposure of the esophagus to harmful stomach acids can cause inflammation, scarring, narrowing, and a change in the lining the esophagus called Barrett's Esophagus. Many patients with GERD may also have a hiatal hernia.

Procedure

There are three basic treatments for GERD. Patients with mild GER should modify their diet, loss weight, and avoid alcohol and tobacco. If symptoms persist despite these initial modifications, patients may be started on antacid medications to neutralize and decrease stomach acids to control symptoms and relieve esophageal inflammation. Medical treatment should be discussed with your physician.

Finally, anti-reflux surgery is the third option for the treatment of GERD. Patients whose symptoms do not respond well to medication or choose not to take lifelong antacid medication are candidates for surgery. Laparoscopic Anti-reflux surgery involves reinforcement of the dysfunctional LES. Five small incisions (all < 1 inch) are used as opposed to a large “open” operation which may require a large 10-12 inch midline incision.

A laparoscope is used as a camera to visualize and magnify the abdominal contents to monitors outside of the body. Long thin instruments are used to wrap the top of stomach around the lower portion of the esophagus to recreate and reinforce the dysfunctional LES. This is called a fundoplication or wrap. There are three different types of fundoplications, the Nissen Fundoplication, the Toupet Fundoplication, and the Dor Fundoplication. The Nissen Fundoplication is the most common and effective anti-reflux procedure.

Advantages of the Procedure

The advantages of laparoscopic anti-reflux surgery include a smaller incision, less pain, shorter hospital stay, lower chance of future hernia formation, and an earlier return to work and normal activities.

Recovery

A liquid diet is started the day after surgery and advanced to a soft diet as tolerated. Patients will need to continue on soft foods for approximately 2-4 weeks after surgery. Most patients spend one night in the hospital and are discharged home on the next day. Most patients return to work in less than one week depending on the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.

Bariatric Surgery

Washington DC Weight Loss Surgery

Morbid obesity is a significant health concern effecting a growing percentage of the adult population of the United States. Significant and potentially life threatening complications are associated with morbid obesity such as diabetes, high blood pressure (hypertension), coronary artery disease, breathing difficulties (obstructive sleep apnea), and arthritis and joint problems. Patients who suffer from morbid obesity and are not able to lose enough weight with lifestyle modification alone may benefit from laparoscopic weight loss surgery.

Procedure

There are three main laparoscopic weight loss procedures performed including the laparoscopic gastric bypass, laparoscopic adjustable gastric band, and laparoscopic sleeve gastrectomy. All of these procedures restrict or reduce the size of the stomach to produce early satiety. Due to the smaller stomach, patients eat smaller meals post-operatively. Early satiety and smaller meals result in substantial weight loss. The laparoscopic gastric bypass also “bypasses” a portion of the small intestine and limits the absorption of food. All of these operations are performed laparoscopically through 5 or 6 small incisions (all < 1 inch) and uses a laparoscope and long thin instruments. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. Long thin instruments are inserted through the other small incisions in order to perform the operation.

Advantages of the Procedure

The advantages of laparoscopic bariatric surgery includes less pain, a faster recovery, a smaller incision, a lower chance of future hernia formation, lower wound complications, and a faster return to normal activity.

Recovery

The majority of patients spend 1-2 days in the hospital depending upon the type of bariatric procedure performed. Most patients return to work 2-3 weeks after surgery depending upon the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.

Bariatric Surgery of Excellence

The Surgical Review Corporation promotes the delivery of bariatric surgical care with the highest levels of efficacy, efficiency and safety. Accredited programs undergo a rigorous evaluation process to earn a Center of Excellence (COE). Overall, each CE must meet established guidelines and criteria for assessing bariatric surgical practices to become a Bariatric Surgery COE. Each COE must continue to collect clinical data on bariatrics patients pre- and postoperatively. The “Surgical Review Corporation is a non-profit corporation governed by a Board of Directors comprised of industry stakeholders. The Board of Directors sets the overall policy of the organization. SRC's Bariatric Surgery Review Committee, consisting exclusively of bariatric surgeons, assesses applicants to the Bariatric Surgery COE program and helps formulate requirement and guidelines. The Research Advisory Committee oversees the collection, analysis, and dissemination of data. SRC's Strategic Alliances Group brings together patient groups, providers, payors and other industry stakeholders in an effort to improve outcomes and provide patient, provider and payor value.”

Gallbladder Surgery

The gallbladder lies in the right upper abdomen under the liver edge. Gallstones can form in the gallbladder and may occlude or lodge in the neck of the gallbladder. If this occurs, acute inflammation of the gallbladder (cholecystitis) develops. Many times, the gallstone may pass through the bile duct and into the small bowel. Each episode of cholecystitis results in more inflammation of the gallbladder with subsequent fibrosis and scarring of the gallbladder wall. Also, if the gallstone becomes lodged in the bile duct, it can obstruct the bile duct or the pancreatic duct and cause inflammation of the bile ducts or pancreas.

Procedure

The treatment for gallstones is surgical removal of the gallbladder. This can be accomplished laparoscopically through one to four small incisions (>1 inch each) as opposed to the “open” procedure which may require an 8-10 inch incision. A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The gallbladder is dissected from the liver, and the artery and duct to the gallbladder are clipped and divided. Often an X-ray of the bile ducts is taken during surgery to ensure that gallstones have not occluded the bile ducts.

Advantages of the Procedure

The advantages of removing the gallbladder laparoscopically include; less pain, a faster recovery, a smaller incision, less wound complications, and a lower chance of future hernias.

Recovery

A liquid diet is started after surgery and patients are advanced to a low fat diet as tolerated. Pain medication is given by mouth and the majority of patients return home the day after surgery. Some patients may go home the same day as the operation. Walking is encouraged after surgery, and activity is dependent on how the patient feels. Most patients return to work in less than one week depending on the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.

Hernia Surgery

A hernia is a hole in the fascia of the abdominal wall and allows the inner lining of the abdominal wall to protrude or bulge. The bulge forms a balloon-like sac (hernia sac). Intra-abdominal contents such as fat or loops of intestine can also protrude through the defect in the fascia and into hernia sac. Loops of intestine or fat can become trapped (incarcerated) or twisted (strangulated) in the hernia sac and block the flow or food in the intestinal tract or compromise its blood supply. Although this is very rare, strangulation may lead to a potentially life threatening and serious problem requiring emergency surgery. Most hernias are identified and treated prior to incarceration or strangulation. Hernias occur in the abdominal wall where the fascia is compromised, most commonly in the groin (inguinal hernias), and areas of previous surgical incisions (ventral hernias). Hernias tend to grow larger over time and can become symptomatic.

Procedure

There are two different ways to fix hernias, but the principles of hernia repair are the same. The defect in the fascia needs to be repaired in a tension-free manner. Very small defects can be repaired simply by sewing them closed. Larger defects cannot be repaired in this manner, as they would result in large amounts of tension and a higher chance of recurrence. A tension-free repair is accomplished in larger hernias by “patching” the defect with a mesh or patch. The mesh covers the hole in a tension free manner and reinforces the weakened area in the fascia. The two different approaches to hernia repair are an open repair and a laparoscopic repair.

An open hernia repair involves an incision in the area directly over the hernia. The hernia sac is identified and reduced into the abdominal cavity. This reveals the defect in the fascia. A piece of mesh is placed below the fascia in order to span the entire defect and overlap the edges circumferentially. The mesh is sewn into place and the skin is sewn together over the mesh.

A laparoscopic hernia repair involves 3-5 small incisions (all < 1 inch) around the hernia. A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The contents of the hernia are reduced from the hernia sac to reveal the fascial defect. A piece of mesh is placed across the entire defect and overlaps the edges circumferentially. This mesh is secured in place with suture and tacks.

The patient and their surgeon decide the optimal approach to hernia repair on an individual basis.

Advantages of the Procedure

The advantages of removing the laparoscopic approach include less pain, a faster recovery, a smaller incision, less wound complications, and a lower chance of future hernias.

Recovery

A liquid diet is started after surgery and patients are advanced to a regular diet as tolerated. Pain medication is given by mouth and the majority of patients return home the day after surgery. Some patients may go home the same day as the operation. Walking is encouraged after surgery, and activity is dependent on how the patient feels. Most patients return to work in one or two weeks depending on the physical requirements of their occupation. Patients return approximately two weeks after surgery for routine follow-up with their surgeon.

Liver Surgery

The liver lies in the right upper abdomen and is the largest intra-abdominal organ. It plays a major role in metabolism and production of bile to help digests fatty foods. The liver is a vital organ and necessary for survival. There are many disorders of the liver, which in turn can affect its functions in metabolism and bile production and secretion. These disorders include hepatic adenomas, focal nodular hyperplasia, hemangiomas, hepatocellular carcinoma, liver metastasis, liver cysts and other masses and tumors. Destruction or removal of a portion of the liver can treat many of these disorders. Treating these disorders does not necessarily affect the function of the liver.

Procedure

Laparoscopic liver surgery is a minimally invasive technique which involves destroying or removing a portion of the liver through 4 or 5 small incisions (all < 1 inch,). A laparoscope and long thin instruments are used to perform the operation in order to avoid a large (12-15 inch) abdominal incision. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The liver is visualized and a portion is removed or destroyed using radio-frequency ablation. Staplers are used as well to resect or remove portions of liver.

Advantages of the Procedure

The advantages of laparoscopic liver surgery include a smaller incision, less pain, a shorter hospital stay, a lower chance of future hernia formation, and a faster recovery.

Recovery

A liquid diet is started the day after surgery and advanced to a regular diet as tolerated. Patients are encouraged to walk the day of surgery. The majority of patients are discharged from the hospital one or two days after surgery. Most patients return to work in approximately one week depending on the physical requirements of their occupation. All patients are seen two weeks after surgery for routine follow-up.

Pancreas Surgery

Laparoscopic Pancreatectomy

The pancreas lies in the upper abdomen behind the stomach and next to the first part of the small intestine called the duodenum. It plays an important role in digestion and regulation of sugar levels in the blood. Also, the pancreas excretes digestive enzymes through the pancreatic duct into the duodenum. Finally, the pancreas secretes hormones into the bloodstream such as insulin and glucagon to regulate blood sugar levels. There are many disorders of the pancreas including pancreatic masses, pancreatic tumors, neuroendocrine tumors, pancreatic cysts, pseudocysts, and ductal abnormalities such as Intraductal Papillary Mucinous Neoplasms (IPMNs). Many of these disorders require removal of a portion of the pancreas.

Procedure

Pancreatic resections can be accomplished laparoscopically in order to avoid a large (12-15 inch) abdominal incision. A Laparoscopic pancreatectomy is performed through 4 or 5 small incisions (all < 1 inch). A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. A portion of the pancreas is dissected away from surrounding structures, resected, and removed through one of the small incisions.

Advantages of the Procedure

The advantages of laparoscopic pancreatectomy include a smaller incision, less pain, a shorter hospital stay, a lower chance of future hernia formation, and a faster recovery.

Recovery

The majority of patients spend 2-4 days in the hospital and their diet is slowly advanced. Patients are out of bed and walking soon after surgery. Most patients return to work in approximately one week depending on the physical requirements of their occupation. Patients return two weeks after surgery for routine follow-up with their surgeon.

Spleen Surgery

The spleen lies in the left upper abdomen next to the stomach. It is part of the immune system and filters bacteria from the blood. As the blood is filtered, the spleen removes damaged and old blood cells. The three main types of blood cells are red blood cells, which carry oxygen and nutrients, white blood cells that help kill bacteria, and platelets that help with the clotting of blood. There are many disorders of the spleen that affect the number of blood cells and platelets circulating in the body. Certain disorders can be improved by removing the spleen including Idiopathic (unknown cause) Thrombocytopenia (low platelet count) or ITP and Hemolytic Anemia (low red blood cell count). Other disorders such as Hereditary Spherocytosis, Sickle Cell Disease, and Thalassemia, and certain types of lymphoma and leukemia are treated with splenectomy also.

Procedure

Removal of the spleen or splenectomy is accomplished laparoscopically to avoid a large (12-15 inch) incision and prolonged hospital stay. Laparoscopic Splenectomy is performed through 4 small incisions (all < 1 inch). A laparoscope and long thin instruments are used to perform the operation. The laparoscope functions as a camera to visualize and magnify the abdominal contents to monitors outside of the body. The spleen is dissected away from its attachments to the stomach and large intestine. The blood vessels to the spleen are stapled and divided. The spleen is then placed in a bag and removed through one of the small incisions.

Advantages of the Procedure

The advantages of a laparoscopic splenectomy include a smaller incision, less pain, a shorter hospital stay, a lower chance of future hernia formation and wound complications, and a faster recovery.

Recovery

A liquid diet is started after surgery and advanced to a regular diet as tolerated. Pain medication is given by mouth and the majority of patients return home one or two days after surgery. Most patients return to work in approximately one week depending on the physical requirements of their occupation. Patients return two weeks after surgery for routine follow-up with their surgeon.

Thyroid Surgery

Minimally Invasive Treatments for Thyroid & Parathyroid Disorders

Recent developments in minimally invasive surgery have been applied to thyroid and parathyroid disorders. These innovations have improved recuperation, decreased hospital length of stay, and decreased scar formation. Also, these operations allow patients to return to work and normal activities faster.

The principles of minimally invasive thyroidectomy include small incisions about 2 1/2 inches and no drainage tubes. Once the incision is made, the thyroid is mobilized into the wound and the vascular supply is controlled. The nerves are identified and carefully preserved prior to extracting the specimen. Most patients have little discomfort after a minimally invasive thyroidectomy and are discharged in 23 hours.

The hallmarks of minimally invasive parathyroidectomy include pre-operative imaging to identify the location of the abnormal parathyroid gland or glands, small incisions about 1 1/2 inches, minimal exploration in the neck, and parathyroid hormone measurements to guide surgery and define success. During the surgery, a small neck incision is made directly over the parathyroid pathology based on the pre-operative imaging. The parathyroid gland is mobilized into the wound and the vascular supply is controlled. As with thyroid surgery, the nerves are identified and carefully preserved.

Advantages of the Procedure

Most patients experience less pain and a faster recovery utilizing these techniques. For the most part, these techniques provide a smaller incision that fades over time and is hidden from view.

Recovery

Once the surgery is completed, most patients are discharged in 23 hours. Again, most patients can return to normal activities quickly with excellent cosmetic outcomes with minimal scars. Most patients follow up with their surgeon in 1-2 weeks and are back at work in 2 weeks.