These acute symptoms can range from mild to severe and may require hospitalization.

A mild attack of gallstones which resolves spontaneously is called biliary colic.  When a stone becomes lodged in the cystic duct, this causes more severe pain, which usually does not resolve.  It may be associated with an infection as well.  This is called acute cholecystitis.

Gallstones can also migrate out of the gallbladder and into this common duct and get lodged in the common duct.  This causes jaundice or yellowing of the skin.  Stones can actually pass further down and irritate the pancreas and cause pancreatitis.

So gallbladder symptoms can be mild to severe. We also know that once people start to develop symptoms from their gallstones, recurrent symptoms do tend to increase in frequency as well as in severity.

Once an attack has occurred and then resolved, there is no way to predict how severe or when another attack will occur.

Therefore, once people develop symptoms from their gallstones, surgery is recommended.  There really is no other treatment option.

However, the timing of surgery is a different story.  The easy answer is to remove the gallbladder as soon as possible after an initial attack.  If the patient is hospitalized for their symptoms, the gallbladder can be removed during that hospitalization. 

If a patient develops biliary colic, a common bile duct stone or pancreatitis, the symptoms will generally resolve and then the timing of surgery is dependent on multiple factors.  The most important factor is patient choice.  Many patients will choose to have the surgery as soon as possible or during the initial hospitalization.  However, due to multiple factors, patients may want to delay surgery. 

Patients may have important events in their lives and want to delay surgery until after that event and thus postpone surgery.

The longer surgery is delayed, the more chances increase of having another attack while waiting for surgery.  There is no predictive tool to predict when it another gallbladder attack may occur.

These principles can be applied to the pregnant patient. In the past, we would delay surgery until after the pregnancy. 

However, we now know a pregnant patient who experiences a gallbladder attack in the first trimester, has a 92% chance of having recurrent attacks, and a pregnant patient in the second trimester, has a 64% chance of having recurrent attacks.

So, a pregnant patient who does not undergo gallbladder removal, has a high probability of recurrent attacks, recurrent ER visits, and recurrent hospitalizations.  Further, while initial attacks may be mild, future attacks may be more severe and complicated.

Therefore, the current recommendation is to remove the gallbladder during the index attack in the first or second trimester.  There are NO studies showing fetal demise with laparoscopic surgery during the first and second trimesters.  Thus, it is a very safe procedure. 

If gallbladder symptoms are mild, there is no increased rate of spontaneous abortion or preterm labor comparing surgery to nonoperative management, such as waiting till after pregnancy to have your gallbladder removed.  However, there is a high spontaneous abortion rate and preterm labor late with complicated gallstone attacks.

Further, if the pregnant patient chooses NOT to remove the gallbladder during pregnancy, there is really not a great time after pregnancy.  The patient will have a newborn and will, in my experience, have difficulty finding  the time to have surgery in that year first year after pregnancy.  The patient will be dealing with a newborn and will not really have the time to have surgery and recover from the surgery without needing additional help.  That can be an issue for many.  

Also, the chances of having another attack and that year, when waiting when waiting to find the time to have surgery, is high as well.  Thus, a patient may wind up having a non-elective gallbladder removal (i.e. an emergency)  in the first year after pregnancy because symptoms are too debilitating. 

Thus, the recommendation are to remove the gallbladder in the first or second trimester during pregnancy once an attack 

Author Dr. Matthew Lublin

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When Can You Wait?

There are certain cases where repairing a hernia is not an urgent situation – this is especially true for older patients as well as those with asymptomatic hernias. Patients with larger hernias have a lower risk of complications than those with smaller ones. However, for most patients, the decision whether to undergo a hernia repair is not quite as black-and-white.

Considerations for Hernia Surgery

There are several potential scenarios that a patient must consider when deciding whether they will repair the hernia surgically or not:

First is continued discomfort and possible pain. Typically, when a patient comes to our office suspecting a hernia, it is because they either feel a bulge somewhere in their abdomen or they have pain – commonly caused by abdominal contents getting stuck in the hernia. This pain and discomfort tends not to go away and patients may be mildly or severely limited in the activities they can perform as a result. Depending on the degree of discomfort, this may or may not be an important consideration to the patient

The fact that hernias are progressive also makes the decision more complicated. While losing weight and placing less the strain on the abdomen is a good way to reduce hernia-causing abdominal pressure, an existing hernia will not get better, it will only get worse. As it progresses, the surgical process for repairing it becomes more complicated and the risks increase.

A small number of patients will suffer from what is known as incarceration or strangulation of the hernia. This is where the abdominal contents become stuck in the hernia. Incarceration is somewhat less emergent then strangulation as the latter means that blood flow is cut off to the tissue stuck in the hernia – usually intestinal tissue. Both require immediate medical care and swift surgery to avoid potential complications including the necrosis or death of strangulated tissue. Waiting in a situation such as this can lead to serious surgical complications and even death.

Younger patients in good health and with smaller hernias are often recommended for surgery as their surgical risk is typically very low and their outcomes are often very good. Older patients who present with larger hernias and have her lower risk of strangulation, may be able to choose their preferred course of action with fewer potential consequences.

One common hernia – a femoral hernia – that affects women more often than men, almost always requires prompt surgical care as femoral hernias have a very good chance of strangulating and can cause serious consequences if not treated quickly.

The best way to learn about your hernia repair options is to visit a hernia specialist like Dr. Lublin. After diagnosing the hernia and understanding its characteristics, you and your surgeon can decide whether a repair is right for you, now or in the future. It is important that all patients understand the risks of surgery versus the risks of doing nothing about their hernia.

The post Evaluating Potential Risks of Waiting to Repair a Hernia appeared first on Matthew Lublin, MD.

• Learn more about robotic bariatric surgery
• Learn more about robotic general surgery

However, with all its benefits, robotic surgery is not appropriate in every case. When we screen patients for surgery, we consider first the safety and second the effectiveness of the procedure. Robotic surgery often offers the best of both worlds, especially when complexity is involved.

However, there are circumstances where a robotic procedure is no safer or more effective than its laparoscopic counterpart (this is true for many hernia surgeries and virtually all gallbladder removal surgeries). Some reasons include:

Benefit and Effectiveness

Many procedures do not benefit from a robotic approach when compared to a laparoscopic approach. Incision size, recovery, and actual operative time are sometimes the same or even better with a pure laparoscopic approach. Thus, a robotic approach is not needed or beneficial.

Procedures That Must Be Performed in an Open Manner

While laparoscopic technology has become the norm in general surgery, there are times where a patient benefits from open surgery. In this case, of course, robotic and traditional laparoscopy simply cannot be employed.

Some Procedures are Not Suited to Robotic Surgery

While many procedures can be performed with robotic assistance, there are some that simply cannot. Dr. Lublin will discuss the appropriateness of the robotic platform for each case.

Time and Availability

Because of the cost and limited availability of robotic surgical devices, hospitals must prioritize the robot, assigning surgeries that benefit greatly from the robotic platform first. This means that not all patients will have access to a robotic surgical suite at any given time.

Cost Considerations

Robotic surgery tends to be more expensive to the patient and the payer, and if the safety and efficacy of the procedure is the same as traditional laparoscopy it benefits both to opt for the minimally invasive, non-robotic approach.

Consulting with an experienced robotic general surgeon about the appropriateness of using the robot for your upcoming procedure is the best way to learn more about your options and which technique is best for you. Please contact our office to learn more.

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The question posed in this blog touches on both circumstances. A patient who discovers they have a hernia from an incidental exam has likely been living with that hernia for quite a while. Indeed, many hernias go unnoticed and undiagnosed for years, decades or even the remainder of the patient’s life. Asymptomatic hernias, as they are known, do not warrant treatment, in most cases, because we simply do not know they exist, but also because the risk of strangulation is very low. Ultimately, if the potential hernia does not cause any interference in lifestyle, there would be no reason to repair.

In this case, diagnostic imaging or a medical exam for a different condition has yielded the diagnosis of a hernia. At this point, the patient should most definitely consult with an experienced hernia surgeon. During this consultation, a physical exam will be performed once again to determine exactly what kind of hernia and any risks that the patient may have because of it. Certain hernias, for example femoral hernias, almost always need to be repaired as they have a high incidence of strangulation. Other hernias, depending on their location and characteristics might be better left alone.

The decision to have hernia surgery or to wait until later depends on the patient. Please consider the following points:

With all the above being said, an experienced hernia surgeon such as Dr. Lublin will repair many thousands of these defects over the course of their career. Most hernia cases are straightforward and come with minimal risk. Scheduling a consultation with Dr. Lublin or a qualified experience surgeon in your area is the first step to understanding whether repairing a hernia is appropriate for your circumstance.

The post My Doctor Found a Hernia Incidentally but I Have No Symptoms. What Do I Do? appeared first on Matthew Lublin, MD.

The Tension-Free Method

The most commonly performed hernia repair technique is known as the tension-free repair. This can be performed an open or laparoscopic manner and employs a surgical mesh to cover the defect or hole in the fascia of the abdomen. The mesh is placed over the defect, essentially creating a barrier – the defect is not closed.

Bottom line benefit: The main benefit of this technique is that the synthetic mesh creates a very strong wall over the hernia defect. As the body’s inflammatory response kicks in, tissue begins to grow in and around the mesh, creating an extremely strong barrier. Mesh repairs have a very low recurrence rate as a result.

Bottom line risk: Having a foreign body implanted can have different consequences in different people. Some patients will experience chronic pain, possibly as a result of the mesh, but more likely due to the hernia being repaired in the open method. Other potential issues such as inappropriate mesh size or quality as well as the way that the mesh is affixed have been overcome with modern surgical mesh technology.

The No-Mesh Repair

The traditional tension repair involves suturing the edges of defect closed. It is called a tension repair because the sutures pull on the edges of the hernia defect to close it.  All hernias were fixed in this matter when hernias started to be repaired in the early part of the 19th century.  Due to the high recurrence rates, mesh repairs were adopted and now become the standard of care.

Bottom line benefit: Tension repairs do not employ surgical mesh and therefore do not have any of the risks associated with the implantation or fixation of a foreign body in the abdomen.

Bottom line risk: Because of the very nature of the technique, the risk of recurrence of the hernia is relatively high. Of course, a recurrence requires an additional surgical procedure. To further complicate the problem, a recurrence of the hernia will require a second more difficult repair to fix the hernia.

What’s the Better Method?

There are various techniques that have been developed over the history of hernia repair to address the most common pitfalls of each of type of surgical repair. Hernia mesh has come a long way since it was first developed, with more options combined with improved surgical techniques. Others have sought to reduce the risk recurrence and complications in tension/no mesh repairs.

Ultimately, the most important factor in the success of a hernia procedure lies in the surgeon’s experience.  That is why employing a hernia specialist for your procedure is critical for the success of your hernia repair.  Dr. Lublin believes that a tension-free hernia repair using mesh is the ideal method for repair because: the risks of significant and long-term chronic pain are very low in the hands of an experienced surgeon, modern meshes and fixation techniques have significantly reduced the chance of chronic pain, and the recurrence rate is extremely low. Thus, the need for a more complicated revisional hernia procedure is quite minimal.

Of course, no two patients are the same and the technique ultimately employed depends on the patient’s particular circumstance, their general health, and their preference. We encourage our patients to arrive at their preliminary consultation with plenty of questions to ensure that they understand and feel comfortable with the procedure that they will undergo.

The post Comparing No Mesh and Tension-Free Hernia Repairs appeared first on Matthew Lublin, MD.

When patients first start experiencing gallstone pain, they are usually referred to an imaging center for a comprehensive abdominal ultrasound, both to confirm the presence of a gallstone or gallbladder disease and rule out any other abdominal conditions. The report we receive from the imaging typically states the size of the gallstone. So, what exactly does the size of the stone tell us?

• First, the larger the gallstone, the lower the likelihood that it can be passed out of the gallbladder into the common bile duct. A large sized stone simply cannot pass through the small cystic duct and therefore not cause the complications of jaundice or pancreatitis associated with gallstones.
• Second, studies have shown a possible correlation between the size of a gallstone and gallbladder cancer. There are many factors that affect gallbladder cancer and it remains a relatively uncommon disease in the United States. However, most patients with gallbladder cancer also have gallstones. This may be, in part, related to the organ’s inflammatory response to the stone.
• Lastly, the size of the gallstone is somewhat less important than whether the gallstone is symptomatic or asymptomatic. We tend to remove the gallbladder only when gallstones become symptomatic, regardless of the size of the stone (unless it is extremely large).

What Is a Normal Size Gallstone?

The answer is that there is no normal size when it comes to gallstones. Some patients have anywhere from a few to hundreds of tiny gallstones. Other patients will have a single gallstone as large as 5 cm, although a gallstone of this size is rare.

When We Treat Gallstones

Not everyone with gallstones will become symptomatic. Approximately 10 to 20% of those with gallstones ever experience symptoms. Others may experience a single attack, typically mistaking it for food poisoning or other digestive issues, and never have another. However, typically, after the first attack, the chances of a subsequent attack increase dramatically. These subsequent attacks may come frequently or infrequently.

Ultimately, no matter what the size of the stone, it is important that symptomatic stones are treated early because they can lead to more serious complications of gallbladder disease. Patients who have their gallbladder removed electively, tend to have fewer complications and a shorter recovery.

The post What Does the Size of Your Gallstone Mean? appeared first on Matthew Lublin, MD.

• First, plan out meal time. Some research into restaurants near your destination may give you a glimpse into how you’ll eat when you go there. You don’t necessarily have to choose your dish days in advance, but at least understanding at least choosing a restaurant with a suitable menu makes it much easier to find and choose healthy and delicious options.
• If you’re staying at a hotel, find one that has his fitness center and bring appropriate clothing. Many times, even budget hotels have a fitness center that can be used 24/7. Finding one of these hotels and taking advantage of their amenities can help you burn those extra calories. If the hotel at which you’re staying does not have a fitness center, most gyms have short-term memberships for a relatively low fee and are well worth it.
• Plan activities that require exercise. Hiking trails or long walks can be very beneficial to your diet while you’re on the road. Forgoing car rides for more strenuous activities will help you maintain your exercise regimen.
• Finally, continue to follow the tips and tricks that you have learned over the course of your weight loss journey and make sure you apply them to your vacation or trip. Just because you’re relaxing on vacation does not mean you should relax your diet. You can still enjoy many delicious items that are also healthful.

Eating on the road may be daunting but it doesn’t have to derail your progress. Hopefully your new and improved lifestyle has become second nature and you find yourself able to follow your dietary guidelines without much second thought. If you do find yourself straying, contact a trusted weight loss support partner and discuss your dilemma. Talking to someone who understands is often the best way to get right back on track.

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• A surgeon’s experience in the procedure being considered is extremely important. Not every surgeon is experienced in every bariatric procedure and studies show that choosing an experienced surgeon can result in better outcomes and fewer complications. Choosing a surgeon that has experience in the procedure of your choice is an important first step.
• A surgeon’s dedication to continuing education is also very important. Surgical techniques have changed significantly from the first bariatric procedures to today, and it is important that your surgeon is abreast of the most current surgical trends.
• Choosing an ASMBS Center of Excellence surgeon is yet another layer of help in your decision-making process. The American Society for Metabolic and Bariatric Surgery has a strict set of criteria for certification, meaning that surgeons with this designation have proven above-average results and below-average complication rates. While a Center of Excellence designation does not mean that the surgeon is right for you, it can be helpful.
• Speaking to a surgeon’s former patients may also give you an idea of what to expect from the practice. Some people require more attention than others, and some are more comfortable with certain personalities than others. It is important to fully evaluate your surgeon’s bedside manner, as well as the facilities at which they perform the surgery.
• Finally, it is important to ensure that the support you receive, before, during and after surgery is of the highest quality. Financial advisers can help guide you through the process of paying for surgery, while support staff including exercise physiologists and dieticians can help you be as successful as possible after surgery.

Ultimately choosing a surgeon requires time, patience and research. Attend seminars and even drop by a support group or two. You will be happy that you spent the time making the right decision.

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The BMI itself is an imprecise system. Results are calculated based on limited criteria, which do not take into account important factors such as age, gender, muscle mass and bone structure. This means that a bodybuilder, for example, may register as overweight or obese when in actual fact, they are far from it. This is not to say that BMI isn’t useful; it is as a rough guide.

Those considering bariatric surgery should also remember that the Body Mass Index is not the only qualifying criterion. Rather, there are several different criteria that your surgeon and primary physician will take into account before they decide that you are an ideal candidate for weight loss surgery. Some of these may include whether or not you have an acceptable level of surgical risk, your general health, the results of pre-operative testing, any diseases associated with morbid obesity, past attempts at weight loss and variables including insurance coverage, financial considerations and the specific procedure being performed.

All in all, the Body Mass Index calculation is useful; however it should not be relied upon as a definitive answer to the question: Do I Qualify for Bariatric Surgery?  It’s always best to speak to your primary physician and bariatric surgeon to learn more and get started on you weight loss journey.

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The several arms that the robotic system employs to assist in the surgery are wristed, much like the human wrist, but with an even greater range of motion. This allows for unparalleled access and flexibility within the abdomen, especially during more complex cases. Further the surgeon’s field of vision is enhanced over traditional laparoscope because of a magnified, 3-D camera array. This leads to an incredible, sharp and clear image inside the abdomen.

Many patients will benefit from robotic assisted surgery through shorter hospital stays, less pain and less blood loss during surgery. It is important to note however that all surgical procedures including those assisted by robots come with some risk, which should and will be fully discussed during your consultation with Dr. Lublin. Further, not all patients will qualify for gallbladder removal using robotically assisted technology.

We look forward to offering you additional information on how robotically assisted surgery can benefit you and we encourage you to contact our office to learn more.

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