Category Archives: EZ 56 – Medical

Does Key Hole Surgery Hold The Key To The Future?

Mr. Low Kah Pin

Obstetrician & Gynaecologist
MBBS (UM), MObGyn (UM), MRCOG (UK), FMAS/ART (India), MSc BHARE (Spain)

Mr Low Kah Pin is an enthusiast in Obstetrics and Gynaecology with a soft spot for laparoscopy and fertility. An avid multi-sports lover with penchant for creative literature snippets, humor, art and the occasional minute dose of politics.


Key hole surgery is the laymen term for laparoscopy or minimally-invasive surgery where the surgeon makes a small incision of 5mm, usually at the patient’s belly button and puts a camera, called laparoscope, into the abdominal cavity to visualize the cavity via the television screen. The non-toxic and odourless carbon dioxide gas is used to create an air pocket within abdomen for the surgeon to operate. Additional small incisions are made, to insert surgical instruments into the cavity to perform the operation.

Misconception

In my clinical practice, there are a few misconceptions by the general public. Laparoscopy is incorrectly regarded as “laser” surgery although no laser equipment is being used. Laparoscopic removal of ovarian cyst are being known as “sucking” out the cyst or the tumor, not knowing that the actual procedure requires surgical dissection of the lesion, extraction out from the cavity through the key holes and prevention of bleeding from the surgical site. It is not just sucking out the lesion like using a vacuum cleaner. Lastly, the public has the idea of laparoscopy being “incomplete” or “not clean enough” surgery as the incision is small, but in actual fact, the laparoscope camera allows the surgeon to view the entire abdomen cavity, which is impossible in open surgery. Washout and suturing can be done efficiently via laparoscopic instruments.

Advantages

The glaring advantage of laparoscopy, as compared with traditional large incision surgery is less postsurgery pain. Hence, patients have less discomfort, use less painkillers, better cosmesis and able to resume activities much earlier. Indirectly, patients will less likely to develop blood clots in vessels or pneumonia as patients are ambulated earlier. Some laparoscopy surgery can be done as daycare surgery, meaning no overnight hospitalization is required. Patients are being admitted to ward in the morning, to be operated in the afternoon and walk back home in the evening.

The other benefits of laparoscopy include rare occurrence of hernia from incision and less likely to have wound infections. Therefore, patients can lift or carry objects earlier. The incisions are closed with dissolvable sutures or held together with small dressings without going through the discomfort of removal of stitches or staples.

Limitations

Laparoscopy requires patients to undergo general anaesthesia requiring patients to be put to sleep on the breathing machine during the operation. This may cause sore throat and nausea. Air pockets within abdomen cavity may lead to the feeling of belatedness and occasional neck and shoulder pain, especially when the air pockets are trapped under the diaphragm (muscle between chest and abdomen cavity).

Thus, laparoscopy surgeries are off limits to patients with severe heart or lung disease as surgeries should be safely performed in open surgery with regional anaesthesia. Laparoscopy should be done in caution for patients with multiple prior operations as built-up of previous scar tissues increases the difficulty of laparoscopy surgery as well as the risk of complications.

Evolution and the future

The first laparoscopic procedure was performed in dogs by Georg Kelling of Dresden, Germany in 1901 and in humans by Hans Christian Jacobaeus of Sweden in 1910. More than a century later, by today, laparoscopy had evolved greatly. Key hole surgery can even be performed during pregnancy ie removal of ovarian cyst. Personally, I had removed large cyst of more than 10 centimeters ie mucinous cyst, endometriotic cyst, dermoid cyst with pregnancy unaffected and progressed normally postoperatively till delivery. Laparoscopic surgeries are usually done with at least 3 small incisions, but currently many surgeons are trained in single port laparoscopy where only one incision is required or key hole surgery through natural orifices such as removal of ovarian cyst through incision in vagina, hence the incision are hidden and appear scarless! 

Living with Parkinson’s

Dr. Tan Kenny

Neurologist & Physician (Subspecialty in Parkinson’s Disease & Movement Disorders)
MD (UKM), MRCP (UK), Fellowship in Neurology (Mal.), Fellowship in Parkinson’s Disease & Movement Disorder (Northwestern University, USA), CMIA (NIOSH)

He is a Neurologist and Physician at Loh Guan Lye Specialists Centre. He has vast experience in diagnosing and managing various neurological conditions. He has special interest in treating Parkinson’s disease and movement disorders including tremors, involuntary movements and gait disorders. He is committed in creating awareness and education and holds the position as the Medical Advisor for the Penang Parkinson’s Disease Association, Honorary Lecturer for Penang International Dental College and Penang Medical College.


What is Parkinson’s Disease (PD)?

PD is a slow progressive nerve cell degeneration disease causing reduced production of dopamine, a brain chemical that is responsible for brain cell signal transmission. Lack of dopamine will cause PD symptoms like tremor, stiffness, slow movement and other associated complications like constipation, mood disorders (depression, anxiety), sleep disorders (insomnia) and memory decline (dementia).

There is an estimate of 10 million people worldwide having PD. It is the second most common neurodegenerative disorder after Alzheimer’s disease and it affects 1% of people above the age of 60. It may also affect younger individuals as approximately 4% of people with PD are diagnosed before age 50.

How to recognize PD? How does it affect people with PD?

The diagnosis of PD is a challenge as currently there is no lab investigation or imaging to confirm it. PD is a clinical diagnosis requiring specific neurological assessment skills to accurately identify the cardinal symptoms i.e. tremors, slow movement (bradykinesia) and stiffness (rigidity).

In the early stages, PD may be difficult to diagnose as symptoms are subtle like mild hand tremors, lack of facial expression and stooped posture. As the disease progresses, other symptoms may set in i.e. stiffness in the arms, difficulty getting up from bed and slow small steps when walking. Simple routine activities of daily living like eating, dressing and driving may become challenging as response and movements become slower, affecting dexterity as the disease progresses. At late stages, balance might be affected posing dangers to falls and injuries.

At times, people with PD may become socially withdrawn due to their motor limitations and PD features. They are often misunderstood as being inattentive or show lack of interest due to their limited facial expressions, slow responses and monotonous voice. Hand tremors and their slow, shuffling gait may cause psychological stress and embarrassment to both patients and their family especially when attending public functions. Some people with PD may concurrently have depression and anxiety that further inhibit their social circle.

What are the treatment options?

The treatment of PD needs to be individualized as no two patients are the same. Currently, there is no cure for PD but modern medicine aims at controlling symptoms to improve their quality of life. Besides oral PD medications, there are surgical options and advanced therapeutics with modern devices like deep brain stimulation for symptomatic control. With the help of advanced therapeutics, there can be better regulation of PD symptoms and less dependence on medications.

PD patients will require physiotherapy, occupational therapy and speech therapy as well. Some of the aspects that needs special attention include balancing, gait training, posture correction, fine motor skills for activities of daily living and speech training. These also include exercises to improve muscle strength, agility and stability.

Interestingly, new evidences show that some leisure activities can actually help to improve PD symptoms. Activities like dancing, cycling, tai chi and non-contact boxing are encouraged as they show promising results providing extra-benefits like relaxation, reduce falls, improve balance and coordination.

Any special diet required for PD?

There is no food restrictions or special diet for PD. Generally a healthy, balanced diet rich in vitamins, fiber and fluid help them stay energized and relieve constipation that is a common problem in people with PD. Adequate hydration is important to prevent dehydration as PD patients frequently experience low blood pressure which may cause dizziness or falls.

Both PD patients and their family members face daily challenges living with Parkinson’s. However, it is important to understand that PD is not a fatal disease as with adequate and appropriate treatment, they can have a normal and fruitful active lifestyle.