Cardiac Surgical procedures

Cardiac surgery consists of basically two types of procedures, Open heart and Closed heart, the former being done with the help of a heart lung machine and the latter, without the need for a heart lung machine.

• The commonest open heart procedures, include coronary artery bypass CAB (the commonest surgical procedure in the world today), valve replacements, aneurysm repairs and correction of congenital heart defects.

• In SSSIHMS, a majority of Coronary artery bypass procedures are done without the help of a heart lung machine, (Off pump Coronary Artery Bypass – OPCAB) but with a fully assembled pump available, if needed.

• Majority of the valve procedures are replacements, with repairs accomplished when feasible.

• Aortic aneurysms depending on their location, are treated appropriately, with valve conduits or grafts as indicated.

• Total correction procedures form a major part of the pediatric surgical procedures, with palliative closed procedures when indicated.

• Examples of closed heart surgery include PDA ligation, Bi-Directional Glenn, Blalock-Taussig shunt, Coarctation of Aorta repair, and so on.

Following are the most common procedures done in the department of CTVS at SSSIHMS Wfd.

1. ALCAPA repair: Anomalous Left Coronary Artery Arising from Pulmonary Artery. This is a rare congenital anomaly where the Left Coronary Artery instead of arising from the aorta arises from the Pulmonary Artery. The surgical procedure involves re-implanting the left coronary artery back to the ascending aorta where it should have been arising, to start with.

2. Aortic Root Replacement: A surgical procedure where both the aortic valve and the ascending aorta are replaced with artificial valve and graft and re-implantations of the coronary buttons into the prosthetic graft.

3. AP Window closure: Aorto Pulmonary Window closure – a communication between ascending aorta and the pulmonary artery. Repair involves closure of this communication using a prosthetic or pericardial patch.

4. ASD closure: Atrial Septal Defect –Surgical closure of a defect in the septum/partition between the left and right atria, usually with a pericardial patch.

5. AV canal repair: Atrio-Ventricular canal repair. This is a complex defect where not only are the valves incompletely formed, but the atrial and/or ventricular septae / partitions are also deficient. Repair consists of not only repairing the two valves but also reconstituting the septae.

6. AVR: Aortic Valve Replacement, a procedure where the Aortic valve is replaced with a prosthetic (mechanical) /bio-prosthetic (tissue) valve.

7. BD Glenn: Bidirectional Glenn – It is an initial procedure that improves the blood flow to lungs, by connecting the Superior vena cava to the right pulmonary artery, as a prelude to connecting the inferior vena cava to the main pulmonary / left pulmonary artery.

8. Modified BT Shunt: Modified Blalock Taussig Shunt – A palliative procedure for many cyanotics with decreased pulmonary blood flow, Tetralogy of Fallot being the most common, where the subclavian artery is connected to the corresponding pulmonary artery using an an appropriate sized artificial tube graft.

9. CABG: Coronary Artery Bypass Graft: This is a procedure whereby blocked coronary arteries are bypassed using conduits from another part of the body (Left/Right Internal Mammary Artery from the chest wall, radial artery from the forearm and / or veins from the legs). The surgery is usually done with out the help of a Heart lung machine using myocardial tissue stabilizers, called as OPCAB and in selective case using cardio pulmonary bypass.

10. CoA Repair:This is a condition where there is a narrowing (Coarctation) of the aorta usually occurring in the proximal thoracic aorta section. The surgery involves removing the narrowed segment and connecting the two ends of the aorta directly whenever possible, or by placing a prosthetic graft between the two aortic segments.

11. Cor Triatriatum repair: An abnormal membrane in the Left Atrium that divides the LA into two chambers. The membrane is surgically removed during this procedure.

12. DCRV repair: Double Chambered right ventricle – abnormal obstructing muscle bundles inside the Right ventricle that are surgically removed.

13. DORV repair: Double Outlet Right ventricle generally occurs with both the great arteries arising from the right ventricle. The repair consists of closing the ventricular septal defect such that the left ventricle pumps blood into the aorta and the right ventricle into the main pulmonary artery.

14. Fontan: A procedure for congenital heart diseases with a functionally single ventricle where the systemic venous return is directly sent to the pulmonary circulation by detaching the SVC and the IVC and connecting them to the Pulmonary arteries. It is most often done without the use of heart lung machine, by using SVC-RA and IVC- RA shunts.

15. Lung resection: A procedure for removal of tumors and cysts in the lungs.

16. MV Repair: Mitral Valve Repair, where the mitral valve is surgically repaired.

17. MVR: Mitral Valve Replacement, where the Mitral valve is surgically replaced with a prosthetic (artificial) / bio-prosthetic (tissue) valve. This is done only when the valve is beyond salvage and cannot be repaired.

18. Myxoma excision: a surgical procedure where a myxoma – a connective tissue tumor usually found in the heart chambers, is excised (cut and removed). Commonly occurs in atria.

19. PAPVC repair: Partial Anomalous Pulmonary Venous Connection repair. One are more of pulmonary veins drain into RA. Surgical correction involves closure of the associated ASD, routing the pulmonary vein/s to LA.

20. PDA Ligation / Division: Patent Ductus Arteriosus Ligation /Division, a procedure in which the Patent Ductus Arteriosus, a connection between the pulmonary artery and the aorta is ligated (tied) or divided (cut).

21. Pericardiectomy: A surgical procedure for the condition of Pericarditis (infection of the pericardium) involves removal of the adhered pericardium.

22. RSOV repair: Ruptured Sinus Of Valsalva repair – a condition where one of the cusps of aorta in the sinus of Valsalva ruptures (tears / opens up) into one of the right sided chambers of the heart. Repair involves closure of the rupture.

23. SAM Excision: Sub Aortic Membrane excision, a surgical procedure on the aorta where a membrane below the aortic valve is obstructing the outflow of blood into the aorta.

24. Supra Valvular Aortic Stenosis: Surgical repair of severe narrowing supra valvular portion of the ascending aorta.

25. TAPVC repair: Total Anomalous Pulmonary Venous Connection repair – condition in which all the pulmonary veins drain into RA instead of LA. Surgical correction involves routing them to LA.

26. TGA: Transposition of great arteries is a serious congenital condition where the aorta arises from the right ventricle and the pulmonary artery from the left ventricle leading to parallel systemic and pulmonary circulation. Senning’s, Mustard are procedures at the atrial level, while Jatene’s is an arterial switch operation with coronary transfer. These procedures are named after their founders.

27. Thymectomy: A surgical treatment for the condition of Myasthenia Gravis which involves excision of the thymus gland. This is also done for tumors of the Thymus.

28. T.O.F Repair: A surgical procedure performed for the Tetralogy of Fallot (TOF) condition (Ventricular Septal Defect, Pulmonary Stenosis, Right Ventricular Hypertrophy, Overriding Aorta,), the VSD is closed and the Right Ventricular Outflow Tract (RVOT) is reconstructed / augmented.

29. VSD closure: Ventricular Septal Defect – Surgical closure of an abnormal opening in the septum/partition between the left and right ventricles. There are various types of VSD depending upon the position of the opening in the septum.

Neurology

Neurological conditions evaluated and treated routinely at SSSIHMS include the following:

1. Face head and neck pain

2. Epilepsy and related conditions

3. Cerebrovascular diseases

4. Infections of the CNS

5. Multiple Sclerosis (MS) and other demyelinating disorders

6. Dementia

7. Parkinson’s Disease and movement and ataxic disorders

8. ALS and Other Motor Neuron Diseases

9. Trigeminal Neuralgia, Bell’s Palsy, and Other Cranial Nerve Disorders

10. Spinal Cord Diseases

11. Peripheral Neuropathies including Guillain-Barre´ Syndrome

12. Neuromuscular diseases

13. Tumors of the Nervous System

14. Psychiatric disorders and Mental health problems

Face, Head and Neck pain: These patients are generally managed on OPD basis.

1. Atypical Facial Pain

2. Cervical Spondylosis

3. Migraine, other headaches and variants

4. Muscle Contraction Tension Headache

5. Chronic Back Pain

6. Post-herpetic Neuralgia

7. Trigeminal Neuralgia

Epilepsy and related conditions: These patients are investigated as required and treatment instituted. Some patients depending upon their condition are admitted as part of their management.

1. 1. Fits, black outs, jerks and faints

2. 2. non – epileptic attacks

3. 3. Sleep disorders

Cerebrovascular diseases : Acute cases are admitted and managed with anti-coagulants and physiotherapy. Chronic cases are evaluated as required.

1. Acute Stroke Management

2. Cerebral Venous Thrombosis

3. TIA Transient Ischemic Attack

Infections of the CNS.: These patients are managed following diagnosis of the infections based on Lumbar puncture and other investigations with admission and institution of appropriate anti-microbial therapy.

1. Meningitis-acute and chronic-bacterial/viral/protozoal/fungal

2. Encephalitis

3. Brain abscess

Multiple Sclerosis (MS) and other demyelinating disorders:

1. Optic Neuritis

2. Transverse Myelitis

3. Other demyelinating disorders

Dementia: These patients are investigated.

1. Alzheimer’s disease

2. Vascular dementia / Multi-infarct dementia

3. Reversible dementias

4. Prion (Creutzfeldt-Jakoband Gerstmann-Straussler-Scheinker disease)

Parkinson’s Disease and movement and ataxic disorders : These patients are seen on an OPD basis and treatment is instituted and optimized as required.

1. Dystonia

2. Tremors

3. Parkinson Disease and related disorders

4. Spinocerebellar ataxias

ALS and Other Motor Neuron Diseases : ENMG and conduction studies are used to reach a definitive diagnosis in these patients.

1. Amyotropic lateral sclerosis / MND

2. Spinal muscular atrophy

Trigeminal Neuralgia, Bell’s Palsy, and Other Cranial Nerve Disorders: Are investigated and treated appropriately.

Spinal Cord Diseases: When surgical intervention is required then the patients are reffered to the sister dept of neurosurgery.

1. Myelopathy

2. Spinal cord tumors

3. Cervical spondylosis

4. Prolapsed disc

5. Transverse myelitis

Peripheral Neuropathies including Guillain-Barre´ Syndrome: ENMG, NCV and Nerve biopsies are conducted for diagnosis.

1. Polyneuropathies eg.diasetic

2. Acuteneuropathies eg GB Syndrome

Neuromuscular diseases: These are investigated by ENMG and Muscle biopsy.

1. Dermatomyositis/Polymyositis

2. Inclusion Body Myositis

3. Limb-Girdle Muscular Dystrophy

4. Metabolic Myopathies

5. Periodic Paralyses

Tumors of the Nervous System: These once diagnosed are dealt by the Neurosurgery department. Psychiatric disorders and Mental health problems: Psychiatric problems when secondary to neurological disorders if diagnosed are treated in-house by a Consultant Psychiatrist.

Cranial Surgery Procedures

Excision of Cranial and Spinal Arterio-Venous Malformation (AVMs)

These are complex surgeries aimed at removing malformed conglomeration of blood vessels that parasitize the brain’s blood supply. The operation involves meticulous dissection around the tumour like growth of abnormal blood vessels and removal in toto. Similar AVMs in the spinal cord require greater expertise. However the procedure involved in similar to the one described above.

Clipping of aneurysms

Intracranial aneurysms are out -pouchings of blood vessels, similar to a balloon. These may burst causing life threatening sub-arachnoid haemmorage. We are equipped with the facilities to perform ‘clipping’ of these aneurysms in any location in the brain after performing a digital subtraction angiogram (DSA). Clipping means, that the aneurysm is removed from the circulation by application of a clip at its base.

Surgery for giant aneurysms under CPB

For certain aneurysms which are located in exquisite areas or are giant in size, clipping as described above may not be feasible. In such cases, the help of the Cardiac surgery team is sought to perform a Cardio Pulmonary Bypass and temporarily block the blood flow to the site of the aneurysm. This is done by cooling the patient to profound hypothermia conditions and initiating Total Circulatory Arrest. The window of opportunity is around 30 minutes within which the clipping has to be accomplished. This expertise is available in a only a handful of centers around the world.

Dural AV fistula (DAVF)

DAVFs are rare anomalies which may be managed with either open surgery or interventional procedures. At SSSIHMS a variety of operative strategies are employed in an attempt to disconnect the abnormal communication between an artery and a vein.

Excision of Cavernomas

Carvernomas are mulberry shaped overgrowth of intracranial small blood vessels, which may bleed. They may be located in almost any part of the brain or spinal cord. Great care has to be exercised in removal of these lesions which may be small and may be located in eloquent regions of the brain or at great depth. Sophisticated surgical aids like a neuro-navigation system are often employed to reach the lesion and remove it without damaging the surrounding brain tissue.

Trigeminal Neuralgia

This is a painful condition involving the face where the patient presents with unbearable, episodic, shooting pain in a particular portion of his/her face. The offending structure is usually a loop of an intracranial blood vessel which irritates the nerve conducting sensation from that portion of the face. Surgery is very gratifying and involves separating these two structures under the operating microscope.

Intracranial gliomas

These are brain tumours which may range from benign to malignant high grade tumors(Grade I to grade IV). Depending on its location, size and patient condition, the surgical strategy is planned for tackling each tumor.

Acoustic tumors( Vestibular schwannoma)

These are common tumors arising from the nerve responsible for conducting the sound from the ear. Unfortunately even in this day and age, the patients seen at SSSIHMS present at a late stage with some even losing vision and almost all tumors being extremely large in size.

Meningiomas

Meningiomas are benign tumors arising from the covering of the brain and spinal cord. Depending on its location, the surgical approach is planned.

Complex cranial base tumors

Cranial base surgery is a sub specialty in neurosurgery which is oriented towards the approach of lesions located at areas in the brain where routine surgical approach may not be successful.

Pituitary tumors

The pituitary gland which has been described as the master gland in the human body may be home to a variety of tumors some of which may present with mass effect (visual deterioration, neurological symptoms) and others with endocrinological symptoms. Trans-nasal, trans-sphenoidal approach is used commonly to operate these tumors. i.e the surgeon operates on the pituitary gland through the nose. Other larger tumors may require an intracranial approach.

Skull tumors

A variety of primary and secondary skull tumors are seen. Surgery involves removal of the tumor and reconstructing the bone defect.

Intracranial metastasis

The brain is a common site for the lodging of cancer deposits from primary malignancies elsewhere in the body. Sometimes the location of the primary may elude detection.

Intraventricular tumors

The ventricles of the brain are cavities filled with the cerebrospinal fluid. A whole range of tumors from, the most innocuous to the most malignant may be harbored within the ventricles. By virtue of its location, the approach has to be planned in great detail before embarking on surgery.

 Pediatric Neurosurgery:

1. Pediatric Tumors

• Posterior Fossa tumors:

  These are the commonest location for tumors in children. Medulloblastomas and ependymomas are the commonest pathologies noted.

• Optochiasmatic / hypothalamic tumors:

  These tumors arise from the optic pathway and hypothalamus. Therefore apart from vision, they may present with hypothalamic disturbance.

• Craniopharyngiomas:

  They are common childhood tumors located in the portion of the brain above the pituitary gland. Of uncertain etiology, they may prove to be a surgical challenge to remove in toto.

• Pineal tumors:

  The pineal gland is located in the geometrical centre of the cranial cavity. This innocuous structure has unknown and mysterious functions.

2.Neuro – Developmental disorders:

• Chiari malformation:

  The hind brain may protrude downwards causing symptoms. Treatment involves removing a portion of the skull, creating greater space and shrinking the cerebellar tonsils in an effort to alleviate symptoms.

• Encephalocoele:

  These are out-pouchings of portions of the covering of the brain in areas deficient of bone. Some may have significant amount of brain tissue contained within them.

• Hydrocephalus:

  This refers to a collection of excess fluid within the ventricular system. Treatment involves placing an alternative conduit for draining this fluid. This is achieved by inserting a shunt one end of which is within the ventricular cavity, and the other end is in the abdominal cavity. An alternative procedure is to endoscopically open the floor of the third ventricle to internally drain the fluid.

• Spinal Dysraphism repair:

  These are abnormalities in the development of the spine and spinal cord. Surgery involves appropriate planning to achieve the most optimal results.

• CVJ (Craniovertebral junction) anomalies:

  These are complex clinical conditions involving the transitional region between the brain and spinal cord. Surgery may involve, two procedures one, performed through the mouth and another in the back to place an implant.

 Spinal surgery procedures:

Degenerative Spinal Conditions

1. Lumbar Spondylosis

• Micro lumbar discectomy

• laminectomy

Lumbar disc disease is one of the most common conditions encountered in the clinic. If non operative measures fail, surgery is offered. Surgery is done with the help of an operating microscope or with the endoscope. The surgery involves removal of the disc material and decompressing the compressed nerve roots.

2. Lumbar Spondylolisthesis

• Pedicle screw fixation

• PLIF Posterior lumbar instrumentation and fusion

• ALIF Anterior lumbar instrumentation and fusion

Lumbar spondylolisthesis means, a slip of one vertebra over another. Correction involves, realignment with the help of titanium alloy screws and rods and bony fusion.

3. Cervical Spondylosis

• Anterior cervical discectomy

• Laminectomy

• Laminoplasty

• Corpectomy and instrumentation

• Lateral mass plate or screw fixation

4. Cervical Spondylolisthesis

• Anterior and posterior fusion

Similar to the lumbar disc disease the cervical or uppermost portion of the vertebral column may also degenerate. One or two levels of disc protrusion and cord compression are treated by removing the offending disc and fusing that level by interposing a bone chip in the space. For two or more level involvement, the disc spaces concerned and the intervening vertebral body is removed and a large bone graft placed and this is reinforced by placing a plate and screws (Corpectomy). A larger level of involvement requires either removal of the back portion of the vertebrae (laminectomy) which may be aided by placing screws through the lateral masses. Sometimes laminectomy may be inappropriate and here the back portion of the vertebrae may be opened out (laminoplasty)

5. Thoracic Disc Disease

• Laminectomy

• Discectomy

Similar to cervical and lumbar degenerative disc disease, the thoracic vertebrae may also degenerate though less frequently. However, the approach for these locations is more complex because of the lungs and heart located in front of them.

6. Spinal Tumors

• Intramedullary – (Glioma, Ependyomoma)

• IDEM (Intra-dural extramedullary Tumour)

Spinal tumors require gentler handling and precision. They may range from benign IDEM which originate from either the nerve roots or from the coverings to tumors arising from the neural tissue itself.

• Vertebral Bony Lesions

7. Spinal Infection

• Tuberculosis

Tuberculosis infection of the spine may require surgery because of the compression of the neural structures by the pus or destroyed bony elements. Surgery is followed by antituberculosis chaemotherapy for a course of one and a half years.

• Pyogenic spinal infections

Other procedures:

Stereotactic procedures:

• Biopsy

• Drainage of abscess / cyst

• Placement of reservoirs

Stereotaxy is a technique which uses the Cartesian coordinates to precisely localize any portion within the cranial cavity. This is helpful in performing surgeries for conditions located deep within the brain.

Intracranial Infections:

• Cardiogenic Intracranial Abscesses

• Otogenic Abscesses

Intracranial abscesses are decreasing in occurrence because of better medical facilities. However at SSSIHMS because of a large cardiac department, brain abscesses secondary to congenital heart disease is seen very often. Emergency surgery is done to remove the pus. Apart from heart conditions, infections anywhere in the body like ear, tooth etc, may spread to the brain.

Peripheral nerve surgery:

• Carpal Tunnel Syndrome

• Ulnar nerve release

Peripheral nerve surgery involves operating on the nerves which come out of the spinal cord. One of the commonest procedures it involves, decompressing the median nerve at the wrist by opening out, the carpal tunnel through which it passes.

Ophthalmology

Scope of Work:

ROUTINE REFRACTIVE ERRORS

Screening and examination of refractive errors is performed and suitable glasses are prescribed.

RETINA

• Medical retina : Screening , laser treatment , intravitreal injections for diabetic retinopathy/retinal vein occlusions/ age related macular degeneration

• Surgical retina :

• Retinal detachment surgery

• Diabetic vitrectomies

• Macular surgeries (ERM, Macular hole, VMT)

• Intraocular foreign body removal

GLAUCOMA

• Diagnosis, medical / surgical management of primary and secondary glaucomas.

• Facilities offered are:

• Humphrey visual field testing

• Laser peripheral iridotomy

• Trabeculectomy

• Combined cataract and trabeculectomy surgery

CATARACTS

• Senile cataract

• Traumatic cataract

• Complicated cataract

• Subluxated and dislocated lens

• Pediatric cataract

• Secondary intraocular lens implantation

ANTERIOR SEGMENT

• Diagnosis and management of:

• Infections and inflammatory conditions of conjunctiva and cornea

• Conjunctival / corneal trauma

NEURO-OPHTHALMOLOGY

• Complete Neuroimaging facilities like CT and MRI scanning are available. Retinal nerve fiber layer analysis and Ganglion cell layer analysis are done.

PAEDIATRIC OPHTHALMOLOGY AND STRABISMUS

• Congenital cataract surgery

• Strabismus evaluation and management(surgical and non-surgical)

OBSTETRICS AND GYNAECOLOGY

Services offered include normal deliveries, episiotomies, Caesarean section, assisted breech deliveries, assisted Twin deliveries, retained placenta, forceps deliveries, cervical cautery, dilatation & curettage, suturing cervical tear, examination under anaesthesia, ectopic pregnancies, tubectomy in certain cases, cervical cytology (pap smear), hysterectomies (both abdominal & Vaginal), Caesarean hysterectomy, laparotomies, removal of ovarian cysts etc.

The Orthopedic department does following surgeries on regular basis:

• Total joint replacements

• Arthroscopic surgeries of knee, shoulder, ankle, elbow, hip and wrist

• Spine

• Complex deformity corrections

• Trauma including pelvic and acetabular

• Neglected trauma

• Benign bone tumors and cysts

Pediatrics:

• OPD services for common pediatric problems.
• Post delivery care of the Neonates.
• Pediatric ward, equipped with 3 infant warmer, 4 LED phototherapy units, infusion and syringe pumps, Multipara monitor, nebulizers, CPAP machine, central oxygen and air lines.
• Developmental clinic: All children are screened and intervention given to needy.
• Retinopathy of Prematurity (ROP) screening: for all premature babies by retinal specialist.
• Counseling and education at group and individual level for nutrition and hygiene, breast feeding, and general care of babies.
• Routine Immunization of the children.

ENT

Consultation, diagnosis and treatment for the following:

1. Ear conditions

2. Nose conditions

3. Throat conditions

4. Neck swellings

5. Chronic dacryocystitis

6. Foreign body in Ear, Nose and Throat

Services not available:

1. Audiological tests

2. Hearing aid trials

3. Cochlear implants

4. Bronchoscopies

5. Oncosurgeries

6. Extensive skull base tumours

Dental Department

Services in Dental specialty including consultation, diagnosis and treatment for the following:

1. Root Canal treatment

2. Tooth extraction

3. fillings,

4. scaling,

5. orthodontic treatments

6. aesthetic fllings

7. Detailed Dental Clearance for surgery cases

General Medicine

Routine General Medicine OPD consultation and treatment is done

The General Surgery department

The following laparoscopic and open surgeries on regular basis:

Hernia,

Hydrocele,

Appendix,

Intestinal perforation,

Wound debridement