What Is Median Arcuate Ligament Syndrome?

The diaphragm is the large muscle under your lungs that moves with every breath. Near its lower edge, a fibrous arch called the median arcuate ligament passes in front of the aorta, close to the point where the celiac artery branches off. In most people the ligament lies above the artery and never touches it.

In some people the ligament crosses lower, or the artery branches higher, and the ligament presses on the top of the artery. The pressure tends to be greater when you breathe out, because the artery moves up toward the ligament as the diaphragm relaxes. The celiac artery narrows, and the bundle of nerves around it, the celiac plexus, is squeezed along with it. When this produces symptoms, the condition is called MALS. You may also see it called celiac artery compression syndrome or Dunbar syndrome.

Many people have the same anatomy and never have a problem, and it is sometimes noticed on a scan done for another reason. MALS is diagnosed only when the anatomy and the symptoms fit together and other causes have been looked for.

Symptoms of Median Arcuate Ligament Syndrome

• Pain in the upper belly after eating, often in the middle just below the ribs. It can start within minutes of a meal and last an hour or longer.
• Weight loss without trying, often because eating has become something to avoid.
• Fear of eating, or choosing small portions and bland food to keep the pain away.
• Nausea, vomiting and bloating.
• Pain with exercise in some people.
• A whooshing sound, called a bruit, that a clinician hears over the upper belly with a stethoscope. You will not notice it yourself.

Symptoms range from mild to disabling, and they often change from week to week. The pattern that stands out is pain that follows meals and weight that keeps falling.

When to Get Help Now

Call 911 or go to the emergency department for:

• Severe belly pain that comes on suddenly.
• Vomiting blood, or black, tarry or bloody stools.
• Vomiting along with being unable to pass gas or have a bowel movement.
• Chest pain, sudden shortness of breath or fainting.

Call rather than driving yourself; care begins when paramedics arrive.

Call your care team the same day for:

• Pain after meals that is getting worse or starting sooner after you eat.
• Weight that keeps dropping, or being unable to eat enough to keep your strength.
• Nausea or vomiting that keeps you from holding down fluids, or dizziness when you stand.

When you cannot tell which list you are in, call and describe what is happening; if nobody can be reached and it looks like the first list, go.

Causes of Median Arcuate Ligament Syndrome

MALS comes from how the body is built. Nothing you ate or did causes it. Two ideas explain the pain, and both may play a part:

• Reduced blood flow. The ligament narrows the celiac artery, and after a meal the digestive organs call for more blood than the narrowed artery can easily deliver.
• Irritated nerves. The celiac plexus lies right at the point of pressure, and squeezing it can send pain signals on its own, even when blood flow is fairly well preserved.

Researchers are still working out why the same anatomy causes symptoms in one person and none in another, and that is part of why careful testing matters.

Risk Factors for Median Arcuate Ligament Syndrome

MALS is most often found in adults in their 20s to 40s, more often in women, and often in people with a slim build. Having these traits does not mean you will develop it. It is not tied to a habit or a lifestyle, so there is nothing to blame yourself for.

Diagnosis of Median Arcuate Ligament Syndrome

Because the symptoms resemble many other digestive problems, the first step is usually to look for those. Your team will ask about your pain, meals and weight, and will examine your belly. Tests may include:

• Blood tests and an upper endoscopy to check for ulcers, inflammation and other causes.
• A gallbladder and stomach evaluation, such as an ultrasound or a gastric emptying study, when your symptoms point that way.
• Duplex ultrasound. A painless ultrasound that measures blood flow in the celiac artery while you breathe in and out. Flow that speeds up or slows with your breathing is a clue.
• CT angiography or MR angiography. Scans with contrast dye that show the artery and the ligament, and often the typical hooked or notched shape of the artery from the pressure.
• Further testing for some people, such as a nerve block at the celiac plexus, to see whether the pain responds.

Diagnosis rests on putting these findings together with your symptoms, and a specialist who sees MALS will review your scans with you.

Treatment Options for Median Arcuate Ligament Syndrome

Your plan depends on your symptoms, your scans and your overall health, and you make the choices with your care team.

Supportive Care

Smaller meals, nutrition support from a dietitian, anti-nausea medicine and pain management can help you eat and keep your strength while the diagnosis is confirmed. They ease symptoms and do not remove the pressure on the artery.

Procedures and Surgery

The treatment for MALS is surgery to release the ligament, which frees the celiac artery. Many surgeons use a laparoscopic or robotic approach, which means several small incisions and a quicker recovery than open surgery; see minimally invasive surgery for how these compare. During the operation, the surgeon also addresses the nerve tissue around the celiac artery, since it can add to the pain. Open surgery is an option when it is the safer route for you.

Some people still have a narrowed artery after the ligament is released. In that case, additional vascular treatment, such as a stent, may be considered, and your surgeon will bring in a vascular specialist if it is needed.

Many people feel better after surgery, though results vary, which is why your team reviews your tests and symptoms carefully before recommending it.

Living With Median Arcuate Ligament Syndrome

Until treatment, small, frequent meals often cause less pain than large ones. Keep a simple log of what you eat, when pain starts and your weight; it gives your team a clear picture and helps you see change. A dietitian can help you get enough protein and calories. After surgery, your team will guide you through the return to regular meals and activity, and many people regain weight in the months that follow.

Living with pain you cannot explain wears on a person. Ask for support, from family, your care team or a counselor, as part of your plan.

When to Talk to Your Care Team

Bring your food and weight log, your earlier test results and imaging, and a list of the medicines you have tried. Tell your team if pain changes, if your weight keeps falling, or if you have a new symptom. After treatment, tell them if the pain returns, since there are further options to review.

What Is a Hernia?

Your abdominal wall is made of layers of muscle and connective tissue that hold the organs inside. When one spot in that wall weakens or opens, tissue from inside, such as a loop of intestine or a piece of fat, can push through and form a bulge. Hernias are named for where they form:

• Inguinal hernia: in the groin. The most common kind.
• Femoral hernia: in the upper thigh, just below the groin.
• Umbilical hernia: at the navel.
• Epigastric hernia: in the upper middle belly, between the navel and the breastbone.
• Incisional hernia: along the scar of an earlier operation.
• Ventral hernia: a general term for a hernia in the front wall of the belly, including umbilical, epigastric and incisional hernias.
• Hiatal hernia: inside the body, where part of the stomach pushes up through the diaphragm. It can cause reflux and heartburn.

Some hernias are complex. Complex hernias have come back after earlier repairs, are very large, involve infected mesh from an earlier repair, form next to an ostomy (a parastomal hernia), or come with an abnormal connection between the intestine and the skin. They have a higher chance of complications and recurrence, and they often need a team experienced in rebuilding the abdominal wall.

Symptoms of Hernia

• A bulge in the groin, belly or along a scar that may appear when you stand, cough or strain and may flatten when you lie down.
• Aching, burning or pressure at the spot, often worse with lifting, bending or at the end of the day.
• A heavy or dragging feeling in the groin.
• Heartburn or reflux, with a hiatal hernia.
• Belly pain, constipation or nausea, with larger hernias.

Some hernias cause no symptoms at all. The size of the bulge does not always match how much it hurts.

When to Get Help Now

Call 911 or go to the emergency department for:

• A hernia that is hard, red, purple or dark, or that will not go back in.
• Severe or sudden belly pain.
• Vomiting along with being unable to pass gas or have a bowel movement.
• Chest pain or sudden shortness of breath.

These can be signs that tissue is trapped or has lost its blood supply, which needs surgery right away. Call rather than driving; care begins when paramedics arrive.

Call your care team the same day for:

• A bulge that is new or getting bigger but still goes back in when you lie down.
• Pain or aching that is increasing or keeping you from your usual activities.
• Redness, warmth or drainage at an incision after a repair.
• A fever over 101 degrees after surgery, or chills.

When you cannot tell which list you are in, call and describe what is happening; if nobody can be reached and it looks like the first list, go.

Causes of Hernia

A hernia occurs when pressure inside the belly meets a weak spot in the wall. Some spots are weak from birth. Others weaken over time or after surgery. Things that raise the pressure or wear down the tissue include:

• Aging, as muscle and connective tissue lose strength.
• Straining from chronic constipation, or from heavy lifting done again and again.
• Long-term coughing, such as with COPD or smoking.
• Added pressure from obesity or pregnancy.
• Earlier surgery, where the healed wall is not as strong as before, or a past repair that did not hold.

Risk Factors for Hernia

You are more likely to develop a hernia if you:

• Smoke.
• Have extra weight.
• Have a job or hobby that involves heavy lifting.
• Have had belly surgery before, or a hernia repair that failed.
• Have a family history of hernias.
• Have a chronic cough or ongoing constipation.

Having a risk factor does not mean you will have a hernia.

Prevention of Hernia

Not every hernia can be prevented, especially those that come from the way the body is built. A few steps lower the chances and help a repair last.

• Reach and keep a healthy weight.
• Stop smoking, which supports healing and eases the cough that strains the wall.
• Lift with your legs and ask for help with heavy loads.
• Treat constipation with fiber and fluids rather than straining.
• After surgery, follow your surgeon's activity limits so the incision can heal.

Diagnosis of Hernia

Most hernias are found with an exam. Your doctor looks at the area while you stand, and asks you to cough or bear down, which makes a bulge easier to see and feel. Tell your doctor when you first noticed it.

When the exam is not clear, or the hernia is deep, your doctor may order imaging:

• Ultrasound. A painless scan using sound waves, often used for groin and belly wall hernias.
• CT scan. An X-ray scan that shows the belly wall in detail, useful for large, recurrent or complex hernias and for planning repair.
• Upper GI series or endoscopy, for a suspected hiatal hernia.

Treatment Options for Hernia

There is no medicine that closes a hernia. The choice is between watching it and repairing it, and the decision belongs to you and your surgeon.

Monitoring and Support

For a small hernia with few or no symptoms, a surgeon may suggest watching it over time. Many hernias eventually grow or start to ache, so you will learn the warning signs and have regular checks. Treating a cough or constipation helps too.

Procedures and Surgery

Repair is the standard treatment for hernias that cause symptoms, and it is considered for others based on type and risk. The surgeon returns the tissue to its place and strengthens the wall, most often with a piece of surgical mesh for support. A repair can be done through one incision (open) or through several small incisions with a camera. Learn more about laparoscopic surgery, robotic surgery and minimally invasive surgery. Many repairs are outpatient. Complex hernias may require a longer operation and an overnight stay, and open surgery is sometimes the safer choice for a hard-to-reach hernia.

Your plan is your own, made with your surgeon, and it may include a visit with other specialists before surgery to lower risks such as smoking or high blood sugar.

Living With Hernia

If you are watching a hernia, learn how it normally looks and feels so that a change stands out. Avoid heavy lifting and straining where you can, and bring up any new pain. After a repair, light activity returns within days to weeks, and full recovery often takes several weeks; avoid heavy lifting and strenuous exercise until your surgeon clears you. Keep follow-up visits, since a repair is checked as it heals.

When to Talk to Your Care Team

Contact your team if a bulge grows, pain increases, or a repaired area looks different. Bring a list of your medicines, details of any past surgeries, and your questions: which approach is best for you and why, how pain is managed, the chance of recurrence, whether mesh is used and what the risks and benefits are, and when to call after surgery.

What Is Cholecystitis?

The gallbladder lies beneath the liver on the upper right side of the belly. Between meals it stores bile, and when you eat it squeezes bile into the small intestine to break down fat. When the tube that drains it, the cystic duct, is blocked, bile backs up and the gallbladder becomes inflamed. Infection can follow.

Cholecystitis comes in two forms:

• Acute cholecystitis starts suddenly, most often because a gallstone blocks the cystic duct. It needs prompt attention.
• Chronic cholecystitis develops when the gallbladder is inflamed again and again, often from gallstones. Over time the wall of the gallbladder can thicken and harden, and it stops working as well.

Gallstones and cholecystitis are related but not the same thing. Gallstones are hardened deposits, usually of cholesterol, that range from the size of a pebble to a golf ball. Cholecystitis is the inflammation that can result when a stone blocks the flow. Many people have gallstones for years and never have symptoms, and those stones usually need no treatment.

Symptoms of Cholecystitis

Acute cholecystitis causes:

• Pain in the upper right belly, or in the middle just below the ribs, that is constant and may last for hours. It can spread to the back or below the right shoulder blade, and it often follows a large or fatty meal.
• Nausea and vomiting.
• Fever and chills.
• A tender belly, especially on the upper right when you press or take a deep breath.
• Yellowing of the skin and eyes (jaundice), or pale, clay-colored stools, if a stone is blocking the bile duct.

Chronic cholecystitis is milder and may come and go, with bloating, gas, indigestion, heartburn, discomfort after fatty or greasy food, and tiredness. Symptoms that do not ease with over-the-counter pain relievers, a change of position or passing gas deserve a medical visit.

When to Get Help Now

Call 911 or go to the emergency department for:

• Severe belly pain that comes on suddenly.
• Fever with yellowing of your skin or eyes.
• Vomiting along with being unable to pass gas or have a bowel movement.
• Vomiting blood, or black, tarry or bloody stools.
• Chest pain or sudden shortness of breath.

Call rather than driving; care begins when paramedics arrive.

Call your care team the same day for:

• Constant pain in the upper right belly that lasts longer than 30 minutes.
• Pain after fatty meals that keeps coming back.
• Nausea or vomiting that is getting worse, or that keeps you from holding down fluids.
• Pale, clay-colored stools or dark urine, which can mean a blocked bile duct.

When you cannot tell which list you are in, call and describe what is happening; if nobody can be reached and it looks like the first list, go.

Causes of Cholecystitis

Most cholecystitis comes from gallstones. A stone lodges in the cystic duct, bile backs up behind it, and the gallbladder swells, causing pain, inflammation and sometimes infection. Stones form when substances in bile, especially cholesterol, clump and harden, or when the gallbladder does not empty often enough.

Less often, cholecystitis results from:

• Infection of the gallbladder.
• Injury to the gallbladder.
• Tumors or other problems with the cystic duct.
• Acalculous cholecystitis, a rare form that occurs without gallstones, usually in people who are very ill or who have conditions such as diabetes or HIV.

Risk Factors for Cholecystitis

The risk factors for cholecystitis are mostly the risk factors for gallstones:

• Age over 40.
• Being female.
• Excess weight, or losing weight very fast.
• A diet high in fat and cholesterol, and low in fiber.
• Diabetes, liver disease and some blood disorders.
• A family history of gallstones.
• American Indian or Mexican American ancestry.

Prevention of Cholecystitis

Because gallstones are the main cause, the steps that lower your chance of gallstones also help here. Eat plenty of fruits, vegetables and whole grains, limit high-fat and fried foods, keep a regular eating schedule, drink enough water, and stay active. If you need to lose weight, aim for gradual loss rather than a fast drop, since rapid weight loss can raise the risk of gallstones. These steps lower the risk without removing it.

Diagnosis of Cholecystitis

Your doctor will ask about your pain, what brings it on, and your health history, and will examine your belly. Tests that help confirm cholecystitis and rule out other causes:

• Abdominal ultrasound. A painless scan that shows gallstones and swelling of the gallbladder wall. It is often the first test.
• Blood tests. They check for signs of infection or inflammation, and for liver or pancreas involvement.
• CT scan. A detailed scan used when the picture is unclear or complications are suspected.
• HIDA scan. A scan that follows a tracer through the liver and gallbladder to see whether bile flows normally.

Treatment Options for Cholecystitis

The plan depends on whether the condition is acute or chronic, how severe it is and your overall health, and you decide together with your surgeon.

Medicines and Hospital Care

Acute cholecystitis is often treated in the hospital with fluids through a vein, pain medicine, and antibiotics if infection is suspected. Eating is paused to rest the gallbladder. Milder chronic cases may be managed with diet changes and watching for flare-ups.

Procedures and Surgery

Removing the gallbladder, called a cholecystectomy, is the standard treatment for acute cholecystitis, often during the same hospital stay, and for repeated attacks or complications. Most gallbladder removals are done through several small incisions with a camera. Read more about gallbladder removal, laparoscopic surgery and robotic surgery. When a person is too ill for surgery, a drain placed through the skin can relieve the swelling until they are stronger.

Treating cholecystitis prevents complications such as infection that spreads, a gallbladder that ruptures, or pancreatitis. Your plan is your own, and a second opinion is welcome.

Living With Cholecystitis

If you have gallstones that cause no trouble, you can keep your usual routine, and know the warning signs. Pay attention to which foods bring on pain and adjust. Lean proteins, vegetables, fruit and whole grains are easier on the gallbladder than fried and fatty food, and regular meals and water help. If your gallbladder is removed, most people return to a normal diet, and some notice looser stools for a while at first.

When to Talk to Your Care Team

Tell your team if attacks of pain come more often, if foods you used to tolerate now cause pain, or if you have fever or yellowing. Before a visit, note when each attack started, how long it lasted and what you had eaten. After surgery, ask what to expect for eating and activity and when to call.

What Is Robotic Surgery?

Robotic surgery, also called robotic-assisted surgery, is an operation done through small incisions with instruments attached to robotic arms. The surgeon works at a console in the operating room. A thin camera gives a high-definition, magnified 3D view of the area, and the instruments bend and rotate through a wider range than a human wrist. The system also filters out natural hand tremor and can scale large hand movements down to very small, precise ones. Every maneuver stays under the surgeon's direct control.

A surgical team stays at your side throughout. An assistant at the operating table changes instruments and helps with the view, and an anesthesia team looks after you from start to finish.

How It Compares With Laparoscopic Surgery

Both approaches are minimally invasive. In laparoscopic surgery the surgeon holds rigid instruments and watches a monitor, and the tools move opposite to the hand. In robotic surgery the surgeon uses a console with wristed instruments and a 3D view. Each approach has its uses, and your surgeon recommends the one that fits your operation. Learn more about laparoscopic surgery and the wider group of minimally invasive surgery.

Kinds of Robotic Surgery

Robotic general surgery covers many operations. Surgeons group them by the part of the body they treat:

• Hernia repair. Ventral, incisional, umbilical, inguinal, hiatal and diaphragmatic hernias. See hernia.
• Gallbladder and appendix. Gallbladder removal (cholecystectomy) and appendectomy. See gallbladder removal.
• Reflux and swallowing. Nissen fundoplication and Heller myotomy. See anti-reflux surgery and esophageal surgery.
• Colon, rectum and small bowel. Colon and rectal resection, rectal prolapse repair (rectopexy), small bowel resection and release of scar tissue (lysis of adhesions).
• Pancreas, stomach, spleen and adrenal glands. Distal pancreatectomy, the Whipple procedure, gastrectomy, splenectomy and adrenalectomy. See pancreatic surgery.
• Vascular compression. Release of the median arcuate ligament is sometimes done robotically. See median arcuate ligament syndrome.

Why Robotic Surgery Is Performed

Surgeons choose a robotic approach to reach the same goal as an open or laparoscopic operation, such as repairing a hernia or removing a diseased organ, through smaller incisions and with fine control. It is especially useful in tight or hard-to-reach spaces, such as deep in the pelvis or around the pancreas, and for delicate stitching.

Who Is a Candidate

Many adults who need one of the operations above can have it done robotically. Your surgeon looks at the operation you need, your general health, earlier abdominal surgeries, your body size and the findings on your scans. Some people need a laparoscopic or open operation instead, and surgeons sometimes switch approaches during surgery for safety. A conversation about your options is part of the consultation.

How to Prepare

• Pre-surgery testing. You may have blood tests, an electrocardiogram or imaging so the team knows your health and the area to be treated.
• Medicines. Bring a list of every medicine and supplement you take. Your surgeon will tell you which to stop and when, especially blood thinners.
• Food and drink. Most people are asked to stop eating and drinking several hours before surgery. Your team gives exact instructions.
• Smoking. Stopping before surgery supports healing and lowers the chance of breathing problems and infection.
• Support at home. Plan for a ride home and for help with meals, lifting and errands during the first days.
• What to bring. Photo ID, insurance cards, your medicine list and any imaging or records your surgeon asked for.

What to Expect

During the Procedure

You receive general anesthesia and sleep through the operation. The surgeon makes several small incisions, usually less than an inch, and places the camera and instruments. The belly is often filled with carbon dioxide gas to create working space. The length of the operation depends on the procedure.

After the Procedure

You wake in a recovery area where nurses monitor your breathing, pain and vital signs. Some people go home the same day. Others stay a night or longer, depending on the operation. The team encourages you to get up and walk soon after surgery, which helps prevent blood clots and supports your recovery. You may have shoulder or belly discomfort from the gas for a day or two.

Recovery

Recovery depends on the operation. Orlando Health surgeons describe these general ranges for robotic procedures compared with open surgery:

• Bowel resection: about 2 to 3 weeks, compared with 4 to 6 weeks for open surgery.
• Appendectomy: often a few days before light activity, compared with 2 to 3 weeks for open surgery; a full return to usual activities can take a few weeks.
• Splenectomy: a shorter hospital stay and faster recovery than open surgery.

Your surgeon will tell you when you can drive, lift and return to work. Heavy lifting and straining are usually limited until your surgeon approves them.

Call 911 for chest pain, sudden shortness of breath, severe belly pain that comes on suddenly, vomiting blood or black stools. Call your care team the same day for a fever over 101 degrees, redness, warmth or drainage at an incision, or pain that your medicine does not control.

Risks and Complications

Robotic surgery has the general risks of any operation under anesthesia.

• Bleeding or infection at an incision or inside the belly.
• A reaction to anesthesia or breathing problems after surgery.
• Blood clots in the legs or lungs.
• Injury to nearby organs or blood vessels, which is uncommon.
• A change to open or laparoscopic surgery during the operation, when the surgeon decides it is the safest way to finish.
• Risks that belong to the specific operation, such as a hernia returning. Your surgeon reviews these with you.

Results of Robotic Surgery

Compared with open surgery, robotic surgery often brings smaller incisions, less blood loss and less need for a transfusion, less pain, a shorter hospital stay, less scarring and an earlier return to usual activities. Surgeons also point to improved precision. The results for you depend on the operation, your health and the skill of your team, and your surgeon can explain what to expect for your condition.

What Is Minimally Invasive Surgery?

Minimally invasive surgery is a surgical approach that lowers the trauma of an operation, aims for the best possible result and helps you return to your normal life quickly. The surgeon reaches the operating area through small cuts rather than one long opening. Because less muscle and tissue is disturbed, the body usually has less to heal from.

For many operations, the surgeon puts a narrow tube called a port through each small incision. One port holds the camera. The others hold instruments. In the belly, the surgeon often fills the space with carbon dioxide gas so there is room to see and work. At the end of the operation the gas is released and the incisions are closed with stitches, skin glue or small strips.

Kinds of Minimally Invasive Surgery

• Laparoscopic surgery. The surgeon holds slender instruments and watches a camera image on a monitor. A laparoscope is a thin, lighted tube. It is used for operations such as gallbladder removal, hernia repair and appendectomy. See laparoscopic surgery.
• Robotic-assisted surgery. The surgeon controls robotic arms from a console with a magnified 3D view. Orlando Health uses the da Vinci surgical system. The robot cannot be programmed to operate without the surgeon's direct input. See robotic surgery.
• Hysteroscopy. A thin scope passes through the cervix to diagnose and treat problems inside the uterus without an incision.
• Endoscopic procedures. A flexible scope passes through the mouth or another natural opening to look at or treat the digestive tract.

Why Minimally Invasive Surgery Is Performed

Surgeons choose this approach when it can treat or diagnose your condition safely with less trauma than an open operation. Common uses include:

• Repairing a hernia.
• Removing a gallbladder for cholecystitis or gallstones. See gallbladder removal.
• Treating acid reflux with anti-reflux surgery.
• Removing an inflamed appendix.
• Taking a biopsy, or "staging" a cancer to find out how far it has spread so your team can choose the right treatment.
• Removing part of the bowel, a spleen, an adrenal gland or other organs.

Who Is a Candidate

Many adults can have minimally invasive surgery, and your surgeon decides after reviewing your diagnosis, medical history, previous surgeries, imaging and treatment goals. Some situations call for an open operation, such as a very large or complicated problem, heavy scarring from earlier surgery, or an emergency. Surgeons may also switch from a minimally invasive approach to an open one during an operation if that is the safest way to finish. Florida Medical Clinic Orlando Health surgeons recommend a traditional operation when it is truly the most promising option for the patient.

How to Prepare

• Pre-surgery testing. You may have blood tests, imaging or a heart tracing so your team can plan safely.
• Medicines. Share a full list of medicines and supplements. Your surgeon will tell you which to pause, especially blood thinners.
• Food and drink. You will be asked to stop eating and drinking for a set time before surgery. Your team gives the exact hours.
• Smoking and alcohol. Cutting back or stopping before surgery helps healing and lowers the chance of complications.
• A ride and help at home. Anesthesia makes driving unsafe, so arrange a ride home and help for the first days.
• What to bring. Photo ID, insurance cards, your medicine list and any imaging your surgeon requested.

What to Expect

During the Procedure

You are given anesthesia, most often general anesthesia, so you sleep through the operation. The surgeon makes the small incisions, places the ports, and guides the camera and instruments. The operation may take from under an hour to several hours depending on the procedure.

After the Procedure

You rest in a recovery area while nurses check your breathing, pain and vital signs. Many people go home the same day or after one or two nights, depending on the operation. You may feel soreness at the incisions, and a dull ache in the shoulder or belly from the gas for a day or two. You will be encouraged to get up and walk soon, which helps prevent blood clots.

Recovery

Recovery is usually quicker than after open surgery, and many people return to light activity within days. You may return to a normal diet earlier, and your surgeon will tell you when you can drive, lift and go back to work. Avoid heavy lifting and straining until your surgeon approves.

Call 911 for chest pain, sudden shortness of breath, severe belly pain that comes on suddenly, vomiting blood or black stools. Call your care team the same day for a fever over 101 degrees, redness, warmth or drainage at an incision, or pain that your medicine does not control.

Risks and Complications

Minimally invasive surgery has the risks of any operation under anesthesia. Most are uncommon.

• Bleeding or infection at an incision or inside the body.
• A reaction to anesthesia or breathing problems after surgery.
• Blood clots in the legs or lungs.
• Injury to a nearby organ, blood vessel or nerve while the instruments are placed.
• Gas-related discomfort, such as shoulder pain, which usually passes within days.
• A switch to open surgery during the operation when the surgeon judges it safer.

Results of Minimally Invasive Surgery

Compared with open surgery, minimally invasive operations are often linked with the following benefits. The benefit you gain depends on your operation and your health.

• Less blood loss and a lower need for blood transfusion.
• A shorter hospital stay.
• Less pain and less need for pain medicine after surgery.
• An earlier return to a regular diet.
• Less scarring.
• A quicker recovery and return to normal activities.
• A lower chance of infection and other complications.

Your surgeon can explain what outcome to expect for your own condition.

What Is Laparoscopic Surgery?

Laparoscopic surgery, sometimes called keyhole surgery or minimally invasive surgery, lets a surgeon examine and operate on the organs of the abdomen or pelvis through small cuts. The surgeon makes a small incision, often near the navel, and places a tube called a port. Carbon dioxide gas expands the belly so there is space to see and work. The laparoscope goes through the first port, and two to four more small ports hold the instruments.

In traditional laparoscopy, the surgeon holds rigid instruments, views the area on a monitor, and moves the tools opposite to the hand. Robotic-assisted surgery is a related approach in which the surgeon controls instruments from a console. Learn more about robotic surgery and the wider group of minimally invasive surgery.

Kinds of Laparoscopic Surgery

Laparoscopy has two broad uses.

• Diagnostic laparoscopy. The surgeon looks at the abdominal or pelvic organs to find the cause of pain or to examine a growth. Tissue samples can be taken through the scope for biopsy. It can help diagnose cysts, adhesions, fibroids and infections.
• Operative laparoscopy. The surgeon repairs or removes tissue. Examples in general surgery include:

- Gallbladder removal (cholecystectomy). See gallbladder removal. - Hernia repair, including inguinal, umbilical, ventral and hiatal hernias. See hernia. - Anti-reflux surgery. See anti-reflux surgery. - Appendectomy. - Release of the median arcuate ligament. See median arcuate ligament syndrome. - Removal of part of the bowel, spleen or other organs, and some tumor removal.

Why Laparoscopic Surgery Is Performed

Surgeons choose laparoscopy because it can reach the same goal as open surgery with less disturbance to the body. A smaller cut means less pain from the incision and less scarring, and the body usually has less to repair afterward. Laparoscopy also helps surgeons diagnose a problem when imaging has not given a clear answer.

Who Is a Candidate

Many adults who need one of the operations above are candidates. Your surgeon considers the condition being treated, your health, earlier abdominal surgeries that may have left scar tissue, your body size and any urgent signs. Not every person is an ideal candidate. Surgeons recommend a conventional open operation when it is truly the most promising option, and they may change from laparoscopy to open surgery during the procedure if that is the safest way to proceed.

How to Prepare

• Pre-surgery testing. You may have blood tests, imaging or a heart tracing.
• Medicines. Bring a list of every medicine and supplement. Your surgeon will tell you which to stop and when, especially blood thinners and diabetes medicines.
• Food and drink. You will be asked not to eat or drink for a set number of hours before surgery. Your team gives you the exact time.
• Bowel preparation. Some operations on the bowel call for a special diet or a cleansing routine. Your team tells you if yours does.
• Smoking. Stopping before surgery helps healing.
• A ride and help at home. Arrange for someone to drive you home and stay with you for the first day or two.
• What to bring. Photo ID, insurance cards, your medicine list and any imaging your surgeon requested.

What to Expect

During the Procedure

You receive general anesthesia and sleep through the operation. The surgeon makes the incisions, usually half an inch or less each, fills the belly with gas, inserts the laparoscope and performs the repair or removal. At the end the instruments are removed, the gas is released and the incisions are closed. Operating time depends on the procedure.

After the Procedure

You wake in a recovery area where nurses monitor your breathing, pain and vital signs. Many people go home the same day or after one night, and some operations call for a longer stay. It is common to feel bloated, to have soreness at the incisions and to have a dull ache in the shoulder from the gas, which usually fades in a day or two.

Recovery

Most people recover faster after laparoscopy than after an open operation. Walk a little each day, which supports healing and helps prevent blood clots. You can usually eat normally again within a day or two, though your surgeon may suggest lighter meals at first. Your surgeon will tell you when you can drive, lift and return to work, and will ask you to avoid heavy lifting for a period. Keep the incisions clean and dry as instructed.

Call 911 for chest pain, sudden shortness of breath, severe belly pain that comes on suddenly, vomiting blood, black stools, or a fever with yellowing of your skin or eyes. Call your care team the same day for a fever over 101 degrees, redness, warmth or drainage at an incision, or pain that your medicine does not control.

Risks and Complications

Laparoscopic surgery has the general risks of surgery under anesthesia. Serious problems are uncommon.

• Bleeding or infection at an incision or inside the belly.
• A reaction to anesthesia or breathing problems after surgery.
• Blood clots in the legs that can travel to the lungs.
• Injury to a nearby organ, blood vessel or nerve while instruments are placed, which may need repair.
• Shoulder or belly discomfort from the gas, which passes within days.
• A hernia at an incision site, which is uncommon.
• A switch to open surgery in a small number of operations when it is the safest way to finish.
• Risks tied to the specific operation, which your surgeon reviews with you.

Results of Laparoscopic Surgery

Compared with traditional open surgery, laparoscopic operations are associated with the following benefits.

• Smaller incisions and less scarring.
• Lower risk of infection.
• Less blood loss.
• A shorter hospital stay.
• Less pain, and a faster return to daily activities.

The results for you depend on the operation you need and your own health. Your surgeon can describe what recovery is likely to look like for your condition.

What Is Gallbladder Removal?

Gallbladder removal, called a cholecystectomy, is an operation that takes out the entire gallbladder, a small pouch under the liver. The surgeon closes off the duct and the blood vessel that serve it, then lifts the gallbladder out. A person does not need a gallbladder to digest food, because bile still reaches the intestine from the liver by other routes.

The operation is done under general anesthesia, so you are asleep and feel nothing. Most gallbladder removals take about an hour or two, though the time varies.

Kinds of Gallbladder Removal

• Laparoscopic gallbladder removal. The surgeon makes several small incisions in the belly and places a thin tube with a camera and slim instruments through them. This is the most common approach. See laparoscopic surgery.
• Robotic gallbladder removal. The surgeon operates from a console using a robotic system that gives a magnified 3D view and precise instrument control, through the same kind of small incisions. See robotic surgery.
• Open gallbladder removal. The surgeon makes one larger incision under the ribs on the right. It is used when minimally invasive surgery cannot be done safely, for example because of scarring from earlier operations or inflammation, or when the surgeon decides during the operation to switch.

You can read more about the minimally invasive approaches at minimally invasive surgery.

Why Gallbladder Removal Is Performed

Surgery is recommended for gallbladder problems that keep coming back or cause complications, including:

• Gallstones that cause symptoms, such as repeated attacks of pain in the upper right belly.
• Stones in the bile duct, which can block the flow of bile.
• Cholecystitis, inflammation of the gallbladder, especially after repeated attacks. See cholecystitis.
• Pancreatitis caused by gallstones.
• Gallbladder cancer, where surgery is usually the main treatment.

For mild or occasional symptoms, your doctor may first suggest diet changes and medicine for pain while you decide about surgery. Gallstones often return and cause worse symptoms over time, so removal may be the most effective long-term answer.

Who Is a Candidate

You may be a candidate if gallstones or gallbladder inflammation cause symptoms that affect your life, if you have had a serious attack, or if testing shows a complication. Gallstones found by chance that cause no symptoms generally do not need removal. Your surgeon will review your symptoms, scans and overall health, and the decision is yours to make together.

How to Prepare

• Medicines. Give your team a full list, including blood thinners and supplements. Ask which to take or pause before surgery.
• Food and drink. You will be asked not to eat or drink for a set number of hours before the operation, and your team will tell you exactly how long.
• Smoking and alcohol. Stopping smoking before surgery supports healing.
• A ride home and help at home. Anesthesia makes driving unsafe for the rest of the day, so arrange for someone to take you home and stay with you the first evening.
• What to bring. Photo ID, insurance cards and your medicine list.

Your surgical team will give you written instructions that fit your situation, and you can call with any question before the day.

What to Expect

During the Procedure

You meet your surgical team, an IV is placed, and anesthesia puts you to sleep. In a laparoscopic or robotic operation, the surgeon fills the belly with gas so there is room to see, makes small incisions, frees the gallbladder and removes it through one of them. In some cases the surgeon takes X-ray pictures of the bile ducts during the operation to look for stones. The incisions are closed with stitches or glue.

After the Procedure

You wake in a recovery area where nurses watch your breathing, pain and nausea. Most people having a laparoscopic or robotic removal go home the same day, and some stay overnight. An open removal usually means a longer stay of a few days.

Recovery

Soreness at the incisions and shoulder pain from the gas used during surgery are common for a day or two. Most people are walking the same day and return to desk work and light activity within about a week. Avoid heavy lifting until your surgeon says it is safe, and expect a full return to usual activities in a few weeks, and up to six weeks after an open operation. Start with light, low-fat meals and add other foods as you feel able. Some people have looser stools for a few weeks, and it usually resolves.

Call 911 for chest pain, sudden shortness of breath, severe belly pain, vomiting blood or black stools, bleeding that will not stop, or fainting. Call your care team the same day for a fever over 101 degrees, redness, swelling or drainage at an incision, pain that is getting worse, nausea or vomiting that keeps you from drinking, or dark urine and pale stools.

Risks and Complications

Gallbladder removal is a common operation with a low rate of problems. The risks include:

• Bleeding and infection at the incisions or inside the belly.
• Bile leak, where bile escapes from the duct stump or a small duct, which may need a drain or a second procedure.
• Injury to the bile duct, which is uncommon, and sometimes needs repair.
• Injury to nearby organs, such as the intestine or a blood vessel.
• A stone left in the bile duct.
• Blood clots in the legs, and reactions to anesthesia.
• Switching to open surgery if the surgeon cannot finish safely through small incisions. This is not a failure and keeps you safe.

Your surgeon will talk through the risks as they apply to you.

Results of Gallbladder Removal

For most people, removal ends the attacks of pain and the risk of the complications that gallstones cause. Digestion changes little, and most people eat a regular diet. A small number have lasting digestive symptoms such as bloating or loose stools, which can be managed with diet and treatment. Your surgeon will go over what to expect for the problem that led to your operation and arrange follow-up.

What Is Anti-Reflux Surgery?

Anti-reflux surgery is an operation that treats GERD by strengthening the barrier between the esophagus and the stomach. In GERD, the lower esophageal sphincter relaxes at the wrong times or has been weakened, often by a hiatal hernia, in which part of the stomach slides up through the opening in the diaphragm. Acid then flows back into the esophagus and causes heartburn, regurgitation, chest discomfort, cough or trouble swallowing.

The operation restores that barrier. When a hiatal hernia is present, the surgeon also pulls the stomach back into the belly and closes the opening in the diaphragm.

Kinds of Anti-Reflux Surgery

• Fundoplication. The surgeon wraps the top of the stomach around the lower esophagus. A full wrap, called a Nissen fundoplication, circles the esophagus completely. A partial wrap, such as a Toupet fundoplication, covers part of it. The choice depends on how well your esophagus moves food and on your symptoms.
• Hiatal hernia repair. Often done in the same operation, to close the diaphragm opening and secure the stomach. See hernia.
• Magnetic sphincter augmentation. A ring of small magnetic beads is placed around the lower esophagus. It opens when you swallow and closes to block reflux. National guidelines list it as an option for suitable patients.

Surgeons can perform these operations through laparoscopic surgery or robotic surgery, which are forms of minimally invasive surgery. Some people need open surgery, and your surgeon explains why if that applies to you.

Why Anti-Reflux Surgery Is Performed

Surgery can bring lasting improvement for many people whose reflux does not improve enough with other treatment. It can also reduce or end the need for daily acid medicine. Reflux that is left untreated can inflame the esophagus, and in some people it leads to narrowing or changes in the lining, so the goal is to protect your esophagus and your quality of life.

Who Is a Candidate

Your surgeon may discuss anti-reflux surgery if you:

• Used to control your symptoms with medicine and lifestyle changes and no longer reach good control.
• Have significant side effects from acid-suppressing medicines.
• Prefer to avoid a lifelong reliance on reflux medicine, understanding that some people still need medicine for occasional heartburn after surgery.
• Have a large hiatal hernia that causes symptoms such as regurgitation, chest pain or trouble swallowing.

Surgery is generally offered once testing confirms that reflux is the cause of your symptoms. People with other conditions, such as a swallowing disorder, may need a different operation. See esophageal surgery.

How to Prepare

• Tests first. Expect an upper endoscopy to look at the esophagus. You may also have a swallowing X-ray, esophageal manometry to measure how the esophagus squeezes, and a pH study to measure how much acid reaches it. These show that reflux is the problem and guide the choice of operation.
• Medicines. Share a list of every medicine and supplement. Your surgeon will tell you which to stop, especially blood thinners.
• Food and drink. You will be asked not to eat or drink for several hours before surgery. Some surgeons ask for a short liquid diet beforehand. Your team gives the exact plan.
• Smoking. Stopping before surgery supports healing.
• A ride and help at home. Arrange for someone to drive you home and help with meals for the first days.
• What to bring. Photo ID, insurance cards, your medicine list and your test results.

What to Expect

During the Procedure

You receive general anesthesia and sleep through the operation. For a laparoscopic or robotic operation, the surgeon makes several small incisions in the upper belly, wraps the stomach around the esophagus, and repairs any hiatal hernia. The operation usually takes a few hours.

After the Procedure

You wake in a recovery area. Many people stay in the hospital for one or two nights. You may have a sore throat from the breathing tube and soreness at the incisions.

Recovery

Plan on about 2 to 3 weeks of recovery after a laparoscopic operation and 4 to 6 weeks after open surgery. For the first weeks the new wrap and the swelling around it can make swallowing feel tight, so your surgeon will guide you through a staged diet that moves from liquids to soft foods and then to normal meals. Eat small portions, chew well and avoid carbonated drinks and large bites. Avoid heavy lifting until your surgeon approves it.

Call 911 for chest pain, sudden shortness of breath, severe belly pain that comes on suddenly, vomiting blood or black stools. Call your care team the same day for a fever over 101 degrees, redness, warmth or drainage at an incision, or food that will not go down.

Risks and Complications

Anti-reflux surgery has the general risks of surgery under anesthesia, such as bleeding, infection and blood clots. Risks that belong to this operation include:

• Trouble swallowing, which is common in the first weeks and usually improves. A small number of people have longer-lasting trouble and may need a procedure to stretch the area.
• Gas bloat. The wrap can make it hard to burp or vomit, so gas may build up and cause bloating.
• Reflux that returns, if the wrap loosens or slips over time.
• Return of a hiatal hernia.
• Injury to nearby organs, such as the esophagus, stomach or spleen, which is uncommon.
• Diarrhea or early fullness for a period after surgery.

Your surgeon explains how these risks apply to you and how they compare with continuing medicine.

Results of Anti-Reflux Surgery

For most people who are carefully chosen for surgery, fundoplication brings long-term improvement in heartburn and regurgitation and lets them reduce or stop their reflux medicine. Some people still take medicine for occasional heartburn. Results depend on the cause of your reflux, the type of operation and your overall health. Your surgeon can describe what is realistic for you.

What Is Esophageal Surgery?

Esophageal surgery is any operation on the esophagus, or on the places where it meets the throat and the stomach. The goal depends on the problem. A surgeon may remove a tumor, cut a tight muscle that blocks food, repair part of the stomach that has slid up into the chest, or rebuild the valve that keeps acid from flowing back up.

Surgeons can reach the esophagus through the chest, through the belly, through both, or through the mouth with an endoscope, a thin flexible tube with a camera. Which route is used depends on the condition and on your health. Orlando Health surgeons use minimally invasive and robotic methods for some of these operations.

Kinds of Esophageal Surgery

• Esophagectomy. The surgeon removes part or all of the esophagus, most often to treat esophageal cancer or precancerous changes that cannot be treated another way. The stomach, or sometimes a piece of intestine, is shaped into a new passage so food can still travel to your stomach. It can be done as an open operation or with minimally invasive and robot-assisted tools.
• Heller myotomy. For achalasia, a condition in which the muscle at the bottom of the esophagus will not relax, the surgeon cuts that muscle so food can pass. A partial wrap of the stomach is often added to guard against reflux. Orlando Health surgeons perform this operation robotically.
• Paraesophageal hernia repair. When part of the stomach pushes up through the diaphragm beside the esophagus, the surgeon pulls it back down and secures it. See hernia for the other kinds of hernia.
• Anti-reflux surgery. A fundoplication wraps the top of the stomach around the lower esophagus to strengthen the valve. It is described on its own page, anti-reflux surgery.
• Endoscopic resection. For early precancerous changes such as high-grade dysplasia, a surgeon or gastroenterologist removes the affected lining through the mouth, with no incision.

Radiofrequency ablation is a non-operative option that uses heat to treat certain changes in the esophageal lining, such as Barrett's esophagus, without surgery.

Why Esophageal Surgery Is Performed

Surgery is recommended when the esophagus is blocked, damaged, out of position or diseased in a way that medicine cannot fix. The most common reasons are esophageal cancer, achalasia, a paraesophageal hernia, gastroesophageal reflux disease (GERD) that has not improved with medicine, and precancerous changes in the lining.

Warning signs that lead people to a surgeon include trouble swallowing, food that feels stuck, regurgitating food, chest pain with eating, weight loss without trying and heartburn that keeps coming back.

Who Is a Candidate

You may be a candidate when your symptoms or tests point to a problem surgery can treat and you are healthy enough for the operation. Your care team looks at the diagnosis, how far it has progressed, your heart and lung health, your nutrition and what other treatments you have already tried. For some conditions, a team of surgeons, gastroenterologists and oncologists reviews your case together. Surgery is one option among several, and your surgeon will go over all of them with you.

How to Prepare

• Tests. Expect an upper endoscopy, and often a barium swallow, a pressure study of the esophagus (manometry) or a pH test for reflux. For a suspected cancer, CT or PET scans show whether it has spread. Your surgeon explains which tests you need and why.
• Nutrition. If swallowing has been hard, you may have lost weight. A dietitian can help you build strength before surgery, sometimes with supplement drinks.
• Smoking and alcohol. Quitting smoking before surgery lowers the chance of breathing problems and helps healing. Ask your care team for support in stopping.
• Medicines. Bring a list of everything you take. Blood thinners and diabetes medicines often need adjustments. Do not stop any medicine on your own.
• The day before. You will be told when to stop eating and drinking. Arrange a ride home for a smaller procedure, or plan for a hospital stay if you are having a larger one, and ask someone to help you at home afterward.

What to Expect

During the Procedure

You receive general anesthesia, so you are asleep and feel nothing. Depending on the operation, the surgeon works through small incisions with a camera and thin instruments, through a robotic system that the surgeon controls from a console, or through a larger open incision. Endoscopic procedures use no incision at all. Operations take from about an hour for some endoscopic and hiatal procedures to several hours for an esophagectomy.

After the Procedure

You wake in a recovery area, then move to a hospital room. For minimally invasive repairs, the stay is often a few days. After an esophagectomy it is usually longer, and the first days may be in an intensive care or step-down unit. You may have a drain, a feeding tube or a tube in your nose for a short time, and your team will ask you to walk early and to practice deep breathing to protect your lungs.

Eating returns in stages. Most people begin with sips or liquids, move to soft foods and then to a regular diet over weeks. Some operations include a swallow test with contrast dye before you eat.

Recovery

Plan on several weeks of recovery after a minimally invasive repair and a few months after an esophagectomy. Small, slow meals, chewing well and staying upright for a while after eating help. You will avoid heavy lifting for a period your surgeon sets. Follow-up visits check healing, weight and swallowing.

Call 911 for chest pain, trouble breathing, vomiting blood or black stools. Call your surgeon the same day for fever, redness or drainage at an incision, vomiting that will not stop or food that will not go down.

Risks and Complications

Every operation has risks, and the risks here depend on which one you have. The main ones are listed below.

• Bleeding or infection at the surgical site or inside the chest or belly.
• A leak where the esophagus was joined to the stomach or intestine, which can need further treatment.
• Pneumonia or other lung problems, more likely after chest operations.
• Narrowing of the new connection, which may need a stretching procedure.
• Swallowing changes, including food that moves slowly, and reflux after some operations.
• Heart rhythm problems, such as atrial fibrillation, in the days after a chest operation, and reactions to anesthesia.

Your surgeon will talk through the chances of each for your situation before you decide.

Results of Esophageal Surgery

Results depend on the condition. For achalasia, most people swallow more easily after a myotomy. For reflux and hiatal hernias, surgery can reduce symptoms and the need for daily medicine, though some people still use medicine occasionally. For esophageal cancer and precancerous changes, surgery is often part of a plan that may include chemotherapy, radiation or endoscopic treatment, and the outlook depends on the stage when it is found. Ask your surgeon what you can expect for your own diagnosis.

What Is Pancreatic Surgery?