Prostate Cancer Surgical Treatment | Prostate Gland | Endourology Speciality Treatment | Aastha Healthcare | Super Speciality Center Hospital | India

What is prostate gland?

The prostate is a glandular organ, about size of a walnut, present in males. The prostate is normally about 3 cm long and it lies at the neck of the bladder and in front of the rectum. The prostate gland produces fluid that makes up part of the semen.

What is prostate cancer?

Prostate cancer is found mainly in older men. As men age, the prostate may get bigger and block the urethra or bladder. This may cause difficulty in urination or can interfere with sexual function. The condition is called benign prostatic hyperplasia (BPH), and although it is not cancer, surgery may be needed to correct it. The symptoms of benign prostatic hyperplasia or of other problems in the prostate may be similar to symptoms of prostate cancer. Prostate cancer is often a very slow-growing disease. It can take 10 years or more for a small tumor to spread beyond the gland and pose a serious threat to health.

Cancer occurs when normal cells undergo a transformation in which they grow and multiply without any control. There are four stages of prostate cancer: Stage I - In stage I, cancer is found in the prostate only. It is usually found accidentally during surgery for other reasons, such as benign prostatic hyperplasia. Stage II- In stage II, cancer is more advanced than in stage I, but has not spread outside the prostate. Stage III- In stage III, cancer has spread beyond the outer layer of the prostate to nearby tissues. Cancer may be found in the seminal vesicles. Stage IV- In stage IV, cancer has metastasized (spread) to lymph nodes near or far from the prostate or to other parts of the body, such as the bladder, rectum, bones, liver, or lungs. Metastatic prostate cancer often spreads to the bones.

Stages Of Prostate Cancer

What are the causes?

The cause of prostate cancer is unknown, but hormonal, genetic, environmental, and dietary factors are thought to play roles. The following risk factors have been linked with development of this condition:

Age: There is a strong correlation between increasing age and developing prostate cancer. Autopsy records indicate that 70% of men older than 90 years have at least one region of cancer in their prostate. Race: African American men are 1.5-2 times more likely than white men to develop prostate cancer. Genetic factors: Men, who have a history of prostate cancer in their family, are at an increased risk. Diet: A diet high in fat has been associated with an increased risk of prostate cancer. Chemical agents: Exposure to chemicals such as cadmium has been implicated in the development of prostate cancer.

What are the symptoms?

Prostate cancer can produce many symptoms. Some of them have been listed below. But presence of these symptoms does not necessarily indicate prostate cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur. Some of the symptoms are:

Weak or interrupted flow of urine. Frequent urination (especially at night). Trouble urinating. Pain or burning during urination. Blood in the urine or semen. A pain in the back, hips, or pelvis that doesn't go away. Painful ejaculation.

How is it diagnosed?

The doctor may perform necessary test to detect and diagnose prostate cancer. The following procedures may be used:

Digital rectal exam (DRE): The doctor inserts a lubricated, gloved finger into the rectum and feels the prostate through the rectal wall for lumps or abnormal areas.

Digital rectal exam (DRE)

Prostate-specific antigen (PSA) test: A test that measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in an increased amount in the blood of men who have prostate cancer. PSA levels may also be high in men who have an infection or inflammation of the prostate or BPH (an enlarged, but noncancerous, prostate). Transrectal ultrasound: A procedure in which a probe that is about the size of a finger is inserted into the rectum to check the prostate. The probe is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs and make echoes. The echoes form a picture of body tissues called a sonogram. Transrectal ultrasound may be used during a biopsy procedure.

Transrectal ultrasound showing a series of prostate ultrasound images used to construct a 3-dimesnsional image of the prostate (volume study) and treatment plan. Key: Red line = prostate; Blue line = limit of radiation to be delivered

Biopsy: The removal of cells or tissues so they can be viewed under a microscope by a pathologist. The pathologist will examine the biopsy sample to check for cancer cells and determine the Gleason score. The Gleason score ranges from 2-10 and describes how likely it is that a tumor will spread. The lower the number, the less likely the tumor is to spread. There are 2 types of biopsy procedures used to diagnose prostate cancer: Transrectal biopsy: The removal of tissue from the prostate by inserting a thin needle through the rectum and into the prostate. This procedure is usually done using transrectal ultrasound to help guide the needle. A pathologist views the tissue under a microscope to look for cancer cells. Transperineal biopsy: The removal of tissue from the prostate by inserting a thin needle through the skin between the scrotum and rectum and into the prostate. A pathologist views the tissue under a microscope to look for cancer cells.

If prostate cancer is diagnosed, the other tests( e.g Radionuclide bone scan, MRI. Pelvic lymphadenectomy, Seminal vesicle biopsy) are done to find out if cancer cells have spread within the prostate or to other parts of the body.

What are the treatment options?

Treatments for prostate cancer are effective in most men. But one should remember that they do cause both short- and long-term side effects that may be difficult to accept. So you and your life partner or family members must discuss the treatment options in detail with their urologist and other physicians. It is essential to understand which treatments are available, how effective each is likely to be, and what side effects can be expected. All these must be weighed carefully before making a decision about which course to pursue.

Surgery

There are different types of treatment for patients with prostate cancer. Patients in good health are usually offered surgery as treatment for prostate cancer. The following types of surgery are used:

Pelvic lymphadenectomy: A surgical procedure to remove the lymph nodes in the pelvis. A pathologist views the tissue under a microscope to look for cancer cells. If the lymph nodes contain cancer, the doctor will not remove the prostate and may recommend other treatment. Radical prostatectomy: This approach makes especially good sense for relatively healthy patients under age 65. For one thing, such men generally have the strength to handle a major operation. A surgical procedure to remove the prostate, surrounding tissue, and seminal vesicles. There are 2 types of radical prostatectomy: Retropubic prostatectomy: A surgical procedure to remove the prostate through an incision (cut) in the abdominal wall. Removal of nearby lymph nodes may be done at the same time. Perineal prostatectomy: A surgical procedure to remove the prostate through an incision (cut) made in the perineum (area between the scrotum and anus). Nearby lymph nodes may also be removed through a separate incision in the abdomen.

The two types of radical prostatectomy

Transurethral resection of the prostate (TURP): The standard surgical treatment for an enlarged prostate is Transurethral Resection of the Prostate or "TURP". This is sometimes called a scraping or "Roto-Rooter" of the prostate. It is the "gold standard" against which all other prostate remedies are compared. Under a full general or spinal anaesthetic, a resectoscope (a thin, lighted tube with a cutting tool) is inserted through the urethra. Under direct vision, an electric current passes through the loop, this can then carve out the channel inside the prostate. The chips or pieces of prostate tissue are rinsed out of the bladder with water. After surgery, a soft rubber tube or catheter is left in the bladder for several days to help control bleeding and allow healing to begin. This procedure is sometimes done to relieve symptoms caused by a tumour before other cancer treatment is given. Transurethral resection of the prostate may also be done in men who cannot have a radical prostatectomy because of age or illness.

Transurethral resection of the prostate (TURP).

Bilateral Orchidectomy- Orchidectomy is a surgical procedure in which one or both testicles are removed. Testicles are sex organs in the males that produce sperms and testosterone (a hormone). It is performed under general anaesthesia. Testicles are removed through an incision in the scrotum or the groin. Some of the lymph nodes that are located deep in the abdomen or inguinal area may also be removed. Prostate cancer is known to regress after Orchidectomy, as the source of testosterone is removed.

Radiation therapy

Instead of removing the entire gland, healthy tissue and all, doctors can use radiation to target and kill the cancer cells. There are two ways to deliver the radiation. In a process called external beam radiation, a machine produces a highly focused beam of energy aimed directly at the tumour. It usually takes about five sessions a week over seven weeks to treat the tumour. Alternatively, a doctor can implant radioactive pellets or "seeds" in the tumour. This is called seed therapy or brachytherapy. Brachytherapy is a technique for treating prostate cancer, using tiny radioactive seeds of Iodine-125 (I125) that are inserted permanently into the prostate gland. 'Brachy' means close and, in this treatment, the radioactivity is inserted directly into the cancerous organ. It's a minor procedure, and most patients go home the same day it is performed. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Cross-sectional diagram of the implant process

Hormone therapy

Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances produced by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow.

New types of treatment

There are other new types of treatments that are being tested in clinical trials. These include the following:

Cryosurgery- Cryosurgery is a treatment that uses an instrument to freeze and destroy prostate cancer cells. This type of treatment is also called cryotherapy. Because it is minimally invasive, prostate cancer cryotherapy has fewer complications than surgery. The goals of minimally invasive therapies are: To destroy the local disease To shorten hospital stay To reduce the number of postoperative morbidities To shorten recovery time To reduce the cost of the procedure

Chemotherapy

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Biologic therapy

Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

High-intensity focused ultrasound

High-intensity focused ultrasound is a treatment that uses ultrasound (high-energy sound waves) to destroy cancer cells. To treat prostate cancer, an endorectal probe is used to make the sound waves.

Benefits and drawbacks

Whatever approach your doctor recommends, be sure to ask about the potential risks and benefits. And be sure to stay positive. With so many options available, most patients have a good chance of beating their disease.

TREATMENT BENEFITS DRAWBACKS Radiation Therapy The patient avoids major surgery. The recovery time is minimal. One should be able to resume normal activities within a few days. However, it is advised to lift heavy things for the first two weeks after the implant. There is little risk of serious complications, even if the patient is relatively old and sick. It can be hard on the body. Patients often feel exhausted at the end of their treatment. Up to 30% of all patients briefly suffer from other unpleasant side effects such as rectal bleeding, burning during urination, frequent urination, and diarrhoea. Roughly half of all radiation patients become impotent within two years, according to the American Academy of Family Physicians. This complication is more common with external beam radiation than with seed therapy. Radical Prostatectomy It is major surgery. Most patients have to stay in the hospital for 2-3 days, and they usually have to recuperate for a month before returning to work. The operation can also damage nearby nerves, often causing problems with urine control and erections. There are side-effects( like erectile dysfunction) associated with this operation Cryosurgery less invasive than a radical prostatectomy Not considered the first line of treatment because of uncertainity about its long-term effectiveness. Since freezing also damages nerve cells near the prostate, most men who undergo cryosurgery will be impotent. Other side effects may include blood in the urine, soreness, and swelling for a few days after surgery. Sometimes cryosurgery affects the bladder and bowels, causing pain and the urge to go to the bathroom frequently, but this usually goes away in time. Hormone Therapy The patient avoids major surgery. Many men develop enlarged, tender breasts. Other possible side effects include hot flashes, erectile dysfunction, and loss of interest in sex. Chemotherapy The patient avoids major surgery. While chemotherapy can't cure prostate cancer, it can often slow it down -- prolonging a patient's life and easing his symptoms. TURP The "gold standard' treatment- very effective surgery with little pain or discomfort Best permanent treatment for severe prostatic disease, especially if permanent damage to the bladder or kidneys has occurred. It's also appropriate where other treatments have failed to control symptoms adequately or protect the bladder and kidneys. No other treatment is as effective in relieving the blockage from prostatic enlargement Requires several days in the hospital, has a prolonged recovery period after surgery May infrequently have complications such as bleeding, infection, urinary leakage and scar tissue formation. It will cause retrograde ejaculation, which means that during sexual activity there will be no semen expelled from the penis. Instead, any semen produced will go directly into the bladder. This is not dangerous or harmful in any way and it doesn't affect sensation or enjoyment, but it's disturbing to some patients.

For more information, kindly visit : http://www.aasthahealthcare.com/Prostate-Cancer-Treatment.htm ------------------------------------

Laparoscopic Cholecystectomy Surgery Procedure | Laparoscopic Surgery | Laparoscopy Surgery | Aastha Healthcare | Super Speciality Center Hospital

What is Gall bladder?

The gallbladder is a pear-shaped organ that lies beneath the liver in the right-upper abdomen. The gallbladder is connected to the liver (which produces the bile) by the hepatic duct. Its function is to store bile. When food containing fat reaches the small intestine, a hormone called cholecystokinin is produced by cells in the intestinal wall and is carried to the gall bladder via the bloodstream. The hormone causes the gall bladder to contract, forcing bile into the common bile duct. A valve, which opens only when food is present in the intestine, allows bile to flow from the common bile duct into the duodenum (upper intestine) where it functions in the process of fat digestion.

What is cholecystitis?

Cholecystitis is an inflammation of the gallbladder wall and nearby abdominal lining. Cholecystitis can occur suddenly or gradually over many years. Acute cholecystitis is the sudden onset of inflammation of the gallbladder, resulting in severe, steady upper abdominal pain (biliary colic), which may occur repeatedly. Chronic cholecystitis is long-standing inflammation of the gallbladder characterized by repeated attacks of pain (gallbladder attacks) over a prolonged period. At least 95% of people with acute cholecystitis have gallstones. Gallstones are stones which are formed in the gallbladder. The Gall Bladder stores and concentrates bile. Sometimes the substances contained in bile crystallize in the gall bladder, forming stones. These small, hard concretions are more common in persons over 40, especially in women and the obese. Rarely, acute cholecystitis occurs in a person without gallstones (acalculous cholecystitis). In these cases the cause can be any major injury, operation or burn, bacterial infection in the bile duct system, tumor of the pancreas or liver.

What are the symptoms of cholecystitis?

A gallbladder attack, whether in acute or chronic cholecystitis, begins as severe, steady abdominal pain (biliary colic). The person typically feels a sharp pain when a doctor presses on the upper right part of the abdomen. The pain may worsen when the person breathes deeply and often extends to the lower part of the right shoulder blade. The pain may become excruciating; and may be accompanied by nausea and vomiting. The pain usually lasts more than 12 hours. Within a few hours, the abdominal muscles on the right side become rigid. Fever occurs in about one third of people but is less likely in older people. The fever tends to be mild at first, and then rises gradually to above 100° F (38° C). Typically, an attack of cholecystitis subsides in 2 to 3 days and completely disappears in a week. If the attack persists, it may signal a serious complication. This disorder initially produces symptoms similar to those of indigestion, especially after a fatty meal is consumed. This may be accompanied by nausea and vomiting. But when a stone becomes lodged in the bile duct, it produces severe pain. Many people also remain asymptomatic. The symptoms of cholecystitis may resemble gastric pain but one must always consult their physician for a proper diagnosis.

How is it diagnosed?

Doctors diagnose cholecystitis, both acute and chronic, based on the person's symptoms and the results of tests that suggest gallbladder inflammation. The physician will perform a careful abdominal examination to confirm the diagnosis. The enlarged, tender gallbladder may be felt by the physician through the abdominal wall. Pressure in the upper right corner of the abdomen may cause the patient to stop breathing in, due to an increase in pain. This is called Murphy's sign. Besides this, few diagnostic procedures may be advised. They include: Blood tests: Increased levels of white blood cells suggest inflammation or infection or both. There may also be increase in bilirubin levels. Ultrasound (Also called sonography.) - A diagnostic imaging technique which uses high-frequency sound waves to create an image of the internal organs. Ultrasounds are used to view internal organs of the abdomen such as the liver spleen, and kidneys and to assess blood flow through various vessels. Ultrasound scans can also show thickening of the gallbladder wall, which is typical of chronic cholecystitis. Hepatobiliary scintigraphy - Cholescintigraphy is an imaging technique that is useful when acute cholecystitis is difficult to diagnose. In this test, a radioactive tracer is injected intravenously and its movement from the liver through the biliary tract is followed. Images are taken of the liver, bile ducts, gallbladder, and upper part of the small intestine. If the tracer does not fill the gallbladder, it is presumed that the cystic duct is obstructed by a gallstone. Cholangiography - x-ray examination of the bile ducts using an intravenous (IV) dye (contrast). Endoscopic retrograde cholangiopancreatography (ERCP) - a procedure that allows the physician to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas. The procedure combines x-ray and the use of an endoscope - a long, flexible, lighted tube. The scope is guided through the patient's mouth and throat, then through the oesophagus, stomach, and duodenum. The physician can examine the inside of these organs and detect any abnormalities. A tube is then passed through the scope, and a dye is injected which will allow the internal organs to appear on an x-ray. Computed tomography scan (CT or CAT scan) - a diagnostic imaging procedure using a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.

How is cholecystitis treated?

The approach taken to treat cholecystitis depends upon:

Extent of the disease Age, overall health, and medical history of the patient Tolerance of specific medicines, procedures, or therapies Expectations for the course of the disease Patient's opinion or preference

For acute cholecystitis, initial treatment includes bowel rest, intravenous hydration, intravenous antibiotics and pain management. Whether it is acute or chronic cholecystitis, the physician then takes a step to identify the cause. If the cause is gallstones, then he may suggest the conventional solution in which the gall bladder itself is removed. And if the physician feels that it is best to remove the gall bladder, he may advice the patient to undergo Cholecystectomy after the acute phase subsides. Cholecystectomy merely means removal of the gallbladder. In acalculous cholecystitis, immediate surgery is necessary to remove the diseased gallbladder. Cholecystectomy again can be done by conventional method (also called open method) or by the laparoscopic method. We wish to provide our patients with complete information about the available treatments. So we are discussing (below) both the conventional and new methods.

The conventional method

The conventional method, also called open method was initially the only standard treatment. This was the common treatment offered both for gallstone removal or gallbladder removal. This procedure required a 3 to 7 day stay in the hospital and a 3 to 7 inch incision and scar on the abdomen. The surgeon makes an abdominal incision under the right side of the rib cage, which cuts through the skin and muscle. The gallbladder is then located and removed.

Latest Methods

Laparoscopic Cholecystectomy is now the gold standard treatment and is the commonest operation performed laparoscopically worldwide. Gynaecologists have long used this technique to tie the Fallopian tubes and to inspect the female reproductive organs. Now the use of laparoscopy has been expanded to include removing a diseased gallbladder. The first documented laparoscopic Cholecystectomy was performed by Erich Mühe in Germany in 1985. Currently, over 90% of cholecystectomies are performed laparoscopically; making it the most common procedure performed in general surgery practice.

It is a minimally invasive approach that involves specialized video equipment and instruments that allow a surgeon to remove the gallbladder through four tiny incisions, most of which are less than a half-centimetre in size.

Before the procedure

After deciding upon the line of treatment of the case, the physician will explain the procedure to the patient. He will also give an opportunity to the patient and his relatives to ask any queries or doubts. In addition to a complete medical history, the physician may perform a physical examination to ensure that the patient is in good health. In an otherwise healthy person, little is required to prepare for surgery. Depending on the age, gender, and health problems, some routine blood tests, an EKG and a chest x-ray may be needed. In fit patients, the only investigations needed are ultrasound examination, haemoglobin estimation, and liver function tests. Blood is also collected for group determination and keeping a couple of bottles on the standby. Endoscopic retrograde cholangiopancreatography (ERCP) is performed when ductal stones are suspected on the basis of clinical, biochemical and ultra-sound criteria. The surgeon will also make note if there is any history of allergy to any medication or anesthetic agents. One should be very open with their surgeon and must let him know about all medications he is taking. In general, all blood thinners need to be stopped 3-5 days before surgery.

The physician fixes up the surgery date and the patient is given an outline of the schedule. The patient will be instructed to refrain from eating 8 hours before surgery. On the day of the surgery, the patient is required to sign a consent form. The patient is again thoroughly examined by the physician. Based upon the patient's medical condition, the physician may request the specific preparation. Gallbladder operations are performed under general anaesthesia. An IV line will be placed in the arm for fluids and then the patient is brought into the operation room.

During the procedure

The anaesthesiologist and nurses keep using monitors to check the heart rate and breathing rate during the procedure. These may include EKG leads, a blood pressure cuff and an oxygen mask. The patient is operated in the supine position with a steep head-up tilt. A nasogastric tube is inserted and the stomach aspirated. The tube is kept in the stomach during the operation but removed at the end of the procedure. Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of surgical instruments and a small video camera. So, the surgeon makes a small incision at the navel o insert a thin tube carrying the video camera. The camera sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon then inflates the abdomen with carbon dioxide, a harmless gas, for easier viewing and to provide room for the surgery to be performed. Next, two needles-like instruments are inserted at a different place. These instruments serve as tiny hands within the abdomen. They can pick up the gallbladder, move intestines around, and generally assist the surgeon. Finally, several different instruments are inserted to clip the gallbladder artery and bile duct, and to safely dissect and remove the gallbladder and stones. When the gallbladder is freed, it is then eased out of the tiny navel incision. The entire procedure normally takes 60 minutes. The three puncture wounds require no stitches and may leave very slight blemishes. The navel incision is barely visible.

After the Procedure

After the procedure, the patient is taken to the recovery room for observation. The recovery process will vary depending upon the type of procedure performed and the type of anaesthesia that is given. Once the blood pressure, pulse, and breathing are stable and the patient is alert, they are shifted to the hospital room. It is common to feel groggy and nauseated soon after surgery and medication is available to help with these discomforts.

Benefits and drawbacks

Using advanced laparoscopic technology, it is now possible to remove the gallbladder through a tiny incision at the navel! With new video technology, the laparoscope has become a miniature television camera. Powerful magnification is now possible, showing the intestinal organs in great detail. It is an exciting development because it offers so much to the patient like:

Less postoperative pain because it does not require the abdominal muscles to be cut Shortens hospital stay May result in a quicker return to bowel function Quicker return to normal activity Better cosmetic results

But while the procedure seems very easy for the patient, it is still an abdominal surgery. In many instances, the surgeon may not recommend this procedure. To decide upon the technique, the surgeon has to carefully evaluate each case and weigh the benefit for the patient against the risks. However, in the presence of infection, adhesions, or variations in anatomy, this method becomes dangerous and your surgeon may need to make the prudent decision to continue by making the traditional incision to safely complete the operation. This should not be seen as a failure, but as a wise decision by your surgeon to prevent dangerous complications. In about 5 to 10% of cases, the gallbladder cannot be safely removed by laparoscopy. In these cases, standard open abdominal surgery has to be the mode of treatment. The table given below compares the laparoscopic and open surgery.

LAPAROSCOPIC OPEN Small Incisions (less than ½ an inch) Large Incision Hospital stay is 1 to 3 days Hospital stay of about 5 days Patients usually return to work in 5 to 10 days Return to work in about 4 weeks Lesser risk of Infection Greater risk of infection Less pain More painful Less chance of hernias More chance of hernias

Complications

An uncommon but potentially serious complication with the new procedure is injury to the common bile duct, which connects the gallbladder and liver. An injured bile duct can leak bile and cause a painful and potentially dangerous infection. Many cases of minor injury to the common bile duct can be managed non-surgically. Major injury to the bile duct, however, is a very serious problem and may require corrective surgery. At this time it is unclear whether these complications are more common following laparoscopic cholecystectomy than following standard cholecystectomy.

Care at home

Once the patient is back at home, it is important to keep the incision clean and dry. The physician will give specific bathing instructions. If stitches or surgical staples are used, they will be removed during a follow-up office visit. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.

The incision and the abdominal muscles may ache, especially after long periods of standing. Pain relievers for soreness can be taken as recommended by the physician. Aspirin or certain other pain medications may increase the chance of bleeding. Patients must ensure that they take only recommended medications. Walking and limited movement are generally encouraged, but strenuous activity should be avoided. The physician will give proper instructions about when the patient can return to work and resume normal activities. For more information, kindly visit : http://www.aasthahealthcare.com/Laparoscopic-Cholecystectomy-Surgical-Treatment.htm ------------------------------------