Expertise in general, abdominal, laparoscopic and colorectal surgery

Patient Information

Hernias

A hernia is a weakness in a containing structure that allows its contents to pass through it into an abnormal position. Relating to the abdominal cavity, a hernia usually occurs at a point of natural weakness in the abdominal wall commonly where important organs or blood vessels pass into another body cavity. For example, a hiatus hernia occurs when the oesophagus or stomach is forced back up through the diaphragm into the chest and a femoral hernia occurs when fat or bowel is forced through the weakness next to the major blood vessels travelling to the leg.

Approximately 75% of all hernias occur in the groin and most of these are inguinal hernias; men are more likely to be affected than women. Incisional hernias can occur after surgical wounds have left a weak scar and together with umbilical and other ventral hernias account for another 10% of all hernias. Only 3% of hernias are femoral hernias but these must be repaired surgically as they are likely to become trapped. Because of the way the abdominal wall accepts the umbilical cord, many children have an abdominal wall hernia early in life but most hernias of this type close spontaneously by 1 year of age. However, groin hernias in infants are more dangerous as they have a high incidence of complications.
Whether a hernia needs repair depends on the type of hernia and the symptoms it is giving the patient. The principles of the operation are to restore normal anatomy then to strengthen the weakness with a tension-free repair – this usually means inserting a mesh. There are few hernias that cannot be repaired by laparoscopic methods i.e. keyhole surgery. This technique allows patients to recover faster and for more cases to done as a day case. The other benefits include being able to make a more thorough assessment of the hernia prior to repair, less chronic pain and lower rates of wound infection. Other potential complications after surgery include temporarily being unable to pass urine and bruising. All hernias can recur after time but this is uncommon.

After a laparoscopic hernia repair, you’re likely to be home on the same day with adequate pain killing tablets. You will have absorbable stitches in the skin with a dressing over the top. You can flannel wash or shower with these dressings but check if the dressing is still dry underneath afterwards. After 3 days you should be able to remove the dressing altogether and let the air get to the wound. You should keep mobile but not strain yourself by doing excessive heavy lifting or exertion for about 2 to 3 weeks. Many people are back at work after a week if they have light duties or desk work but if this is not possible then you might need to wait a little longer.

Gallstones

The liver excretes bile into the bile ducts which is temporarily stored and concentrated in the gallbladder. After a meal, stimulation of the gut results in hormones being secreted into the bloodstream that cause the gallbladder to contract and deliver bile into the intestine where it is mixed with the food to help with digestion. Bile is composed of a range of waste products and this is a method of getting rid of these after chemical conversion in the liver, but bile also has a useful role in absorption of fats. Bile acids help to break down fats in the diet by emulsifying them, very similar to the way in which washing up liquid will get thick grease off a frying pan. In addition to needing dietary fat for energy and other essential functions, some constituents of the diet require effective fat digestion in order to be absorbed themselves such as vitamin A,D,E and K. Vitamin K is essential in the production of clotting factors in the liver. Gallstones form when there is an imbalance of the constituents of bile or there is ineffective or delayed emptying of the gallbladder producing stagnant bile which forms crystals. Over time, these crystals get larger and form stones. Most stones contain cholesterol which is a major component of bile.

Gallstones are common, affecting about 12% of men and 24% of women. As well as being female, risk factors for the development of gallstones are age, obesity, diabetes, ileal surgery, haemolytic anaemia and some drugs. Most people with gallstones will never have a complication of them and only about 10 – 20% of people will have symptoms from their gallstones. This is important as the presence of gallstones does not mean that abdominal pain is necessarily being caused by the stones. The best way to diagnose gallstones is by having an ultrasound scan.

Gallstones can just be painful, which in itself is not dangerous but will affect quality of life. However, more serious complications can develop when a large stone blocks the normal outflow of bile from the gallbladder resulting in it becoming distended and inflamed (cholecystitis). A smaller stone can escape into the bile ducts resulting in obstructive jaundice, cholangitis or pancreatitis which usually requires admission to hospital.

Removal of the gallbladder (cholecystectomy) along with the contained gallstones is the only effective method for definitively treating gallstones once they have started to cause trouble. Only about 1% of patients will still have problems after this if the initial symptoms were diagnosed correctly. Today, nearly all cholecystectomies are performed by laparoscopic techniques which improve outcomes and allow daycase surgery. There are some serious but thankfully rare complications during cholecystectomy such as duodenal or bile duct injury, bleeding and post operative bile leak but the vast majority of patients will come through their surgery without any complications at all. After cholecystectomy, you’re likely to be home on the same day with adequate pain killing tablets. You will have absorbable stitches in the skin with a dressing over the top. You can flannel wash or shower with these dressings but check if the dressing is still dry underneath afterwards. After 3 days you should be able to remove the dressing altogether and let the air get to the wound. You should keep mobile but not strain yourself by doing excessive heavy lifting or exertion for about 2 to 3 weeks. Many people are back at work after a couple of weeks if they have light duties or desk work but if this is not possible then you might need to wait a little longer.

Endoscopy

Fibre optic technology was developed in the 1950s and this led to the first flexible endoscopes a decade later. This discovery revolutionised diagnostic medical procedures because it enabled doctors to see deep into the body cavities safely and with enough light. Endoscopes are not only used to diagnose pathology inside the body but also used for treatment and there are many different therapeutic devices available that can be passed down the tiny channels within the endoscope to perform a task. More recently, this technology has been modified to enable more advanced procedures to be performed, in particular natural orifice surgery (see Endo-Samurai, Olympus Tokyo, Japan; Anubis, Karl Storz Co Ltd). Although in its infancy, this field is exciting because it potentially eliminates the need for skin incisions because access to the abdominal cavity occurs via the wall of the internal organ which has a less sensitive nerve supply. This means there is the potential for reduced postoperative pain, incisional hernias and wound infections but the techniques have to be proven to be safe before they can be used more widely and this means that most of these procedures are currently only used under strict trial conditions.

For upper gastrointestinal endoscopy (or gastroscopy), some local anaesthetic spray is usually used to numb the throat and dull the gag reflex prior to the endoscope being inserted but additional intravenous sedation can also be used if necessary. Swallowing the endoscope is not a natural experience, but it is important to remember that it doesn’t affect your ability to breathe normally throughout the procedure and only lasts a minute or two. Colonoscopy or flexible sigmoidoscopy can also be completed without any sedation or pain relief if performed carefully, but there are many cases where sedation becomes necessary as each patient has different anatomy and needs. If tissue samples are taken from the lining of the bowel, analysis usually takes about a week before the results are available.

If you have had sedation, it is important to try and have someone with you or close by for 24 hours after the endoscopy. You should also avoid alcohol, driving and strenuous activity during this period.

Diverticular disease

Diverticular disease is commonly referred to as a benign age-related disease of the colon. It is thought to be caused by high pressures inside the colon over a long period of time resulting in muscular thickening, rigidity and small hernias developing through the bowel wall. The evidence that environmental factors play a leading role in the development of diverticular disease comes from the fact that people who move from an area of the world where the condition is rare to an area of high prevalence often develop the disease. Dietary factors play an important part in creating the environment inside the colon that leads to the structural damage to the bowel but there is no overwhelming evidence to suggest what these factors are. Frequently, a low fibre diet is blamed but there is evidence to suggest that high fibre diets and increased stool frequency may actually be associated with diverticular disease. The incidence in western societies is high and it becomes more common as we age with the majority of people having some evidence of diverticulosis over the age of 70. Most people will not know they have diverticular disease until it is seen on colonoscopy or barium enema but about a quarter of people will have irritating symptoms such as abdominal pain or erratic bowel movements.

About 1 in 10 patients will have a serious complication from their disease. Because the hernias in the bowel wall are situated at the weak points where the blood vessels enter, erosion and bleeding can occur which typically presents with the passage of bright red blood from the rectum which can be copious and worrying, however 90% of these bleeds will settle spontaneously. Blockage of a diverticulum and resulting acute inflammation may lead to diverticulitis which can be treated with antibiotics, or even perforation resulting in life-threatening peritonitis requiring emergency surgery. In a minority of cases, there is a slow progressive narrowing of the colon which can result in stricture and obstruction.

If symptomatic, most people can be treated with conservative measures such as dietary and lifestyle changes but if these fail then there is no other way of reversing the disease other than to resect the segment of bowel worst affected. This involves taking on all the risks of major colonic surgery.

Anorectal conditions

1) Haemorrhoids
The anal canal is a muscular tube that helps to keep us continent of stool. As part of this mechanism the canal is lined with three fleshy columns of tissue that are compressed together under the tension of the surrounding circular muscle. As we age, the underlying tissues that support these columns loosens to allow distortion and bulging to occur and this leads to localised trauma and damage. Although haemorrhoids are a common cause of bleeding because they have such a good blood supply, they can slip down the anal canal and appear externally near the skin around the anus. It is at this stage when they cause further problems such as pain, irritation or difficulty in cleaning. Spontaneous resolution can occur if a pile becomes thrombosed but often a small skin tag if left behind if there has been significant distortion of the tissues at the anal margin.

Treatment is only needed if troublesome symptoms are present. Bleeding can be controlled by rubber band ligation which can be performed in the clinic and is relatively risk-free but may have to be repeated for resolution of symptoms. Surgery can be offered for advanced piles or significant skin tags. There are two main approaches, diathermy excision or stapled haemorrhoidopexy which can be a useful alternative when prolapse is a dominant feature. The latter tends to reduce postoperative pain but has a higher recurrence rate. Simple ligation of the feeding blood vessels is occasionally all that is needed. After surgery, good pain control and laxatives are usually needed for the first week.

2) Anal fissure
Anal fissure typically presents with sharp pain and fresh bleeding after passing a motion. This is a split in the lining of the anal canal which has been caused initially by a difficult or hard stool. A vicious cycle of pain, spasm, further trauma and more pain is established and treatment is based on the principle that if this cycle is broken then resolution will spontaneously occur. Because examination is sometimes too painful, a diagnosis can be made on the history alone, although failure to respond to treatment should mandate an examination under anaesthetic. In the first instance, therapeutic measures include laxatives and smooth muscle relaxants which can be applied to the anal margin as a cream for 6 weeks but if this fails, botulinum toxin injection, sphincterotomy or an advancement flap can be tried.

3) Anal fistula
A fistula is an abnormal communication between two internal or external body surfaces. A fistula can develop around the anal canal because the trapped fluid from a blocked and infected anal gland tries to find its way out onto the skin. The resultant abnormal communication from anal canal to perianal skin continues because of persistent infection being fed into the track from the lining of the bowel. Fistulas can cause symptoms of discharge and irritation but can block causing abscesses and tissue destruction and for this reason they require surgery. The main aim of surgery is to control infection and then to remove the track. Sometimes, because of the location of the fistula and considerations regarding maintenance of continence, these two aims cannot be achieved at the same time and it is not uncommon for a staged approach to surgery to be adopted meaning more than one operation.

4) Perianal haematoma
A perianal haematoma is a painful blue lump within the skin around the anal canal. It is caused by a burst blood vessel and is self-limiting. It requires no treatment other than good pain relief and time to settle.