General Surgery Procedures

Gastroscopy is endoscopic investigation where the oesophagus, stomach and duodenum are examined with a flexible fibre optic instrument which is passed via the mouth. Intravenous sedation is required, and an anaesthetist will administer this.

The examination is not painful, but there may be some soreness of the throat following it. It is possible that biopsies (small specimens taken from the lining of the stomach) may be taken to help in making a diagnosis.

Particular Instructions:

- Do not eat for 6 hours before the examination.
Do not eat or drink anything for 4 hours before the examination.
- Take all your usual tablets (with a sip of water).
- Because of the sedation given, it is very important that you do not drive a car, travel on public transport alone, operate machinery or sign legal documents on the same day as the test.
- After the procedure, as a result of the sedation administered after waking you will feel a little drowsy and may find your memory of the procedure is poor.

You will need to rest for an hour or two before you go home. You may return to your normal diet as soon as you feel ready.

What is a colonoscope?

A colonoscope is a flexible instrument approximately 1.5 m in length and 1-2cm diameter. It is passed via the anus into the rectum and is then maneouvered through the remainder of the large bowel.

What is a colonoscopy?

Colonoscopy is an invasive procedure, which enables the lining of the large bowel to be examined. Unlike x-rays which take photographs, colonoscopy allows direct visual examination of the interior of the bowel and, in most instances, can provide substantially more detail and accuracy than an x-ray. The procedure is performed with the patient asleep under the care of a specialist anaesthetist and may take in the order of 30 minutes.

Sometimes small samples (biopsies) are removed from the lining of the bowel so that they can be examined under a microscope to determine if there is any abnormality or pathology. In addition, if early growths called ?polyps? are present in the bowel, they will usually be removed at the time of colonoscopy. If this is not done there is a possibility the polyps can develop into bowel cancer. It is possible that removal of a polyp could be necessary at any colonoscopy as the need to do so cannot always be predicted.

What preparation is necessary?

For colonoscopy to be successful undertaken it is very important that the bowel is thoroughly emptied and clean. To do this a bowel preparation is used. Please note that this preparation is taken orally the day before colonoscopy or the same day as your examination if your procedure is in the afternoon, and can be obtained from your local pharmacy.

If you are not honest with yourself and do not follow preparation guidelines your bowel may not be totally clean, the colonoscopy might have to be postponed and the preparation would have to be repeated.

What about my normal medication?

You should have your normal medications at the normal time on the day of the examination. Iron should not be taken for four days prior to the procedure. The effect of the oral contraceptive pill may be lost because of the bowel preparation and colonoscopy and alternative contraception should be used for ten days.

If you are on blood thinning drugs then they will need to cease prior to the procedure. This should be discussed with us or your GP.

This list is an example of some of the medications need to be ceased well before your colonoscopy:

- Warfarin (Coumadin, Marevan),
- Clopidogrel (Iscover, Plavix).
- Some naturopathy medications (Gliko Bilba, garlic, St John’s Wort)

In some instances they need to be ceased up to 2 weeks prior to and should not be recommended for up to 2 weeks after a polypectomy procedure. All individual circumstances need to be discussed with your surgeon or your treating physician as well as your GP.

Are there complications?

The risk of complications from colonoscopy is small and is approximately 1:2000. The type of problem which can occur may include bleeding and/or damage from or to the wall of the bowel with or without polypectomy. It is possible that such a complication could require surgical treatment.

If you are intending travelling outside Australia within two weeks of a colonoscopy, which could involve a polypectomy or having rubber band ligation of haemorrhoids, then it should be done no closer than two (2) weeks prior to departure because of the small chance of late bleeding.

What does the follow up involve?

A report will be available to you as soon as you wake up from the anaesthetic in the recovery area. If polyps have been removed from the bowel then further check colonoscopies may be in order, and arrangements will need to be made in this regard. Your doctor will always receive a written report on the procedure. Sometimes a consultation will be necessary to discuss the findings of colonoscopy and any possible implications for treatment.

Special points for consideration:

- Intravenous analgesia and sedation is administered by an anaesthetist so that you will be asleep and the procedure will be carried out without discomfort. Because of the sedation given, it is very important that you do not drive a car, travel on public transport alone, operate machinery, sign legal documents or drink alcohol on the same day as the test.

- Should you require a medical certificate please notify the rooms prior to the procedure.

- The colonoscopy examination will be performed at Montserrat Day Hospital, North Lakes.

- Our hospitals believe in delivering the highest quality care for patients in the safest manner. They use the National Health and Medical Research Council Guidelines for the prevention of transmission of infectious diseases as a reference for infection control.

- Endoscopes have a dedicated patient use and there are different endoscopes for gastroscopy and colonoscopy.

After the procedure:

As a result of the sedation administered after waking you will feel a little drowsy and may find your memory of the procedure is poor.

You will need to rest for an hour or two before you go home.

You may return to your normal diet as soon as you feel ready.

If you have any of the following symptoms in the hours or days after colonoscopy you should contact our rooms or the hospital immediately:
severe abdominal pain
black tarry motions
persistent bleeding from the back passage
fever
other symptoms that cause you concern

How do you get referred for a Colonoscopy?

Men and women at average risk should be offered screening for colorectal cancer and adenomatous polyps beginning at age 45 years. If it is abnormal, a GP would then refer a patient to have a complete examination of the colon and rectum.

We offer both procedures on the same day if there is a clinical indication to do so.

Surgical removal of the gallbladder, known as cholecystectomy, is one of the oldest and commonest operations performed.

There are two basic methods of gallbladder removal, namely laparoscopic (keyhole) cholecystectomy and open cholecystectomy.

Laparoscopic (Keyhole) Cholecystectomy:

Laparoscopic cholecystectomy is now the gold standard treatment for gallstones and has significant advantages over open surgery, including:

- Reduced hospital stay
- Reduced post operative pain
- Improved recovery time
- Decreased post operative complications
- Better cosmetic result
- Reduced post operative pain means that patients are able to mobilise sooner.

Poor mobilisation after surgery is a significant contributor to complications such as lung infections, deep vein thrombosis and wound infections.

Our surgeon routinely performs laparoscopic cholecystectomy.

What does gallbladder surgery involve?

Cholecystectomy requires admission to hospital, usually on the day of surgery, and full general anaesthetic.

The procedure itself involves four small (approximately 5 mm) incisions, one just below the belly button and three underneath the right lower ribcage.

Carbon dioxide is then used to inflate the normally collapsed abdominal cavity to allow proper visualisation of the gallbladder. A specialised telescope attached to a camera is then inserted to allow the surgeon to view the operation on a monitor. Laparoscopic instruments which are specifically designed for gallbladder surgery are used to perform the operation.

The operation requires the careful removal of the gallbladder, as well as the stones it holds, away from the liver. Additionally, a specialised x-ray test is performed during the operation to ensure that no stones have previously escaped from the gallbladder and become trapped in the bile ducts. This is all performed at the time of the operation.

The gallbladder is then removed via one of the small incisions created, the abdominal cavity is irrigated with saline. Occasionally a small tube is temporarily left to drain the area where the gallbladder was removed. The tubing again is brought out via one of the small incisions previously created and attached to a drainage bottle.

The incisions are closed with dissolvable sutures beneath the surface of the skin and dressings applied.

What possible complications can occur?

Despite gallbladder surgery being very safe, there are complications with all procedures that are important to be aware of. It is important to recognise that these complications are uncommon.

The main complications with laparoscopic cholecystectomy include:

- Injury Due to Trocar placement. To allow the smooth insertion and removal of laparoscopic instruments in and out of the abdominal cavity , short, hollow ports are used. Insertion of these ports is done under vision, but rarely, injury to blood vessels or underlying bowel may occur which require repair.

- Bile Duct Injury. Bile may leak from a number of areas following cholecystectomy and the treatment of a bile leak depends on the source. In some instances, bile draining via the drain inserted during the operation is sufficient treatment, but in others further procedures or even re-operation is required.

- Bleeding/Infection. Significant bleeding during or following the operation is rare. Post-operative infection within the abdomen or wound infection are also rare complications.
These complications are reduced by the administration of a single dose of antibiotic at the time of operation.

General risks of any procedure. DVT, atelectasis, death is a rare (1:3000) but a possible event usually associated with pulmonary or air embolus
Conversion to Open Cholecystectomy. In less than 5% of all cases, cholecystectomy is unable to be performed laparoscopically. In these cases, open cholecystectomy is performed. The most common reason for conversion is due to scar tissue present in patients who have had previous operations. WMSA's surgeons conversion rate to open cholecystectomy is less than 1%.


Open Cholecystectomy:

Open cholecystectomy involves a larger incision, usually approximately 10cm horizontally under the right rib cage. The gallbladder is removed along with gallstones as in laparoscopic cholecystectomy.

The major difference between open and laparoscopic cholecystectomy is increased length of the incision and longer recovery time.

What will I be like after the operation?

Following laparoscopic cholecystectomy, most patients are drinking and eating the same evening. Shoulder tip pain is common following laparoscopic surgery, but is not serious. This is usually due to residual air within the abdominal cavity, which irritates the diaphragm. This usually resolves in a few days.

Mobilisation is encouraged early with the aid of pain relief tablets. The drain, if placed, is usually removed the following day. Once patients are mobilising independently, pain control is achieved with oral medications and they are tolerating a normal diet, discharge is achieved. Most people are able to go home the day after surgery.

A post operative appointment with our nurse will be made within 4 weeks.

What is a hernia?

A hernia occurs when the inside layers of the abdominal muscle have weakened, resulting in a bulge or tear. In the same way that an inner tube pushes through a damaged tyre, the inner lining of the abdomen pushes through the weakened area of the abdominal wall to form a small balloon-like sac. This can allow a loop of intestine or abdominal tissue to push into the sac. The hernia can cause severe pain and other potentially serious problems that could require emergency surgery. Both men and women can get a hernia. You may be born with a hernia (congenital) or develop one over time. A hernia does not get better over time, nor will it go away by itself.

How do I know if I have a hernia?

The common areas where hernias occur are in the groin (inguinal), belly button (umbilical), and the site of a previous operation (incisional). It is usually easy to recognise a hernia. You may notice a bulge under the skin. You may feel pain when you lift heavy objects, cough, strain during urination or bowel movements, or during prolonged standing or sitting. The pain may be sharp and immediate or a dull ache that gets worse toward the end of the day. Severe, continuous pain, redness, and tenderness are signs that the hernia may be entrapped or strangulated. These symptoms are cause for concern and you should immediately contact your surgeon.

What cause a hernia?

The wall of the abdomen has natural areas of potential weakness. Hernias can develop at these or other areas due to heavy strain on the abdominal wall, ageing, injury, an old incision or a weakness present from birth. Anyone can develop a hernia at any age. Most hernias in children are congenital. In adults, a natural weakness or strain from heavy lifting, persistent coughing, difficulty with bowel movements or urination can cause the abdominal wall to weaken or separate.

What are the advantages of laparoscopic hernia repair?

Laparoscopic Hernia Surgery is a technique to fix tears in the abdominal wall (muscle) using small incisions, telescopes and a patch (mesh). If may offer a quicker return to work and normal activities with a decreased pain for some patients.

Are you a candidate for laparoscopic hernia repair?

Only after a thorough examination can determine whether laparoscopic hernia surgery is right for you. The procedure may not be best for some patients who have had previous abdominal surgery or underlying medical conditions.

How is the procedure performed?

Hernia Surgery procedures are done in one of two fashions.

I. The open approach is done from the outside through a 8-12 cm incision in the groin or the area of the hernia. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole. This technique is usually done with a local anaesthetic and sedation but may be performed using a spinal or general anaesthetic.

II. Laparoscopic hernia surgery. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a cannula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.

Other cannulas are inserted which allow your surgeon to work “inside”. Three or four 5 mm incisions are usually necessary. The hernia is repaired from behind the abdominal wall. A small piece of surgical mesh is placed over the hernia defect and held in place with small surgical staples. This operation is usually performed with general anaesthesia or occasionally using regional or spinal anaesthesia.

What happens if the operation cannot be performed or completed via laparoscopic surgery?

In a small number of patients the laparoscopic method cannot be performed. Factors that may increase the possibility of choosing or converting to the “open” procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, inability to visualise organs or bleeding problems during the operation.

The decision to perform the open procedure is a judgment decision made by Dr Braun either before or during the actual operation. When the surgeon feels that it is safest to convert the laparoscopic procedure to an open one, this is not a complication, but rather sound surgical judgment. The decision to convert to an open procedure is strictly based on patient safety.

What should I expect after surgery?

Following the operation, you will be transferred to the recovery room where you will be monitored for 1-2 hours until you are fully awake. Once you are awake and able to walk, you will be sent home. With any hernia operation, you can expect some soreness mostly during the first 24 to 48 hours. You are encouraged to be up and about the day after surgery. With laparoscopic hernia repair, you will probably be able to get back to your normal activities within a short amount of time. These activities include showering, driving, walking up stairs, lifting, working and engaging in sexual intercourse. Call and schedule a follow-up appointment within 4-6 weeks after you operation.

What complications can occur?

Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair. There is a slight risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle. Any time a hernia is repaired it can come back. This long-term recurrence rate is not yet known. Your surgeon will help you decide if the risks of laparoscopic hernia surgery are less than the risks of leaving the condition untreated.

Haemorrhoids are considered to be internal or external. Internal haemorrhoids are collections of blood vessels, which form into "3 cushions" in varying positions around the anal canal. External haemorrhoids are really small skin tags which protrude from the anal verge.

Symptoms:

The commonest symptom of haemorrhoids is bright bleeding during and after a bowel motion. Internal haemorrhoids may also prolapse (protrude) and cause some degree of discomfort and irritation. External haemorrhoids may make cleaning the anal area difficult and also act as a source of irritation. Occasionally a blood vessel may burst under the skin and cause a painful and swelling which is referred to as a thrombosed external haemorrhoid or perianal haematoma. This latter condition is common in athletes or individuals who may strain excessively at stool. It is a self-limiting condition, but may often be improved by a minor procedure, which can be undertaken in the office. Thrombosed prolapsed haemorrhoids refer to the complications of internal haemorrhoids which may tend to protrude from the anus after a bowel motion and not return to the lower part of the bowel. This painful and distressing condition sometimes requires semi-urgent operation.

Treatment:

The treatment of haemorrhoids depends on their severity. Symptoms from haemorrhoids may improve by an increased amount of fibre in the diet. Ointments and suppositories may also be helpful. Large haemorrhoids may require the use of rubber bands and very large haemorrhoids may require haemorrhoidectomy (surgical removal). Freezing, infra-red and laser therapy to haemorrhoids are just differing methods of using energy to remove a haemorrhoid. They have no particular advantage over "normal" haemorrhoidectomy.

Rubber Band Ligation of Haemorrhoids:

Your haemorrhoids have been treated by application of small rubber bands which will cut off the nutritional blood supply to the haemorrhoid making it shrink and fall off any time up to fourteen days after the procedure. Often some bleeding may occur during this period. If the bleeding is profuse and there are clots I should be contacted.?It is not uncommon to get some lower bowel discomfort after application of rubber bands but usually this will settle with analgesia such as Panadol or Panadeine. In addition to discomfort there may be a sensation of a desire to evacuate the bowel. This will usually settle down over a 24-48 hour period and straining may cause some aggravation during this time. It is advisable for you to take laxatives, such as Agarol 20-30ml for up to a week following your procedure. After rubber band ligation there is no need to change your diet and you may resume normal activity, provided you are comfortable. Sometimes rubber band ligation is performed during the course of another procedure under general anaesthesia and you should not drive for the rest of the day.

A vasectomy is a simple surgical procedure, which offers birth control for men and a permanent means of contraception for men who do not wish to have more children.

It is also popular as it does NOT:

- Alter male characteristics
- Affect hormonal and sexual functioning
- Impair or alter erections, sexual drive or ejaculation (although there is a potential for psychological impediments)
- Affect sperm production in the testicles, which is subsequently absorbed by the tissue.

How is a vasectomy performed?

The vasectomy procedure is generally performed using local anaesthesia to alleviate the possibility of pain and discomfort. However if you have chosen to undergo the procedure in Hospital, general anaesthesia is more often than not utilised. After the anaesthesia has been administered, the doctor makes two incisions, one on either side of the scrotum. These incisions are made in order to locate the two thin tubes (the vas deferens) that carry the sperm. Once the tubes are located, a small portion of each tube is removed and the tube is sealed off. This forms a permanent barrier and prevents sperm moving from the testes into the vas deferens. The procedure takes approximately 20-30 minutes.

How should I prepare for the procedure?

Shave the scrotum area in the morning of the procedure. No fasting is required if procedure performed under local anaesthesia in the rooms. Fast for 6 hours before the operation if planning to receive general anaesthesia. Bring with you a jockey pair of underpants (not boxers) for support, and arrange for someone to accompany you home afterwards.

What should I do post-operatively?

You will be in recovery for approximately 1 hour. You cannot drive a car for 24 hours after the procedure if general anaesthesia was administered. You must rest, placing a cold pack on the area to prevent swelling. There should be little activity on the day of the procedure, and no strenuous activity for a few days.

How long do I still need other forms of birth control after the procedure?

The reproductive tract is not clear of sperm for several weeks. A semen sample is taken only once, 12 weeks later (after approximately 15-20 ejaculations). There are specific rules for the semen collection which will be carefully explained to you by our Surgeon. You will be given a pathology form on the day of your procedure in order to get this test done. We will receive the test results and report to you via regular mail.

If the sperm count is not completely negative the test will need to be repeated in another 2 weeks. Please bear in mind that until the semen count is totally negative, alternate methods of contraception must be maintained, as one can still be fertile.

What are the risks associated with a vasectomy?

Recovery from a vasectomy is rapid and serious complications are rare. Fewer than 3 in 100 men develop minor complications, which are treatable:

- Swelling, bruising and pain: These are the most common complaints concerning post-operative recovery after a vasectomy. Such discomfort subsides usually within a week and easily treatable with ice packs (wrapped in a towel) and mild pain relief. Remember avoid any exercise or strenuous work for a few days.

- The development of granulomas: A minority of men develop a small lump of inflammatory tissue, called granulomas, which is caused by sperm leaking into surrounding tissues. If they do cause pain, they are generally treated with bed rest and pain relief.

- Infection: Risk of infection is minimised/prevented by the use of sterile techniques and careful wound care post operatively. Infection, if present, tends to cause localised swelling, redness, tenderness with or without pus. The 1% or less of men experiencing an infection, which can involve the skin, testes or scrotum, simply require antibiotics.

- Haematoma: One of the small blood vessels cut during the procedure may leak or if the area is struck (e.g. by a ball or during heavy work), then the sealed wound can open up. This will result in a blood clot forming inside the scrotum. They may need to be drained.

- Epididymitis: This is a local inflammation near the side of the operation, which occurs mostly within the first year after the vasectomy. It is treated with heat and usually clears within a week.

Vasectomy failure
Failure of vasectomy due to re-canalisation (re-joining) of the vas can result in pregnancy. Approximately 1 in 1000. This can happen any time after the procedure, but is most common during the first 5 years post-operatively. The most common reason for vasectomy failure is unprotected intercourse before the sperm have cleared the reproductive tract, so it is important to use alternative contraception until your sample indicates no more sperm present.

Post Vasectomy Syndrome: This affects 2 to 4% of men. You may experience a drawing or dragging sensation in the scrotum. This is usually treated with anti-inflammatory drugs and in most cases will settle down. In rare cases, the vasectomy may have to be reversed

After General Anaesthesia, even though you may be feeling fully recovered, it is important that you MUST NOT:

- Drive a motor vehicle
- Operate machinery
- Consume alcohol
- Consume any drugs that are not prescribed for you
- Sign any important documents
- Do anything that requires fine decision making skills until 24 hours after the procedure.

Contact us to enquire if you need help in relation to:

-Excision of Skin Lesions
-Flap Reconstruction
-Pilonidal Sinus
-Carpal Tunnel
-Adult Circumcision