Procedures

Haemorrhoids are part of the normal anus and contribute to our continence. They are considered “abnormal” when they hang out of the anus, bleed, or develop clots.

“Abnormal” haemorrhoids do not always require an operation and the symptoms may settle with fibre and laxatives.

If this does not work the first step is to place rubber bands in the rectum to reduce the size of the haemorrhoids. This process can be repeated 2-3 times if needed. There is some discomfort after the procedure.

If rubber banding cannot control haemorrhoid symptoms, or if the haemorrhoids are too large for the rubber banding process to work, then several other procedures can help; stapled haemorrhoidopexy (pulling the haemorrhoids back up into the rectum), haemorrhoid arterial ligation (reducing the blood flow into the haemorrhoids), and formal haemorrhoidectomy (removing the haemorrhoids).

Anal fistula are usually identified at the time of an operation for an anal abscess or on examination in the rooms. When left untreated, fistula result in recurrent abscesses at the anus.

Initial treatment involves placing a seton (often a thin piece of soft rubber) in the fistula which prevents the formation of further abscesses.

Thereafter an ultrasound will help to define the amount of the anal sphincter muscle trapped within the fistula. This is an important measurement that determines what procedures are safe to cure the fistula.

Very simple fistula are laid open (the tract is cut open and cleaned to cure it). This has a 95% success rate for anal fistula.

More complex fistula often cannot be laid open and require a different approach, including a fistula plug, LIFT procedure (Ligation of Intersphincteric Fistula Tract), or “cutting seton”.

There are many treatments for pilonidal sinus – each procedure has its specific benefits and risks. The right treatment will be decided in consultation with your doctor.

The first procedure involves laying open the sinus and cleaning the tract. The tract is then marsupialised (the edges are sewn down on to the base) to help healing.

If this is unsuccessful then a flap repair may be required to heal the sinus.

Keyhole removal of the gallbladder is a safe and common procedure for managing the complications of gallstones.

Many patients inquire if the gallstones can be removed rather than the gallbladder – unfortunately removing the stones is pointless as the stones will reform, so the gallbladder itself must be removed to prevent this.

The gallbladder is attached to the under-surface of the liver and must be shaved off the liver to be removed. It is often necessary to perform a special xray dye test to ensure no stones have slipped down into the common pipe draining the gallbladder and the liver; this is called a cholangiogram.

Keyhole surgery to remove bowel cancers is a well-established and extensively researched procedure. The quality of surgery is identical to classic “open” surgery but with less pain and a shorter stay in hospital. Patients usually use less pain relief and have a more rapid return of bowel function.

Small cuts are used to introduce a camera, graspers and dissecting instruments to free and deliver the region of the bowel in question. A small extension of one of the incisions is used to deliver the bowel, remove the cancer and re-join the bowel.

All surgeons who perform laparoscopic bowel resection also have extensive training in open bowel resection and will recommend a suitable approach depending on the circumstances for each individual patient. Laparoscopic surgery may still be possible even after multiple belly operations.

A special note should be made about laparoscopic rectal resection. This is keyhole removal of the rectum, usually with fashioning of a new join to the rectum or right down to the anus. There are many international and national studies looking at the risks and benefits of laparoscopic surgery for the rectum. Your surgeon will discuss the pros and cons of open and laparoscopic surgery for your individual circumstances.

Big hernias in the belly wall are common in the years following major surgery. The scar weakens and the bowel and fat from inside the belly slip between the muscles of the belly wall and sit beneath the skin. This is particularly common in obese patients and those using steroid-based oral medications.

The hernias can be small or large and there are often multiple hernias along the scar. Smaller hernias are safely repaired by either keyhole or classical “open” methods.

Very large hernias can be repaired by keyhole and non-keyhole methods. Although keyhole surgery seems preferable, sometimes it is not the most effective method of repair – particularly when the patient has had the hernia for a very long time because the rest of the belly has shrunken down and the muscles have separated.

One procedure for combatting this issue is a component separation repair. The muscles are brought back to the centre of the belly and the whole belly wall is reinforced with special mesh.

The correct operation for you is best determined in discussion with your surgeon.

Many patients with incontinence achieve control with a combination of dietary adjustment, anti-motility agents (e.g. Gastrostop), fibre supplementation and pelvic floor physiotherapy.

Those who do not respond might benefit from sacral nerve stimulation - an electronic implant is placed in the upper buttock and transmits signals to the nerves in the lower pelvis. This is a successful procedure in appropriately selected patients.

Very young patients with a significant injury to the anal sphincter may benefit from direct sphincter repair. This has good short term benefit however the long-term effect may be limited.

A colostomy (large bowel stoma) or ileostomy (small bowel stoma) is formed to allow bowel content to drain into a bag on the belly.

Temporary stomas allow new joins in the bowel to heal. This can reduce the failure of a difficult bowel join by three fold and ensure that patients remain healthy after complex surgery.

Permanent stomas are formed when the anus must be removed for an extensive cancer, or for patients who are already incontinent and who request a stoma to improve their lifestyle.

Most patients are terrified of the possibility of having a stoma. The reality is the vast majority are temporary.

Stomas can allow the bowel to function even when there is a substantial blockage, and can facilitate important pre-emptive treatments like radiotherapy to shrink cancers before they are removed.

Endoscopic examination of the oesophagus, stomach, and the beginning of the small bowel is called gastroscopy. The procedure is extremely safe and affords good views of the lining of the oesophagus (throat), stomach and duodenum, allowing identification of ulcers, polyps, cancers and dilated blood vessels.

The procedure is often combined with colonoscopy when looking for a cause of anaemia (low blood count), iron deficiency, and bleeding from the bowel.

Endoscopic examination of the large bowel is called colonoscopy. The instrument allows us to look at the inner lining of the bowel from the anus all the way through the large bowel and often some distance into the small bowel as well. Colonoscopy is a very sensitive test for colon and rectal cancer.

At the time of the procedure, polyps can be removed and larger growths can be biopsied to obtain a diagnosis. Haemorrhoids can also be treated with rubber band ligation and abnormal blood vessels can be destroyed with argon plasma coagulation.

A bowel preparation is required prior to colonoscopy to obtain clear views of the colon lining. Several types of bowel preparation are now available, ranging from those where relatively small amounts of fluid are consumed (PICOPREP) to those where large volumes are (GLYCOPREP). Larger volume preparation agents are safer for frail patients.

When the rectum falls out through the anus, this is known as a prolapse.

There are many contributing factors such as age, and repeated straining being the most important.

Once the rectum has started to prolapse it must be repaired. There are two main approaches - Keyhole or trans-anal surgery.

Laparoscopic ventral rectopexy is a keyhole procedure which pulls the rectum back into the abdomen and fixes it to the sacrum (tailbone). This is minimally invasive and very successful.

Laparoscopic hernia repair is a well-established and thoroughly proven method of repair for groin hernias. It involves 3-4 small cuts in the belly to pass a camera deep to the belly muscles and repair a hernia from the inside.

Special meshes are placed and secured after the repair to ensure the hernia does not recur.

Good quality studies have shown a faster return to normal activities and better patient satisfaction with laparoscopic hernia repair when compared to the classical “open” method. But long-term prevention of the hernia is the same.