What is General Surgery?

A combination of surgical specialities. 

General Surgery

Gallstones

What are gallstones?

These are solid pebbles which can be found in the gallbladder and are formed from bile which is stored within it. These can vary in number and size from tiny gravel-like particles to large golf-ball sized stones.

The gallbladder is a pear-shaped hollow organ that stores bile, which is produced by the liver and is used for digestion, especially of fatty food.

Symptoms

Most gallstones do not cause any problems and the patient is unaware of their presence. They are commonly an incidental finding when an ultrasound is performed for some other reason.

Biliary colic is the commonest clinical symptom

This is a pain in the right upper corner of the abdomen, just under the right rib cage which tends to occur soon after eating and can last anything from a few minutes to a few hours. The pain sometimes radiates around the side to the back and can be associated with nausea and vomiting.

It commonly occurs after eating a fatty meal such as fish & chips or pastry because fat makes the gallbladder contract to release bile to help in digestion of fatty food. In the presence of gallstones within the gallbladder this can induce pain. Although often the pain can occur without any obvious predisposing factor.

Acute cholecystitis

The pain can remain persistent with increasing inflammation and sometimes outright infection and may require hospital admission and sometimes emergency surgery.

Jaundice

A stone can drop into the main duct (common bile duct) leading from the liver to the intestine and get stuck at the junction with the intestine. When this happens, the bile produced by the liver cannot drain into intestine and this causes a backlog such that bile products are released into the blood stream and colour the sclera (white of the eye) and skin yellow/green.

An ERCP may be required to remove the stone from the duct and clear the jaundice.

If this bile that is not allowed to flow freely becomes infected it can lead to a condition called ascending cholangitis that can rapidly lead to septicaemia if not treated adequately.

Pancreatitis

This is inflammation of the pancreas (gland which produces insulin and several enzymes that help digestion of food). Gallstones are one of the commonest causes of pancreatitis and this occurs when a gallstone drops into the main bile duct (common bile duct) gets stuck at the junction with the intestine. The pancreatic duct also drains at this point into the intestine and a blockage by a stone could thus affect the drainage of the pancreas leading to inflammation (pancreatitis).

Treatment of gallstones

Avoiding fatty meals may help

Certain tablets have been tried to dissolve gallstones with little success and even when they do dissolve the gallstones, they rapidly return when the medication is stopped. The best way to get rid of the gallstones is with an operation that removes the gallbladder and the stones.

The operation (laparoscopic cholecystectomy) is usually performed using the laparoscopic (keyhole) approach and more than half of these can be done as a day-case procedure.

There are no problems with the functioning of the body after the removal of the gallbladder and the liver continues to produce bile and digestion is thus unaffected although a small proportion of patients may develop some diarrhoea.

The operation involves a general anaesthetic and 3 - 4 tiny incisions in the abdomen to allow the introduction of the key-hole camera and the operating instruments.

LINK to VIDEO

Occasionally it is not possible to adequately see the detailed anatomy using the keyhole method to complete the operation safely and in this it has to be converted to an open operation with a larger incision. This occurs only in about 2% of cases and usually requires admission for a further two or three days.

What is a Hernia

An abdominal wall hernia is a protrusion (bulge) through a defect (hole) in the muscles of the abdominal wall. It may contain loops of bowel. The commonest site for this on the abdominal wall is the groin. Depending on the exact location in the groin, they can be described as inguinal (direct or indirect), femoral or Spigelian. There is no need to worry about the exact terminology because they can all be repaired with essentially the same operation particularly when the laparoscopic (key-hole) approach is used.

Types of Hernia

There are several different types of hernias:
  • Inguinal (Indirect, Direct)
  • Femoral
  • Spigelian
  • Umbilical, Paraumbilical
  • Epigastric
  • Divarication of the recti (separation of the central abdominal muscles), this causes a protrusion in the midline but is not a 'true' hernia and does not carry the risk of bowel becoming trapped within it and thus does not require repair
  •  
  • Obturator
  • Lumbar
  • Gluteal
  • Sciatic
  • Incisional
  • Reducible, Irreducible
  • Strangulated
  • Sliding (retroperitonal contents in sac)
  • Littre’s (Meckel’s diverticulum in sac)
  • Richter’s hernia (Stranulated but not obstructed)
  • Maydl’s (Strangulated above defect)

Hernia Complications

Complications following hernia repair include:

Recurrence <2% in the short term but this can increase to 5-10% over a long period of follow-up

Bleeding leading to haematoma which usually resolves spontaneously but occasionally may require aspiration/operation

Spermatic cord damage

Wound infection

Urinary retention

Chronic groin pain - this has been found to be more common in patients who have significant pre-operative pain, younger patients and those who have operations for recurrent hernias

Testicular atrophy

Open Mesh Repair

A 2 - 4 inch incision is made in the groin.
The hernia is reduced and a mesh inserted to prevent recurrence of the hernia.

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