eSurgery

An inguinal hernia repair with a mesh using the open technique has been the gold standard operation. Hundreds of thousands of these operations have been done worldwide. The technique is simple and the recurrence rate with a mesh is low. In addition, this can be done under local anaesthesia.
The reason for using a mesh is that it will provide an anatomical repair and provide a scaffold for the body’s scar tissue to grow through the mesh(this gives long term strength to the repair and reduces the rate of recurrence)
The repair is done without any tension – the mesh is secured with staples/sutures to the muscles in a way which does not pull on the muscle(If the mesh is sutured too tightly onto the muscles under tension, there may be pain on coughing/straining)
Length of the incision – A cut is made over the inguinal canal – the length of the cut depends on the thickness of the body fat. In a lean person, it is about 3-4cm in the author’s hands. (Just slightly longer than a keyhole. This is nearly the same length as the sum of the length of 3 incisions needed in a laparoscopic repair)
Occassionally a mesh plug may be used to as well to patch the “hole” in the abdominal wall where the hernia is popping out from.

Advantages of having surgery – Planned elective surgery is much safer than leaving a hernia until it strangulates!

Risks of not having surgery:
1. Hernia may get bigger – as it gets bigger, there is more likelyhood that the intestine will come out in the hernia as well.
2. Risks of contents of the hernia becoming trapped and blocked or gangrenous(if there is bowel in it, the bowel wall may die and burst causing life-threatening peritonitis). Treatment of the latter would mean a more extensive bowel resection and a weaker repair especially if a mesh is contraindicated in the presence of infection

What anaesthetic options are available? Local anaesthesia & sedation vs General anaesthesia vs Spinal(rarely used by the author) This should be discussed with your surgeon and anaesthetist before your operation.
Benefits of local anaesthesia and sedation: 1. For patients with serious heart or lung problems, there is a significantly lower anaesthetic risk having a repair under LA and sedation. 2. Patient is awake throughout the procedure – some patients are afraid of being put under a general anaesthesia. 3. Quicker recovery as the patient is given a lower dose of the anaesthetic drugs when compared to a general anaesthesia(although this benefit is minimal in someone who is fit and well – ie a matter of minutes)
Benefits of general anaesthesia – some patients prefer to be asleep for the procedure(Local anaethesia will also be injected during the operation)

Risks of any inguinal hernia repair – both from open or laparoscopic method
1. Urinary retention – usually a temporary problem and more common in elderly men who have enlarged prostate. May need a temporary urinary catheter. There risks is low if local anaesthesia has been effectively injected
2. Wound problems -
(i)Wound infection (1%) : may need antibotics
(ii)Bleeding into wound/ bruising around wound( 3%)
(iii)Scar/keloid – the scar may thicken and be prominent
3. Testicular problems – swelling of the testicles/scrotum, testicular pain. Injury or damage to the vas(sperm tube) – especially in a recurrent hernia repair. Damage to the blood vessels to the testicles – this may cause testicular ischaemia and testicular pain.(the risks are increased in a recurrent hernia repair). Change in position of the testicle – the testicle on that site of surgery may sit slightly higher in the scrotum after the operation.
3. Damage to bowel/bladder and blood vessels(rare – more so in a laparoscopic repair where one can get serious life threatening vessel injury). Development of adhesions in the bowel that is pushed back in.
4. Recurrence of hernia(<1-3%) : Higher in laparoscopic inguinal hernia repair
5. Unexpected findings – eg bowel cancer in the hernia – this may mean having a bigger operation than planned
6. Ongoing pain and discomfort – sometimes this is due to a nerve in the groin being cut or trapped in a stitch/staple or caught in scar tissue.

General risks of any operation
There are risks with any operation which may also happen with a hernia repair.
1. Deep venous thrombosis(Blood clots in the deep veins of the leg) with risk of pulmonary embolism(clot may break off and go to the lung – this can be life-threatening). The risks are less if local anaesthesia is used instead of general anaesthesia and if the operating time is shorter.
2. Lung collapse. Chest infection. Heart attack, stroke and death.
Also in general, smokers and obese patients have increased risk of developing complications.

Risks specific to laparoscopic surgery include:
(i) Injury to organs near the hernia site such as the intestine and bladder
(ii) Massive haemorrhage from injury to major blood vessels
(iii)Gas embolism – from the carbon dioxide gas used to insufflate; this can be life threatening
(iv)Swelling of scrotum due to seroma – may need decompression postop
(v)New hernia – at any of the laparoscopic port sites(usually 3 keyhole sized cuts are made)
(vi)Adhesions causing bowel obstruction
(vii) Subcutaneous emphysema – gas tracking in soft tissue causing swelling under skin from chest to scrotum
(viii)Injury to nerves from pigtail metal staples used to tack mesh down – causing postop pain
Studies have also shown a HIGHER RISK OF HERNIA RECURRENCE from a laparoscopic repair compared with an open mesh repair(N Engl J Med 2004; 350:1819-1827).
The is also a potentially higher risk of blood clots developing from the combination of the laparoscopic technique and general anaesthesia.

POSTOP RECOVERY
You are encouraged to move you legs and flex and extend your ankles as soon as you can once in the recovery ward. Once fully alert, you can eat and drink.
Pain-killers – It is recommended that Parecetamol be taken regularly for the first few days together with a non-steroidal anti-inflammatory medications(eg Brufen) (Provided there are no contraindications to the latter eg peptic ulcer disease, severe asthma). In addition, stronger analgesics like Codeine can be used in the first few days depending on the degree of pain.
Bowel motions – It is important to drink plenty of fluids and take lots of fibre(fruits and vegetables) after the operation to avoid constipation.
Dressings – Dissolving sutures is usually used on the wound. Sometimes adhesive strips are placed across the wound for additional closure strength. A waterproof dressing is usually placed over the top of the wound. This should be left in place for 5-10 days. The adhesive strips can be removed another week later.
RECOVERY – You are encourged to walk and do light activities as soon as you get home. Take care when you get out of bed(avoid straining). It is advisable not to do any heavy lifting for 4-6 weeks.
BACK TO WORK – this varies from person to person. For office work – about 1-2 weeks. For manual work – it slightly longer. (The author has had self-employed patients return to work lifting 10kg boxes from the 3rd day without any problems with the repair)
DRIVING – it is best to not drive for at least a week(the risk is of pain in the wound when braking)

Nipple inversion is usually caused by contraction and scarring of the breast ducts draining into the nipple. Most of the time this is due to non-cancerous conditions. However, it is important to see a general surgeon who deals with breast cancer as one needs to exclude breast cancer as a cause.

Procedure:
This can be done under general anaesthesia or local anaesthesia alone.
The breast is prepped and draped.
A suture is placed to pull up the retracted nipple
A tiny keyhole incision is made in a corner of the base of the nipple – the ducts are cut
The wound is sutured – with the suture also going through the base of the nipple to prevent further inversion in future
The nipple is then dressed around a sponge dressing

Risks:
Not being able to breast feed anymore on that side
Loss of sensation on the nipple
Nipple ischaemia – loss of blood supply to the nipple
Pain
Scar

This is written with the aim of helping my medical students and doctors in training go through my thought process in the outpatient clinic. This list is not meant to be all comprehensive but rather a practical guide in coming to a diagnosis quickly.

Take a full history:
including age, past history and family history
age of menarche, menopause and pregnancies(breast feeding history)
Ask too for nipple discharge ?blood stained(papilloma and cancer), greenish(duct ectasia, fibrocystic disease)

On examination:
Feel for suspicious features of a breast cancer – be especially suspicious of any hard lump in woman over 50yo
In young woman, if the lump is mobile – most likely fibroadenoma

Investigation:
Ultrasound ?fibroadenoma ?cyst ?breast cancer
Mammogram
Tissue diagnosis to complete triple assessment – Fine needle aspiration cytology , biopsy

Other causes –
Skin/subcutaneous lump – epidermal cyst
Silicone granuloma – there are some patients who may have had injections of silicone overseas many years ago(now the women are usually more than 50 years old and their breast cancer risks are increasing)

This is written with the aim of helping my medical students and doctors in training go through my thought process in the outpatient clinic. This list is not meant to be all comprehensive but rather a practical guide in coming to a diagnosis quickly.

1. Duration – has this lump been there for some time and growing slowly (most likely epidermal/pilar cyst)
2. If the lump is of recent onset and is painful – consider if that could be an inflammed epidermal cyst or abscess
3. Lymph node – especially in back of scalp eg occipital lymph node. An US can be helpful if the lump is large – to see if the normal lymph node architecture is present or absent. In case of the latter, consider US-guided FNAC
4. Have a look : if subcutaneous – epidermal cyst. But also to consider lipoma especially at back of scalp. The pilar/epidermal cyst usually has a punctum – but that may not be easily seen(although when you inject LA into the lump, you can sometimes see a bit squirting out) Because of the thick skin, it can be difficult to differentiate a lipoma from a cyst.
If on the skin – consider – skin cancer eg melanoma, BCC or SCC. (I can recall a sad case where a young woman in her 20s presented with a large nodular melanoma on the scalp with satellite nodules – this was discovered by her hairdresser )
5. Other rarer causes – osteoma (bony tumours of the scalp), other soft tissue tumour, tricholemmal cyst

Management:
Offer excision under local anaesthesia – to remove the lump. Best to use an artery to dissect bluntly in the plane around the cyst wall if possible. The Local anaesthesia is also good at helping in creating a plane between the cyst and the surrounding tissue(a bit of hydrodissection). Be careful when injecting in LA or when you incise a cyst that is tense with local anaesthesia – the LA may just squirt out (together with some sebaecous material that may not be smelling all that good…think months of accummulated dirt under the armpit) I always send the lump for histology. If lipoma, it is important to exclude the rarer spindle cell variant which can be more likely to turn to a liposarcoma. Make sure too to remove all the pseudopodia of the lipoma to reduce the risk of recurrence.

This is written with the aim of helping my medical students and doctors in training go through my thought process in the outpatient clinic. This list is not meant to be all comprehensive but rather a practical guide in coming to a diagnosis quickly.

1. Ask the patient how long this pain has been there for – acute ie recent onset – most likely abscess or chronic(?coccydynia) or intermittent(recurrent pilonidal abscess)
2. Examine the patient: Look at the lump ?red, swollen, discharging pus, tender(abscess); any pits/sinus in the midline in the natal cleft(pilonidal sinus)
3. If no pits/sinus openings and the red tender lump is away from the midline – think of other differentials: fat necrosis(has the patient been sitting a lot eg cycling long distances), abscess arising from folliculitis. If the abscess is near the anus low in the natal cleft – then consider a perianal abscess.
4. Always keep at the back of the mind other differentials which are much rarer but as a specialist one has to be aware of:
(i) Skin cancer in the area – BCC, SCC, melanoma
(ii) Other types of soft tissue tumour and sacral tumours
(iii) Dermatitis – ?chronically scratching the area
5. Less commonly – infected/inflammed sebaeceous cyst can also occur there

Management:
If pilonidal sinus abscess – I would do a small operation to drain the abscess through the pits/sinus by making a small incision around the sinus opening, putting in an artery to remove the hair and drain the pus, swiping the cavity with Betadiene soaked gauze. This can be done with LA infiltration around the area if the patient is tolerant or in theatre under Local anaesthesia & sedation in lateral position(easier for the anaesthetist and safer). I would normally treat with oral antibiotics for a week. Review again next week. (In the long term, if recurrent infections, to consider operation with lower recurrence rate namely Modified Karydakis surgery)

http://www.heraldsun.com.au/news/more-news/hospital-waiting-list-pain-to-get-worse/story-fn7x8me2-1226237797257
4800+ patients added to the hospital waiting lists in those hospitals where records being kept (not including smaller country hospitals – eg Kilmore, Seymour)
9500 less surgery being done
And this is despite $13 billion being spent on health last year in Victoria

With the ageing population, the demand for surgery will only get worse.

One needs to look at how theatre efficiencies can be increased.

I would propose that one small step to the solution could be to look if an additional case can be done in each public hospital theatre each day. This would help reduce the numbers on the waiting lists. This would require flexibility on the part of the booking office, day ward, patients, medical staff, nursing staff and admin. But this can be done. There is usually enough spare time during a day’s operating list where the theatre is used to fit in a short case – eg carpal tunnel, skin cancer, gastroscopy, colonoscopy and even a simple hernia repair. All that is needed is a common desire to reduce the waiting lists as much as possible. Without fear that this will mean the budget to the hospital will be cut the next year etc

Interesting data I read from the Victorian Surgical Consultative Council Outcome analysis published in their recent mailout…complication rates for colonoscopy
Public hospital Same Day is 34 out of 79175 for the 2 years from July 2008 to June 2010
Public hospital Multiple Day is 55 out of 12885…(hence rate here is more like 4.2 out of 1000 or about 1 in 250)

For private hospitals, the risks are much lower
14 out of 220 327 for same day
19 out of 12641 for multiple day.

In Victoria, 157,073 patients had elective surgery last financial year, but 182,462 were added to the waiting list.
Ninety per cent of Victorian patients had surgery within 182 days, and the median waiting time was 36 days.

http://www.theage.com.au/victoria/hospitals-behind-in-national-rating-20111129-1o571.html#ixzz1f6CHlkpb

This means that there were additional 25000 patients being added to the waiting list last financial year in Victoria alone…how will this waiting list be reduced?
The capacity is there – eg if one increases the hours theatres are utilized – extending lists to 6-8pm on weekdays, Saturday lists but the costs are prohibitive…esp with a cash-strapped Victorian government

Australia has one of the better public health system in the world in terms of what it offers patients who are sick.
Central to this is Medicare.

What is Medicare?
“Medicare ensures that all Australians have access to free or low-cost medical, optometrical and hospital care while being free to choose private health services and in special circumstances allied health services”. You can read more about this including eligibility from the Medicare website. Basically Medicare sets up a list of fees for various medical items. Eg Consult with GP, consult with specialist, excision of skin lesion, blood tests. Each item has a specific item number. (You can find that online if you search for the Medicare Benefits Schedule)

What is Bulk-billing?
Medicare pays only 85% of the Medicare Benefit Schedule for most outpatient services and 75% for inpatient services done privately. This Schedule is determined by the Australian government and has not kept pace with inflation over the years. Clinics that bulk bill would get their patients to sign the Medicare slip and claim the fee directly from Medicare. Hence patients would not need to pay anything out of pocket.

What is a Gap?
Most doctors would charge fee higher than the 85% of the Medicare Benefit Schedule – the difference in the fees is the gap.

Why is a Referral needed to see a Specialist?
Specialists can only claim their specialist consulting fees only if the patients have a referral. The standard referral from a general practitioner(GP) is valid for 12 months unless otherwise stated. A referral from another specialist is only valid for 3 months.

Why is it important to have a family doctor?
There is a lot more preventative medicine practiced here in Australia. Having a GP would ensure that you are that you have adequate screening for common medical conditions and that you have had the appropriate vaccinations. Also it is a lot easier to see a GP when one is really ill if one already is a patient of a particular clinic.
For routine consults, there can be a waiting time to see a popular GP – eg It can take 1-3 weeks to get an appointment to see some of the GPs I know(of course if one is really ill, the GP will try to fit you in or the clinic will try to fit you in to see another GP at the same practice)

Why are there waiting times here in Australia?
That is the culture here… eg there can be even a few weeks wait to book dinner here in some popular restaurants
Also not as many doctors work long into the night or as many weekends like say the GPs in Malaysia – there is a good work life balance here in Australia. Hence you can be assured that the doctor you see is fresh and not fatigued!

If the public system is free , why should I get private insurance?
There is a waiting list in the public system. While the public system is all right for cancers and other life threatening illness – for other medical conditions, the public system is too overburdened to meet the demands in time.
There is an online website where you can actually check the waiting times for surgery for common medical conditions eg hernia repair
Lets say a 35year old patient has bleeding in the toilet bowl from haemorrhoids. The patient first sees his GP. The GP first treats this with haemorrhoid ointment and advise a high fibre diet. The patient then returns for review with ongoing intermittent bleeding after 2 weeks. The GP then refers the patient to a surgeon at the public hospital. The patient would usually have to wait for a few weeks and sometimes months to get an appointment at the surgical outpatient clinic. Once the patient is seen in the outpatient clinic, if the haemorrhoids require banding or the bleeding needs to be investigated further to rule out bowel cancer with a colonoscopy, the patient is then put on a surgical waiting list. This can be either Category 2(up to 90 days) or Category 3(up to 365 days). Hence it will be a few more months before one has the procedure.
If one goes privately or tells the GP that one has private insurance and wishes to see a surgeon privately, then the GP would refer directly to see the surgeon(usually around 1-2 week wait) and then from there the patient will be booked in to have the procedure in 1-2 weeks.

Also after a certain age, the cost of private health insurance increases for each year later that one takes it up.
So if one were to need a knee or hip replacement one day – one has either pay much more to take up the private insurance later in life or wait 1-2 years in the public health system.

Furthermore, if one’s income is above a certain level, one has to pay an additional 1.5% Medicare Levy Surcharge(additional tax) if one does not have private insurance.
“Currently, you have to pay the surcharge if you are:
a single person with an annual taxable income for MLS purposes greater than $80,000 in the 2011-12 financial year; or
a family or couple with a combined taxable income for MLS purposes greater than $160,000 in the 2011-12 financial year. The family income threshold increases by $1,500 for each dependent child after the first;
and do not have an approved hospital cover with a registered health fund.”

Often this task is left to the junior registrar in the public hospital on minor procedure list with little supervision ..these are a few tips.

1. Terminology: Depending on location – they are more likely epidermal/epidermoid cysts or pilar cysts.

2. A cyst can certainly get infected – I have seen green pus amongst the cheesy white keratinous material (and it can certainly smell!). If there is a lot of induration – it may be best to just drain the pus and keratin material first.

3. If the cyst has recurred because part of the wall has been left behind, then the cyst may not feel as tense as a normal cyst. It will feel boggy and soft.

4. The cyst can be easily excised with the wall intact – local anaesthesia is used to hydrodissect around the cyst as well as for anaesthesia. Care must be taken not to let the fluid squirt out through the punctum! (no problem for the patient – but more for the surgeon and the assistant) A small incision is made right down to the wall of the cyst – care must be taken not to cut into the wall. Then a fine artery forceps can be used to dissect the cyst off the surrrounding tissue. The cyst can then be squeezed out throught the narrow incision …usually intact.

5. If a cyst has been been knocked or inflammed, then it may not be as easy to remove the cyst. Sometimes, the wall has be be excised with a scalpel.

These are relatively common in surgical practice. Despite having done lots of these, I still find the occasional challenging ones which are hard to excise. And it is not always possible to remove the wall intact.