With the right technique and positioning, this can be done through a short incision eg 2cm in a lean patient
(best position is with the arm at about 70-80 degree angle from the body)
A grooved director is used to protect the median nerve as the transverse carpal ligaments is cut
One cannot see the benefit from doing it endoscopically from making two cuts instead of one – in fact the serious risk of median nerve injury is well documented in endoscopic carpal tunnel release. In addition, on is dividing the transverse carpal ligaments – hence pilar pain postop(the main cause of chronic pain after the surgery) can still be present
Dr LP Cheah has had a lot of request to do scopes on a Saturday morning.
He will be having a list on Saturday August 27th at John Fawkner Private Hospital.
Dr Cheah normally prefers to see all his patients beforehand so that full informed consent can be obtained. Dr Cheah will be consulting at:
The Clinic Footscray (Wednesday) – Aug 17th and 24th
1st Floor, 91 Paisley Street, Footscray 3011 Tel: 9687 2271 Fax: 9689 6008
John Fawkner Private Hospital Consulting Rooms(Monday – Aug 22nd)
267 Moreland Road, Coburg 3058 Tel: 9385 2285
Caroline Springs Specialist Centre Suite 3-5, 224-226 Caroline Springs Blvd, Caroline Springs 3023 Tel: 8361 7655
(Please inform the reception that this is consult is for endoscopy on Sat Aug 27 if there is no appointment times available)
Please bring along a referral from the general practitioner. (If you have seen Dr LP Cheah before, you would need a new referral if the last referral letter from your GP was more than 12 months old)
If it is not possible to come for a consult before hand or it is an urgent referral(ie acute bleeding from haemorrhoids) – please contact Dr LP Cheah directly through the rooms.
For more information about the procedures and the bowel preparation please see www.melbournesurgery.com
History:
Most important symptom is abdominal pain – pain in the right lower abdomen. History of central(around belly button), intermittent pain moving to the right side of the abdomen(and the pain becoming constant). Patients may give history of being sore to move, of feeling all the bumps in the drive to hospital.
Other symptoms:
1. Loss of appetite – but beware, a young patient who has not eaten for some time can still say they feel hungry even with appendicitis
2. Nausea and vomiting – usually the vomiting is mild
3. Loose bowel action, abdominal pain on urinating(if inflammed appendix tip is sitting on the bladder)
4. Fever
Examination findings:
Patient lying still in bed, sore to move around
Vital signs – may have fever and tachycardia
Abdominal examination : Tender in right iliac fossa, rebound tenderness , crossed tenderness
(note: the tenderness can only be mild if the inflammed appendix is sitting behind the caecum – ie retrocaecal appendicitits)
Ix:
Imaging – an increasingly used modality, helps reduce incidence of negative appendicectomy; Ultrasound can show a swollen appendix(but may not pick up an early appendicitis, also dependent on sonographer and body habitus) CT abdomen – can be helpful but the disadvantage is the radiation exposure
Blood test – elevated white cell count in particular neutrophilia with left shift, elevated C-reactive protein(an inflammatory marker)..but there are cases of appendicitis where the blood test is normal early on
Treatment:
Nil by mouth
Intravenous antibiotics as soon as diagnosis is suspected(why wait?)
Surgery – Appendicectomy : through short incision if diagnosis is confirmed on CT/US, Laparoscopy if uncertain eg in females ?ovarian pathology ?endometriosis or other pathology
Differentials – other diseases that can mimic appendicitis:
1. Diverticulitis – ie if long redundant sigmoid colon, esp in elderly
2. Cancer of caecum
3. Inflammatory bowel disease involving the caecum or terminal ileum
4. Meckel’s diverticulitis
5. Gynaecological – ovarian cyst rupture, Mittelschmerz, torsion of ovary, ectopic pregnancy
6. Worms – eg pin worm
7. Torsion of fat around right colon
8. Low lying inflammed gallbladder
Will the waiting lists for surgery here continue to rise like the US debt as the population ages and more surgical options are available?
Unlike the US debt, there is no QE solution…
Problems we face:
1. Increasing population
2. Increasing percentage of patients from elderly age group…people do get sick eventually even with the best of care – such is life…
3. Budget pressures on hospitals leading to inefficient use of theatre times eg some hospitals do not allow cases after 11am or 4pm on morning or afternoon lists in case of theatre overruns; prolonged theatre closures over Easter and Xmas(to reduce hospital costs)
4. Lack of surgical beds….more and more presssure on beds for medical patients, more patients in hospital waiting for nursing home beds
Overall, I am not optimistic… although there are steps that may help.
Hopefully with the promise of transparency, we will get a true picture of:
1. Waiting lists for patients to surgical outpatients
2. Waiting lists for surgery in smaller country hospitals – these are not normally reported, hospital not required to collect the data
3. Waiting lists to see specialists privately in hospitals without public outpatient clinic
I was just referring a patient to surgical outpatients at a tertiary hospital in Melbourne(too high risk to be operated on in the country) – was asked to tick the urgency for the outpatient consultation…Cat 1 (within 30 days) Cat 2(30-90 days) Cat 3….
Once the patient gets the appointment and sees the specialist there(or the registrar or intern) – they will then be put on another waiting list for their surgery ..again Category 1 , 2 and 3
(and the patient’s wait did not just begin when the patient saw me…he had been waiting for a few weeks for an appointment to see me, prior to that he had to have some investigations..and also wait 1-2 weeks to see his GP…and again 1-2 weeks to see his GP again for the referral to me)
Sometimes, I find it incredible that there is so much waiting in the health system despite the amount of money the government pours in (perhaps a lot is wasted on various levels of bureaucracy/administration) … This seems to be one big weakness of our health system.
Due to budget constraints, one of the most efficient public hospital in Victoria is rapidly building up a waiting lists for its local patients to have surgery.
(This hospital is not WIES funded – but bulk funded) The CEO is under pressure from the DHS to balance the budget.
Steps taken:
1. Cut down on theatre days – ie closing longer over Xmas and New Year and also for Easter ie 4-6 weeks closure
2. Reduce operating time for whole day sessions – finishing by 3:30pm instead of 5pm
3. Not allowing patients to be put on standby (even if the list can finish early) – the are often patients who fail to turn up for their schedule surgery
Other steps:
1. Limiting access to surgery to patients from local postcodes
Unfortunately patients in suburds who are just out of the area suffer – longer waiting lists at other hospitals
Patients who have moved out of the area but still see the local GPs are not able to access the hospital
Patients from other areas – will increase the waiting lists of their local hospitals
2. Encouraging patients to use their private insurance and getting surgeons to increase number of private cases in their lists(however this will only be successful if there is a short waiting list …I don’t believe that public patients should be deferred if their case is urgent in order to operate on a private patient in a PUBLIC HOSPITAL)
In the long-term, this will only add to the state wide waiting lists for elective surgery…true every hospital needs to balance the budget. But when the facility is available, the theatre staff are available not using the theatres to its full efficiency is really a waste of resources. Building new hospitals is not the only answer..more importantly theatre services should be fully funded to function at its capacity.
Leave plastic waterproof dressing on for 1 week
If steristrips used – they can be left on for a further week.
If non-dissovable sutures used – they need to be removed usually in 1 weeks time, may be left in longer in certain areas where there is higher risk of the wound pulling apart(eg lower legs, back), can be removed earlier from face(eg 5 days postop)
Answers to FAQ:
1. Showering – you can shower anytime if waterproof dressing is on. If there is no dressing eg sutures on the scalp – best to keep that area dry for 1-2 days.
2. Bleeding – If a cyst/lipoma has been excised, the residual cavity will initially fill with blood-stained fluid(haemoserous fluid – this can have the colour of red wine). This can sometimes leak out from the wound. So be careful if you lie on the wound – it might be a good idea to have a towel under to soak any discharge. If there is a lot of thick red blood or pain from a hard swelling under the wound – you must contact me again.
3. Pain – The wound can be sore eg like any cut. The local anaesthetic usually lasts for a couple of hours. Paracetamol is usually all that is needed after that. If still in pain , consider adding something stronger like Ibuprofen(please from that there is no contraindication). If the pain is severe or the wound becomes painful after a few days (and there is surrounding skin redness) – please contact me
4. Work – most patients can go back to work the next day. But it is important to keep the surgical area clean.
5. Swimming – best not to swim in a public swimming pool until the wound is fully healed. After the sutures are removed, one should wait a few more days until the stitch holes are fully sealed over. (same applies to water sports eg in the Murray – best not to let the unhealed wound get into contact with water)
To prevent wound breaking open/scar getting wider after the sutures have been removed: sometimes it might be neccessary to reinforce the healing scar with Steristrips or even simple Bandaid. Also you should apply more sunscreen to the scar especially in the first 12 months to avoid the scar getting sunburnt.
LP Cheah
Surgeon
MelbourneSurgery.com
Many condition can cause rectal bleeding. It is important that you exclude a serious cause first by speaking to your doctor! Risks symptoms for a more serious cause include having clots, blood being mixed with the stools, having lots of bleeding, bleeding frank blood, passage of mucus, increasing age(the older you are the higher your risk of bowel cancer), presence of anaemia and loss of weight
Causes include:
1. Bowel cancer – in particular a rectal cancer or cancer in the sigmoid colon
2. Polyps in the bowel – especially large ones in the rectum
3. Haemorroids – this is quite common but it is important to speak to your doctor about it and be examined throughly to exclude more serious cause
4. Inflammatory bowel disease eg proctitis, ulcerative colitis, Crohn’s disease
5. Anal fissure – usually there is a lot of pain when or after opening the bowels(but be warned : rectal cancer invading into the anal canal can also be painful)
6. Trauma to the perianal tissue
Lifetime risk of developing bowel cancer in Australia by the age of 85 years old:
1 in 10 men
1 in 14 women
Medial age at diagnosis: 70 years old
Risks in next 5 years:
30 year old person – 1 in 7000(less than the risks from a colonoscopy of perforation and serious bleeding)
40 year old person – 1 in 1200
50 year old person – 1 in 300
60 year old person – 1 in 100
70 year old person – 1in 65
80 year old person – 1 in 50
The risk is also greater for people with a family history of bowel cancer
Eating a healthy diet and having a healthy lifestyle can lower your risk of developing bowel cancer.
Lifestyle steps you can take include;
1. Having a healthy body weight(ie body mass index below 25)
2. Regular exercise 30-60minute a day
3. Limiting alcohol drinks to not more than 2 standard drinks a day for a man(and not more than one standard drinks a day for a woman)
4. Not smoking
Your diet should:
1. Have adequate fibre( 30G/day) – take lots of poorly soluble fibre(eg wheat bran), have at least 5 serves of vegetables a day, have at least 2 fruits a day
2. Take adequate calcium 1-1.2G/day (may need calcium supplements)
3. Restrict daily energy intake to <2500 calories/day for a man and <2000 calories/day for a woman
4. Be low in fat – <25% of total energy intake should be from fat. (eg avoid fried oily food like fish and chips, be aware too that even instant noodles have a lot of fat in them as they are sprayed or fried in fat in their preparation!!)