Apart from being breast and endocrine surgeon I also perform a range of general surgical procedures and see patients with general surgical problems.
I will see patients with all general surgery problems like abdominal wall hernias, gallstones, abdominal pain, bleeding per rectum (PR bleeding or bleeding from back passage), change of bowel habit, skin lesions, skin and neck lumps/masses and enlarged lymph nodes.
I perform a range of general surgical procedures including:
Laparoscopic (keyhole) and open hernia repairs
Laparoscopic and open gallbladder surgery
Excision biopsy of lymph nodes
Excision of skin lesions
Excision of skin and neck masses
Small bowel surgery
I do not perform these procedures:
Gastroscopy and colonoscopy
Hiatus hernia Surgery
Stomach (gastric) surgery
Hiatus hernia operations
If during any of the investigations I find a problem that requires surgery or procedure that I do not do, I will refer the patient to appropriate surgeon.
If you have any questions, please either email me on the link below.
Abdominal wall hernias occur when an organ or tissue protrudes through a weakening in the front abdominal wall. The abdominal muscles and surrounding tough tissue normally hold the abdominal contents in place. The lining of the abdominal cavity (peritoneum) is pushed by organs or intra-abdominal tissues like a sac or a balloon which often becomes visible. Majority of hernias occur in the groin, either as inguinal or femoral hernia.
Epigastic hernia is a hernia that develops anywhere in the midline and above the belly button (umbilicus) and below the breast bone.
Umbilical hernia is hernia that develops at the level of umbilicus (belly button).
Inguinal hernia is a hernia that develops in the inguinal canal. The inguinal canal is an area of the abdominal wall that allows the spermatic cord and testicle to descend from the abdomen into the scrotum as the fetus develops and matures. In females this area contains round ligament of the ovary.
Femoral hernia is a that develops through the weaker area where the femoral vessels and nerve (going to the leg) leave abdomen and go into the leg.
Spigelian hernia is very rare and occur on the outside edges if the rectus abdominis muscle.
Incisional hernia develops as a complication from abdominal surgery at the site of previous incision. All surgeons repair and close the incision, this area is always weaker than the normal abdominal wall and more susceptible for development of hernias.
Risk factors for developing hernia are: chronic constipation, chronic cough, recurrent vomiting, obesity, ascites (collection of fluid inside the abdominal cavity), dialysis, abdominal masses, pregnancy, previous surgeries and repeated heavy lifting.
Hernias may be asymptomatic (not causing any problems) or they can cause abdominal pain and discomfort. The other, more serious complication is if organ becomes caught in the hernia and cannot be pushed back. The tissue that is caught can die. If this happens to bowel, the dead part will perforate (make a hole) and patients develop septicaemia.
If hernias are asymptomatic, they may not need any treatment. If they are symptomatic, then they need to be repaired. Also symptoms like constipation or abdominal masses need to be investigated prior to repair.
There are 2 types of surgical repair: open and laparoscopic repair.
In open repair the surgeon often makes the incision at the site of the hernia. The protruding tissue is pushed back into abdominal cavity and weakened area (defect in the abdominal wall) stitched. A piece of mesh may be placed into the area to prevent hernia. In open inguinal hernia repair the mesh is almost always used. In other types of surgery mesh is used less.
In the laparoscopic repair the hernia is reduced (pushed back into the abdominal cavity) and mesh is always inserted to close the defect in the abdominal wall. It is not possible to perform laparoscopic repair without the mesh.
The complications of hernia repair are rare.
Hernia recurrence – inguinal less then 5 %, others up to 10%.
Infection (less then 2%)
Damage to blood supply to testicle.
Damage to bowel
The gallbladder is a small hollow organ that stores bile which is produced by the liver. It is a pear shaped organ that lies beneath the liver and is attached to liver. It is usually 7-10cm in length and is divided into 3 sections: the fundus, the body and the neck. The fundus is the rounded end that faces the abdominal wall. The body lies in a depression in the undersurface of the liver. The neck tapers and is continuous with the cystic duct which joins the common hepatic duct and forms the common bile duct (CBD). The CBS tapers and joins the duodenum (first part of the small bowel). The gallbladder may vary in size, shape and position in different people.
The main purpose of gallbladder is to store the bile. When the food that contains the fat enters the stomach and small bowel, the body produces a hormone that stimulates gallbladder to release bile. The bile is required as emulsifier for our body to digest fat. The easiest way to think about the role of bile, is to compare it to the dishwashing liquid. If there is no dishwashing liquid when dishes are washed, then the fat is just smeared over the plates. If it is present, it breaks down the fat and plates are able to be washed.
Gallbladder can cause several medical conditions:
Gallstones – we are not sure why some people develop gallstones and other don’t. Gallstones are formed when the bile gets saturated by cholesterol or bilirubin. Some parasitic infections also cause gallstones. Development of gallstones also runs in some families. Presence of gallstones may or may not cause any symptoms. Symptoms that may be caused are: severe colicky (in waves) upper abdominal pain (biliary colic), inflammation (cholecystitis), jaundice (yellow skin) if it blocks main common bile duct and pancreatitis (inflammation of pancreas). The only treatment for symptomatic gallstones is surgery to remove the gallbladder. Medication or lithotripsy to dissolve stones are not very successful or these may cause more problems (like small stones lodging in the common bile duct, or going down the duct and causing pancreatitis).
Cholecystitis is inflamed gallbladder. It is usually caused by stone blocking the gallbladder. Inflamed gallbladder causes worsening pain and fever. It is treated by with intravenous antibiotics and immediate of delayed surgery most of the time.
Gallbladder polyps are benign growths in the gallbladder. With increasing size of the polyp there is increased chance that it may turn cancerous. Due to this gallbladder removal is recommended if these reach 1cm in size.
Gallbladder cancer is uncommon type of cancer. It happens in 1 in 100,000 people throughout their lifetime. It usually develops later in life. Often cancer does not cause any symptoms, otherwise it may cause pain or jaundice. This is an aggressive type of cancer and best treatment is surgery where gallbladder and usually part of liver are removed. This surgery should be performed by trained hepatobiliary surgeon.
Blood tests that are performed at liver test including bilirubin, AST, ALT, ALP and GGT. Often GGT and ALP are raised in presence of gallstones. Raised bilirubin is indication of a stone with in the common bile duct.
Ultrasound is best investigation for gallbladder. It shows presence of gallstones and thickness of gallbladder and presence of polyps.
CT scan is only used when there is suggestion of gallbladder cancer or in large polyps to exclude invasion into liver.
MRI scan is only used when there is suggestion of gallbladder cancer or in large polyps to exclude invasion into liver.
Surgery Cholecystectomy is a surgery that involves removal of gallbladder. It may be performed as open or laparoscopic (keyhole) surgery. Cholecystectomy is always performed under general anaesthesia.
During laparoscopic cholecystectomy 4 incisions are usually made. One around the belly button (umbilicus) tends to be a bit bigger (1cm on average), while other three (one in midline in the upper abdomen and 2 on the right side) tend to be around 5mm in size. Abdomen is inflated with gas and lining around the gallbladder (peritoneum is divided) and cystic duct and cystic artery are identified and clipped and cut. Gallbladder is then peeled of the liver using diathermy and removed in the bag through the umbilical incision. This surgery is very safe. Rates of infection in the incisions is around 2%, other risks are even more uncommon. Bleeding is rare, around 0.5% risk of blood transfusion. Bile leak, injury to surrounding structures like common bile duct, duodenum and large bowel are also very rare. Conversion to open procedure may happen and risks range from 1-10% depending on the underlying condition (less for biliary colic and polyps, more for inflammation). Most people go home the next day, although some may go the same day. Most people will be back to work in 1-2 weeks time.
In open cholecystectomy a 10-15cm cut is made 3-4 cm below the right sided ribs. Muscles and all layers of abdominal wall are cut. This procedure is usually performed when laparoscopic surgery shows that there is too much scarring/inflammation to perform laparoscopic surgery safely. Gallbladder is removed through the large incision. Most patients stay in hospital 3-4 days and are back at work within 3-4 weeks.
Haemorrhoids are the engorged vessels of the anal (backpassage) canal. As it enlarges, it bulges into the anal canal and eventually it may prolapse (protrude) through the anal canal. External and skin tags usually represent the stretched skin arising from the prolapsed internal haemorrhoid. Perianal thrombosis (clot) is extremely painful lump at the edge of the anus. Haemorrhoids do not lead to or associated with cancer.
Internal haemorrhoids are due to weakening of the supportive tissues within the anal canal and cause veins within the haemorrhoids to enlarge. Risk factors are: chronic constipation or diarrhea, pregnancy, straining or anything that increases intra-abdominal pressures (obesity, weightlifting etc).
Symptoms of haemorrhoids may be:
Bleeding – is the most common symptom, usually seen on toilet paper. At times blood may drip into the toilet bowl. PR (backpassage) bleeding should always be investigated to exclude cancer.
Lumps – may develop durin a bowel motion. It is usually reducible.
Discomfort or Pain – some discomfort is common, but severe is either due to thrombosed haemorrhoid or anal fissure (split in the lining) or squamous cell carcinoma (SCC type of cancer).
Itch (pruritis ani) – is usually due to discharge
Treatment A consultation with a GP or a surgeon is necessary to exclude more serious causes of the bleeding. These investigations may include sigmoidoscopy or colonoscopy or CT colonography.
Increasing fibre and fluid in the diet and avoiding straining and prolonged sitting on the toilet is used. Increase in fibre is usually in form of Metamucil or similar bulking agent. Ointments like Ultraproct may be helpful as well. These treatments often completely resolve mild symptoms.
Injection with phenol in oil can be used for mild internal haemorrhoids as well.
Rubber band ligation is used for larger internal haemorrhoids. This obstructs the blood supply for the haemorrhoid and it shrivels and falls off.
Stapled haemorrhoidectomy – alternative to traditional haemorrhoidectomy. I do not perform this procedure. This procedure is performed less and less due to possible complications.
Haemorrhoidectomy – surgical excision of large or complicated haemorrhoids. This is performed under general anaesthesia. I also usually perform bilateral pudendal block (numb the pudendal nerves with local anaesthetic). Following this surgery patients often require laxatives in form of Metamucil and lactulose as well as significant analgesia (Panadol + neurofen/voltaren + Tramadol or codeine).
Lymph nodes are part of the lymphatic channels. They are connected via lymphatic vessels and are present throughout the body. Lymph nodes are important in functioning of the immune system and consist of both B and T cells. They trap foreign particles and cancer cells.
They can become inflamed or enlarged in wide variety of conditions, from viral infections to life-threatening conditions like cancers. There are many causes of enlarged lymph nodes. Mostly diagnosis can be made on history, examination, blood tests and imaging, but at times excision biopsy is needed, especially to diagnose or exclude different types of lymphoma or sarcoidosis.
As a surgeon, I am mostly a technician, only required to perform an excision biopsy requested by another specialist. Usually in these cases patients are referred to me by different subspecialist like haematologist (blood specialist) or respiratory physician. At times I see the patients first, perform tests and request imaging and then perform excision biopsy for a diagnosis. Then I refer the patient to relevant specialty for treatment. When excision biopsy is performed, this is done on the lymph nodes that look abnormal, but that are in easiest location for the biopsy. Most often excision of the groin or armpit is performed, as it is associated with less complications. The next most common excision biopsy performed is that of the neck lymph nodes. Often breast surgeons perform armpit (axillary) excision biopsy. Neck lymph node excision biopsy should be performed by surgeons who are trained to operate in the neck as this is a complex area (endocrine surgeons, thyroid surgeons, ENT surgeons).
Possible complications of excision of the lymph nodes:
Bruising – is common and disappears with time
Haematoma – blood can collect under the skin (haematoma) and cause swelling, discomfort and hardness. It usually resolves, but rarely may need surgery to remove it.
Wound Infection – this is also unusual. Things to look for are spreading skin redness, discharge from the wound or around the drain, worsening pain in the wound, warm and swollen wound and feeling unwell with flu-like symptoms.
Change in Sensation – some will occur in the skin because sensory nerves to this area have been affected by the surgery.
Seroma – fluid will collect in wound in small or larger quantities. If it causes discomfort it may need to be removed using a syringe. This is not a painful procedure.
Lymphoedema – swelling caused when lymph fluid accumulates in the surrounding tissue due to impaired function of lymphatic vessels (for more information see lymphoedema section on the breast page of this website).
Damage to surrounding structures – mostly nerves, but this depends on the area of the body that is operated on.
Wakefield Specialist Medical Centre 99 Rintoul St, Newtown Wellington
Waikanae Specialist Centre Marae Lane Waikanae
Boulcott Specialist Centre 666 High Street, Boulcott Lower Hutt