General Surgery

GENERAL SURGERY

General surgery encompasses comprehensive care that focuses on abdominal abdominal contents including stomach, small bowel, colon, liver, gallbladder and bile ducts, as well as dealing with diseases involving the skin, breast and soft tissue. Other surgical problems that require surgical intervention include hernias and hemorrhoids. Some operations may be performed either traditionally, with a longer incision via an “open” technique, or with the newer, more advanced laparoscopic techniques. Our surgeons are board certified and have extensive experience in both open and laparoscopic techniques.

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COMMONLY PERFORMED PROCEDURES

Hernias (groin, umbilical, incisional)

A hernia is a defect in abdominal wall tissue, called fascia, through which an organ, such as the bowel, may exit the cavity in which it normally resides. Different types of hernia include groin, umbilical and incisional (forming at the site of a previous scar). Groin hernias are divided into inguinal (most common) and femoral type.
Risk factors for the development of a hernia include: smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous open surgery, among others. Hernias are partly genetic and occur more often in certain families.
Hernias symptoms may include pain or discomfort especially with coughing, exercise, or going to the toilet. Often it gets worse throughout the day and improves when lying down. A bulging area may occur that becomes larger when bearing down. The main concern with a hernia is strangulation, were the blood supply to part of the bowel is blocked. This usually produces severe pain and tenderness of the area.
Hernias can often be diagnosed based on signs and symptoms. Occasionally medical imaging is used to confirm the diagnosis or rule out other possible causes.
There is no medical treatment for hernias since it is a physical defect in fascia. Elective repair is recommended because it has less risks for complications. Repair may be done by open or laparoscopic technique. Open surgery has the benefit of possibly being done under local/spinal anesthesia rather than general anesthesia. Laparoscopic surgery is usually reserved for bilateral or recurrent groin hernias and some incisional hernias. Uncomplicated hernias are principally repaired by pushing back, or “reducing”, the herniated tissue, and then mending the weakness in muscle tissue. Muscle reinforcement techniques often involve synthetic materials (a mesh prosthesis). The mesh is placed under the defect and sutures or staples are used to keep the mesh in place. These mesh repair methods are often called “tension free” repairs because, unlike primary repairs without mesh, muscle is not pulled together under tension. Evidence suggests that tension-free methods often have lower percentage of recurrences and the fastest recovery period. If strangulation occurs emergency surgery is required and if bowel viability is compromised, a resection of intestine may be necessary.
About 27% of males and 3% of females develop a groin hernia at some time in their life. Inguinal, femoral and abdominal hernias resulted in 51,000 deaths in 2013.

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Appendix

The appendix is a blind-ended tube connected to the cecum (a pouchlike structure of the colon, located at the junction of the small and the large intestines). The most common diseases of the appendix are appendicitis and carcinoid tumors. Appendix cancer accounts for about 1 in 200 of all gastrointestinal malignancies.

Appendicitis is a condition characterized by inflammation of the appendix. Pain often begins in the center of the abdomen. This pain is typically a dull, poorly localized, visceral pain. As the inflammation progresses, the pain begins to localize more clearly to the right lower quadrant, as the peritoneum becomes inflamed. Fever and an immune system response are also characteristic of appendicitis. Appendicitis usually requires removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, the appendix may rupture, leading to peritonitis, followed by shock, and, if still untreated, death.
The surgical removal of the appendix is called an appendectomy. This removal is normally performed as an emergency procedure when the patient is suffering from acute appendicitis. If acute appendicitis is early (before rupture), most of the time laparascopic appendectomy is performed. In cases when the patient presents after the appendix has ruptured and a localized inflammatory mass formed around the appendix, intravenous antibiotics are used along with percutaneous drainage of the abscess when possible. This is a relative contraindication to surgery. If the collection is inaccessible for percutaneous drainage or the rupture is free, patient needs a more extensive surgery with possible bowel resection.

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Masectomies

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely.

A mastectomy is usually carried out to treat breast cancer. In some cases, people believed to be at high risk of breast cancer have the operation prophylactically, as a preventive measure. Alternatively, some patients can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast.

Both mastectomy and lumpectomy are referred to as “local therapies” for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.
It is normal for people that have mastectomies to remain in the hospitals for 1 to 2 nights and then are released to go home if they are doing well. It is common to have drains coming from the incision site to help remove blood and lymph to initiate the healing process. Patients may have to be taught to empty, care, and measure the fluid from the drains. It is recommended that patients see their surgeon 7–14 days after the surgery, during this time the doctor will explain the results and talk about further treatment if needed such as radiation and chemotherapy. The doctor might refer the patient to a plastic surgeon if they showed interest in breast reconstruction surgery.

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Amputations

When performing an amputation, a surgeon removes a limb, or part of a limb, that is no longer useful to you and is causing you great pain, or threatens your health because of extensive infection. Most commonly, a surgeon must perform this procedure on your toe, foot, leg, or arm. Physicians as well as patients consider amputation a last resort.

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Skin & Soft Tissue Surgery

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Gallbladders

Problems with gallbladder include biliary colic (pain from obstructing gallstone), acute or chronic cholecystitis (inflamation of the gallbladder), gallbladder polyps and biliary dyskinesia (gallbladder not contracting adequately).
Gallstones are the most common problem to affect the gallbladder. Gallstones generally form because the bile is saturated with either cholesterol or bilirubin. Sometimes gallstones may cause symptoms. When symptoms occur, a person may feel severe pain in the upper right part of their abdomen. If the stone blocks the gallbladder, cholecystitis (see below) may occur. If the stone lodges in the biliary tree, jaundice may occur (yellowing of the eyes and skin); and if the stone blocks the pancreatic duct, then pancreatitis may occur. In people with recurrent gallstones, surgery to remove the gallbladder is recommended.
Inflammation of the gallbladder is known as cholecystitis. Inflammation is most commonly caused by obstruction of the duct with gallstones, known as cholelithiasis. Blocked bile accumulates, and pressure on the gallbladder wall may lead to the release of substances that cause inflammation. There is also the risk of bacterial infection. An inflamed gallbladder is likely to cause pain and fever, and tenderness in the upper, right corner of the abdomen. Acute cholecystitis is managed by surgical excision of the gallbladder. In some cases acute cholecystitis may need to be treated with bowel rest (nothing to eat) and antibiotics initially followed by surgery in several weeks. Cholecystitis may also occur chronically, particularly when a person is prone to getting gallstones.
Gallbladder polyps are mostly benign growths or lesions resembling growths that form in the gallbladder wall. If the polyps are multiple or greater than a certain size, it is recommended to remove the gallbladder surgically to rule out malignancy.
Biliary dyskinesia refers to disturbance in the coordination of contraction of the gallbladder and biliary ducts, and/or reduction in the speed of emptying of the biliary tree. The treatment of choice for this condition is cholecystectomy.
A cholecystectomy is a procedure in which the gallbladder is removed. It may be done via an open procedure, or one conducted by laparoscopy. After the gallbladder is removed, bile will drain directly from the liver into the intestines. In our practice most elective cholecystectomies are performed laparoscopically.

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Breast Biopsies

A majority of breast diseases are noncancerous and include fibrocystic breast changes, infectious and inflamatory disease and neoplasms. A breast neoplasm is an abnormal mass of tissue in the breast. A breast neoplasm may be benign, as in fibroadenoma, or it may be malignant, in which case it is termed breast cancer. Either case commonly presents as a breast lump. Approximately 7% of breast lumps are fibroadenomas and 10% are breast cancer, the rest being other benign conditions or no disease, however that varies with patient’s age and risk factors. When a biopsy is needed to determine the type of neoplasia, a needle biopsy is usually sufficient. However, if the biopsy results show malignancy or are indeterminate a lumpectomy may be indicated. Lumpectomy is a surgical removal of a discrete portion or “lump” of breast, usually in the treatment of malignant tumor or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. According to the National Comprehensive Cancer Network guidelines, lumpectomy may be performed for ductal carcinoma in situ (DCIS), for invasive ductal carcinoma, or for other conditions.

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Lifeport Insertions and Removals

A lifeport (also called chemoport or portacath) is a small medical appliance that is installed beneath the skin. A port consists of a reservoir compartment that has a silicone bubble for needle insertion, with an attached plastic tube. The device is surgically inserted under the skin in the upper chest or in the arm and appears as a bump under the skin. It requires no special maintenance and is completely internal so swimming and bathing are not a problem. The catheter is surgically inserted into a vein and terminates in the superior vena cava. This position allows infused agents to be spread throughout the body quickly and efficiently. The surgery itself is considered minor, and is typically performed under both local anaesthesia and conscious sedation. Patients sometimes have a mild discomfort after the procedure which can be managed with pain medications and the patient goes home the same day. When no longer needed, the port can be removed in the operating room. Ports are used mostly to treat hematology and oncology patients.

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Colorectal Surgery

Colorectal surgery is involves dealing with disorders of the rectum, anus, and colon. Colorectal surgical disorders include:
diverticular disease, colon or rectal cancer, anal fissures, fistulas, severe constipation conditions, treatment of severe colic disorders (e.g. ulcerative colitis or Crohn’s disease), and any injuries to the anus. Surgical forms of treatment for these conditions include: colectomy, ileostomy or colostomy, and more depending on the condition the patient suffers from.
Colectomy consists of the surgical resection of any extent of the large intestine (colon). Some of the most common indications for colectomy include colon cancer, diverticulitis, bowel infarction, trauma, and inflammatory bowel disease. Prophylactic colectomy can be indicated in some forms of polyposis, Lynch syndrome and certain cases of inflammatory bowel disease because of high risk for development of colorectal cancer.
Traditionally, colectomy is performed via an abdominal incision.
Resection of any part of the colon entails mobilization and ligation of the corresponding blood vessels. Lymphadenectomy is usually performed through excision of the fatty tissue adjacent to these vessels in operations for colon cancer. When the resection is complete, the surgeon has the option of immediately restoring the bowel, by stitching or stapling together both the cut ends (primary anastomosis), or creating a colostomy. Several factors are taken into account, including circumstances of the operation (elective vs emergency), disease being treated, acute physiological state of the patient, impact of living with a colostomy, albeit temporarily, and use of a specific preoperative regimen of low residue diet and laxatives (bowel prep).

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Hemorrhoidectomies

A hemorrhoidectomy is used for large external hemorrhoids and internal hemorrhoids that have prolapsed. This procedure usually takes place in a hospital. You and the surgeon will decide on the best anesthesia to use during the surgery.

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