General Surgery

Sportsman's groin is a widely used term for painful conditions affecting the groin region in athletes. The pain is usually chronic and affects the lower abdomen, groin or upper medial thigh.

There is no clear agreement on either the name or the exact underlying problems. Other commonly used names include: Sportsman's hernia, athletic hernia, Gilmore's groin, hockey groin syndrome, athletic pubalgia, inguinal ligament enthesopathy, incipient hernia and osteitis pubis.

Symptoms
Symptoms are pain in the groin, typically worse with running, sprinting, twisting and kicking. Stiffness and soreness after sport is common. Typically symptoms are aggravated by abdominal straining, and rapid rotational movements. There is rarely a history of a specific injury (<30%). The symptoms have usually failed to respond to conservative treatments by the time patients are referred. Physical examination usually fails to reveal a clear bulge or weakness associated with traditional hernias. However on examination a dilated superficial inguinal ring may be found with a cough impulse, and this examination will often reproduce the pain. Diagnosis may be aided by both soft tissue ultrasound, or MRI scanning.

Associated injuries
The commonest definition of a sportsman's hernia is a weakening of the posterior inguinal wall, but there a re a large number of other soft tissue injuries which can be associated, and a Sportsman's hernia alone is unusual. The associated defects include:

- Posterior wall deficiency in the inguinal canal
- Transversalis deficiency
- Tear in the conjoined tendon
- Dilatation of the internal inguinal ring
- Thinned or torn rectus insertion
- Thinning or tearing of the internal or external oblique aponeurosis
- Iliopsoas strain
- Adductor tendinopathy

The most common of these is the adductor injury with around 40% of patients with a Sportsman's groin injury having an associated adductor injury.

The sportsman's groin injuries are not seen in youth sports, and is increasingly common in professional and keen amateur athletes. The causes are most likely due to a combination of the increased stresses associated with higher levels of sport, and progressive degeneration injuries which manifest later in an athletes career. Preventing sportsman's groin injuries is key for many sports professionals and core stability and strength exercises are the most effective.

Treatment
Successful treatment of these complex injuries depends on accurate diagnosis, and restoration of normal anatomy, with appropriate physiotherapy for associated injuries. Surgery is usually offered in sportsmen who are unable to play, or fail to respond to conservative treatment. The anatomy of the groin is repaired surgically in a number of layers. Most adductor injuries are treated conservatively, but in severe adductor strains tenotomy or release can be considered.

Surgery is performed as either a day case, or patients stay in hospital one night. Patients should follow a specific rehabilitation programme.

The outcome of surgery is generally good with over 90% of patients improving, most with resolution of symptoms.

Gallstones are small, pebble-like substances that develop in the gallbladder. The gallbladder is a small, pear-shaped sac located below your liver in the right upper abdomen. Gallstones form when liquid stored in the gallbladder hardens into pieces of stone-like material. The liquid—called bile—helps the body digest fats. Bile is made in the liver, then stored in the gallbladder until the body needs it. The gallbladder contracts and pushes the bile into a tube—called the common bile duct—that carries it to the small intestine, where it helps with digestion.

Symptoms and diagnosis
As gallstones move into the bile ducts and create blockage, pressure increases in the gallbladder and one or more symptoms may occur. Symptoms of blocked bile ducts are often called a gallbladder “attack” because they occur suddenly. Gallbladder attacks often follow fatty meals, and they may occur during the night. A typical attack can cause:

- steady pain in the right upper abdomen that increases rapidly and lasts from 30 minutes to several hours
- pain in the back between the shoulder blades
- pain under the right shoulder

Diagnosis is usually by an ultrasound scan, but other tests such as CT scanning and MRI scanning may also be needed

Gallbladder Surgery
Laparoscopic cholecystectomy This keyhole surgery is most commonly used in gallbladder removal and is done under general anaesthesia, often as a day case. A laparoscope (a long, thin telescope with a light and camera lens at the tip) is inserted through a small cut near your navel. Specially adapted surgical instruments are then inserted through some more small cuts to remove the gallbladder. The operation lasts around 60 minutes. At the end of the operation, the instruments are removed and the wounds are closed with stitches or clips.

Open cholecystectomy surgery This is sometimes used if keyhole surgery isn't possible and involves the removal of the gallbladder through a larger cut in your abdomen (tummy). This type of surgery is done under general anaesthesia. Open cholecystectomy surgery has a longer recovery time than keyhole surgery, and you may need to spend a day or two in hospital to recover.

The colon (large intestine) is a long tube-like structure that stores and then eliminates waste material. Pressure within the colon causes bulging pockets of tissue (sacs) that push out from the colonic walls as a person ages. A small bulging sac pushing outward from the colon wall is called a diverticulum. More than one bulging sac is referred to as diverticula.

Diverticula can occur throughout the colon but are most common near the end of the left colon called the sigmoid colon. The condition of having these diverticula in the colon is called diverticulosis.

A patient with diverticulosis may have few or no symptoms. When a diverticulum ruptures and becomes infected, the condition is called diverticulitis. A patient suffering from diverticulitis will have abdominal pain, abdominal tenderness, and fever. When bleeding originates from a diverticulum, it is called diverticular bleeding. A patient who suffers the consequences of diverticulosis in the colon is referred to as having diverticular disease.

More serious complications include:
- diverticulitis
- collection of pus (abscess) in the pelvis
- colon obstruction
- generalised infection of the abdominal cavity (bacterial peritonitis), and bleeding into the colon.

Diagnosis
Usually by colonoscopy to exclude other causes such as polyps and cancers.

Medical treatment for diverticulitis Many patients with diverticulosis have minimal or no symptoms, and do not require any specific treatment. A high fiber diet and fiber supplements are advisable to prevent constipation and the formation of more diverticula.

Patients with mild symptoms abdominal pain due to muscular spasm in the area of the diverticula may benefit from anti-spasmodic drugs.

Surgery for diverticulitis Diverticulitis that does not respond to medical treatment requires surgical intervention. Surgery usually involves drainage of any collections of pus and resection (surgical removal) of that segment of the colon containing the diverticuli. Surgical removal of bleeding diverticula may be necessary for those with persistent bleeding.

Sometimes, diverticula can erode into the adjacent bladder, causing severe recurrent urine infection and passage of gas during urination. This situation also requires surgery. Sometimes, surgery may be suggested for patients with frequent, recurrent attacks of diverticulitis leading to multiple courses of antibiotics, hospitalizations, and days lost from work.

During surgery, the goal is to remove all, or almost all, of the colon containing diverticula in order to prevent future episodes of diverticulitis. There are few long-term consequences of resection of the sigmoid colon for diverticulitis, and the surgery often can be done laparoscopically, which limits post operative pain and time for recovery.

The term haemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed. Haemorrhoids are either inside the anus—internal—or under the skin around the anus—external.

Haemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, ageing, chronic constipation or diarrhoea, and anal intercourse.

Symptoms
Although many people have haemorrhoids, not all experience symptoms. The most common symptom of internal haemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal haemorrhoids may protrude through the anus outside the body, becoming irritated and painful.

Symptoms of external haemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external haemorrhoid.

In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.

Diagnosis
A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.

The doctor will examine the anus and rectum to look for swollen blood vessels that indicate  haemorrhoids.

Closer evaluation of the rectum for haemorrhoids requires an exam with a proctoscope, a short telescope for examining the lower rectum. To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy.

Treatment
Rubber band ligation. A rubber band is placed around the base of the haemorrhoid inside the rectum. The band cuts off circulation, and the  haemorrhoids withers away within a few days.

Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the haemorrhoid.

Haemorrhoidectomy. Occasionally, extensive or severe internal or external  haemorrhoids may require removal by surgery known as haemorrhoidectomy. This can be performed by a number of techniques nowadays, including by open procedures, or internal stapling.

An anal fistula is a connection (opening) between the skin around the anus and the rectum. Anal fistula usually occurs as a result of an infection or an abscess (collection of pus) in the anus. It can also be caused by conditions that affect the bowel such as inflammatory bowel disease or Crohn's disease.

There are different types of fistula. Some have a single connection running from the rectum to the skin. Others branch into more than one opening. Sometimes they cross the muscles that control the opening and closing of the anus (sphincter muscles).

Symptoms
Symptoms and signs of an anal fistula include:
- pain and swelling in and around the anus
- irritation of the skin around the anus
- leakage of pus or blood
- problems with continence

Diagnosis
Anal fistula is usually diagnosed by physical examination of the anus and rectum. Your surgeon may also ask you to have a magnetic resonance imaging (MRI) scan. The scan can help find out how the fistula is linked to the sphincter muscles.

Treatment
Surgery is usually the only option. The type of surgery you have will be tailored to your individual needs.

A hernia is when an internal part of the body, such as an organ, pushes through a weakness in the muscle or surrounding tissue wall. Usually your muscles are strong and tight enough to keep your intestines and organs in place, but sometimes they aren’t, causing a hernia. This sometimes requires a hernia operation to correct.

The most common types are:
- Inguinal hernia This occurs when tissue (usually part of the intestines) pokes through your lower abdomen.
- Femoral hernia This occurs when tissue pokes through into your groin, or the top of your inner thigh.
- Incisional hernia This occurs when tissue pokes through a surgical wound or incision that has not fully healed.
- Umbilical hernia This occurs when tissue pokes through the part of the abdomen near to the navel (belly button).

Hernia Repairs
Traditional methods of hernia repair involve a hernia operation, pulling together the muscle and tissue. This creates tension, causing pain and a longer recovery period. Modern repairs use a synthetic mesh to "patch" the hernia in a tension free manner. These types of hernia operation repair give very low recurrence rates. Various types of patch or mesh are available, and you can discuss this with your surgeon.

Typically groin hernias can be repaired either laparoscopically (keyhole) or by an open technique. The laparoscopic approach is particularly favoured for recurrent or bilateral (both sides) hernias.

Most hernia operations can be performed as day case surgery, and under local anaesthetic in many cases, depending on your general health

Inflammatory bowel disease consists of the major conditions of Crohn's disease and Ulcerative Colitis. There are some people with colonic inflammation which is difficult to fit to a particular pattern, and we call this indeterminate colitis.

Crohn's Disease
Crohn's disease is due to inflammation of the wall of the bowel. It can affect any part of your digestive system, from your mouth down through your stomach and bowel to your anus. However, it's most common in your small bowel or the first part of your large bowel. It may affect more than one section leaving unaffected areas in-between.

If you have Crohn's disease, you will have inflammation and swelling in affected areas of your bowel and ulcers may form. These are raw areas of the bowel lining which can bleed. Your bowel wall will be thickened and this may cause blockages.

Crohn's disease is a chronic condition. This means that it lasts a long time, sometimes for the rest of the affected person's life. Crohn's disease is characterised by flare-ups of symptoms. These alternate with periods of no symptoms at all - this is called remission. Symptoms include:

- diarrhoea - it may contain blood, pus or mucus
- a painful and swollen abdomen (tummy)
- loss of appetite
- weight loss
- fever
- rectal bleeding - this may lead to anaemia (a condition when you have too few red blood cells or not enough haemoglobin in your blood)
- tears, ulcers or abscesses (pus-filled areas) around your anus

Treatment
Medicines Many people with Crohn's disease find that treatment with medicines is effective. Medicines used to treat Crohn's disease include:

- corticosteroids (eg prednisolone) to reduce inflammation
- medicines to suppress your immune system (eg methotrexate or azathioprine)
- a medicine called infliximab

Surgery
Surgery may be needed to treat complications or if medicines aren't controlling the disease. The surgeon will aim to remove as little of your bowel as possible and expand any parts that have become narrowed. Most Crohn's disease patients will need surgery at some time (97%).

Ulcerative Colitis
Ulcerative colitis is an inflammatory bowel disease that affects about one in every 500 people in the UK. It is a chronic (long-lasting) condition that causes inflammation and ulcers to develop in the lining of your large intestine (colon) and rectum. If you have ulcerative colitis you may have inflammation problems in other areas of your body, such as arthritis or red and painful skin or eyes. Ulcerative colitis can occur at any age and affects men and women equally.

Ulcerative colitis is known as a "relapsing and remitting" condition. This means that your symptoms can disappear and then flare up again from time to time. You may have weeks or even months with few or no symptoms at all.

Symptoms
The main symptom of ulcerative colitis is frequent, watery diarrhoea that sometimes has blood and/or mucus in it. You may also have abdominal cramping during bowel movements. Other symptoms include:

- feeling like you haven't finished on the toilet
- nausea
- loss of appetite
- weight loss
- tiredness
- inflammation (redness or pain) in the eyes, skin or joints.

Having ulcerative colitis increases your risk of developing colon cancer. The risk depends on how long you have it for, and how extensive it is. Because of this, if you have ulcerative colitis you should have regular colonoscopies to check for any signs of cancer developing. If these are present you may need surgery to remove the affected area of colon.

Medicines
The most common treatments for ulcerative colitis are either steroids or a type of medicine called 5-aminosalicylate (5-ASA). You may also be given medicines to suppress your immune system (immunosuppressants) if these treatments don't work.

5-ASA medicines work well for reducing moderate flare-ups or relapses. Some people need to switch to steroids if the 5-ASA treatment isn't working or if the flare-up is severe. You take these medicines as tablets, suppositories or as enemas.

Surgery
In most people, the symptoms of ulcerative colitis can be controlled using medication. However, occasionally the colon needs to be surgically removed. This could be because the inflammation and ulceration continue despite treatment. Sometimes the bowel can become severely swollen - a condition known as megacolon. This is very serious and usually means that the colon needs to be removed.

Alternatively, you may choose to have surgery if your symptoms aren't controlled or you are getting severe side effects from your medication.

Surgery for ulcerative colitis can greatly improve your quality of life: removing the colon can effectively get rid of the disease.

Pilonidal means a 'nest of hairs'
A sinus tract is a small abnormal channel (a narrow tunnel) in the body. A sinus tract typically goes between a focus of infection in deeper tissues to the skin surface. This means that the tract may discharge pus from time to time on to the skin.

A pilonidal sinus is a sinus tract which commonly contains hairs. It occurs under the skin between the buttocks (the natal cleft) a short distance above the anus. The sinus track goes in a vertical direction between the buttocks. Rarely, a pilonidal sinus occurs in other sites of the body.

A pilonidal sinus may not cause any symptoms at first. Some people notice a painless lump at first in the affected area when washing. However, in most cases, symptoms develop at some stage and can be 'acute' or 'chronic'.

Acute (rapid onset) symptoms
Pain and swelling develop over a number of days as an infected abscess develops in and around the sinus. This can become very painful and tender.

Chronic (persistent) symptoms
Around 4 in 10 people have a recurrence of their pilonidal sinus. Usually the sinus discharges some pus. This releases the pressure and so the pain tends to ease off and not become severe. However, the infection never clears completely. This then can mean that the symptoms of pain and discharge can persist long-term, or flare up from time to time, until the sinus is treated by an operation.

Treatment
If you have an infection then you may be given some antibiotics. Painkillers (such as paracetamol and/or ibuprofen) may be very helpful to improve the pain. It may be that you need to have an emergency operation to incise (puncture) and drain the abscess.

Chronic Symptoms
In most cases, an operation will be advised. There are various operations which are done to cure this problem. There are pros and cons of each operation. The options may include the following:

- Wide excision and healing by secondary intention. This operation involves cutting out the sinus but also cutting out a wide margin of skin which surrounds the sinus. The wound is not stitched but just left to heal by normal healing processes (healing by 'secondary intention'). This usually means that the wound can take several weeks to heal and requires regular dressing until it heals. The advantage of this method is that all inflamed tissue is removed and the chance of recurrence is low.
- Excision and primary closure. This means taking out the section of skin which contains the sinus. This is done by cutting the skin either side of the sinus (to form an ellipse shape around the sinus), taking out the sinus, and stitching together the two sides of the ellipse. The advantage for this is, if successful, the wound heals quite quickly. However, the risk of a recurrence, or of developing an infection of the wound after the operation, is higher than the above procedure.
In some cases, where the sinus recurs or is extensive, a plastic surgery technique may be advised to remove the sinus and refashion the nearby skin.

There are variations on the above procedures, depending on your circumstances, the size and extent of the sinus, and whether it is a first or recurrent problem.

Colorectal cancer is a cancer of the colon or rectum. It is sometimes called bowel cancer or cancer of the large intestine. It is one of the most common cancers in the UK. Colorectal cancer can affect any part of the colon or rectum. In general, the more advanced the cancer (the more it has grown and spread), the less chance that treatment will be curative.

As the cancer cells multiply they form a tumour. The tumour invades deeper into the wall of the colon or rectum. Some cells may break off into the lymph channels or bloodstream. The cancer may then metastasise (spread) to lymph nodes nearby or to other areas of the body, most commonly the liver and lungs.

Symptoms
The most common symptoms are:

- Bleeding with passing motion
- Passing mucus with the faeces
- A change from your usual 'bowel habit'. This means you may pass faeces more or less often than usual causing bouts of of diarrhoea or constipation.
- A feeling of not fully emptying the rectum after passing faeces.
- Abdominal pains.
- Tiredness
- Anaemia
- Bowel blockages

Diagnosis Your surgeon will examine you in clinic and the lowest tumours can be felt, or seen on a short telescope used in outpatients (rigid sigmoidoscope). However in most cases a test on the large bowel will be required to assess the whole colon and rectum. This is usually a colonoscopy, but can also be a specialised CT scan. If a tumour is found it is biopsied for diagnosis, and this can only be done via the colonoscope. Treatment Surgery is the mainstay of treatment to try and cure bowel cancer. The segment of bowel with the cancer in it can be removed and the ends usually rejoined. In some cases a stoma is needed either temporarily or occasionally permanently (the bowel brought to the abdominal wall and drained to a pouch).Surgery can be performed by open technique or keyhole technique in most cases.

A gastroscopy is a test where the endoscopist looks into the upper part of your gut (the upper gastrointestinal tract). The upper gut consists of the oesophagus (gullet), stomach and duodenum. The operator uses an endoscope to look inside your gut. Therefore, the test is sometimes called endoscopy.An endoscope is a thin, flexible, telescope. It is about as thick as a little finger. The endoscope is passed through the mouth, into the oesophagus and down towards the stomach and duodenum.The test is usually carried out with either a local anaesthetic throat spray, or a light sedative.

This is a test to look at the left side of the large bowel or colon.  It is done by a colonoscopy specialist. 

It should take between 10- 15 minutes, although the whole appointment may take around two hours.

During this test, the specialist uses a thin flexible tube (a colonoscope) with a tiny camera on the end to look inside your bowel.  The tube is about the width of your little finger and is passed through the anus (back passage) into the bowel.

A colonoscopy is a test where the endoscopist looks into your colon. The colon is sometimes called the large intestine or large bowel. The colon is the part of the gut which comes after the small intestine. The last part of the colon leads into the rectum where faeces (stools or motions) are stored before being passed out from the anus. A Flexible sigmoidoscopy inspects the left side of the colon alone and is less invasive.

A colonoscope is a thin, flexible, telescope. It is about as thick as a little finger. It is passed through the anus and into the colon. It can be pushed all the way round the colon as far as the caecum (where the small and large intestine meet). In most cases experienced endoscopists can view the last part of the small bowel as well.

Advanced Colonoscopic Techniques:
Using tiny instruments passed down the colonoscope it is possible to remove polyps and other lesions of the bowel, use laser and heat treatments to lesions, and even position devices to hold open tumours which are narrowing the bowel.

Advanced Upper GI Endoscopy
Using tiny instruments passed down the gastroscope it is possible to remove treat bleeding ulcers and other lesions of the stomach, use laser and heat treatments, and remove polyps. It is also possible to place feeding tubes into the stomach through the abdominal wall (PEG procedure).

Traditional methods of hernia repair involve pulling together the muscle and tissue. This creates tension, causing pain and a longer recovery period. Modern repairs use a synthetic mesh to "patch" the hernia in a tension free manner.

These types of repair give very low recurrence rates. Various types of patch or mesh are available, and you can discuss this with your surgeon.Typically groin hernias can be repaired either laparoscopically (keyhole) or by an open technique. The laparoscopic approach is particularly favoured for recurrent or bilateral (both sides) hernias.

Most hernia surgery can be performed as day case surgery, and under local anaesthetic in many cases, depending on your general health.