General surgery covers a number of areas and there is significant overlap between general surgery and other areas of medical specialisation. In this section you will find video information that deals with the management of ulceration, predominantly of the lower limb, the repair of inguinal hernias and other hernias, laparoscopic cholecystectomy, carpel tunnel decompression, appendicectomy and colectomy.
An ulcer is a defect in the surface lining of the body. Ulcers can occur on the outside of the body or the inside of the body. Ulcers that occur on the inside of the body most frequently occur in the mouth or the gastrointestinal tract. Ulcers that occur on the outside of the body usually involve the skin surface, and in the vast majority of cases, these involve the skin of the lower limb. One of the more common causes of ulcers of the lower limb in skin trauma. Other causes of ulcers to the lower limb are skin malignancies, infections which may be primary or secondary, foreign bodies or underlying venous or arterial disease.
The healing of ulcers is often complicated by coexisting morbidities such as peripheral neuropathy from diabetes, malnutrition, administration of drugs that can cause delayed healing. Occasionally treatments that attempt to promote ulcer healing can have a contrary effect. The following video outlines my general approach to dealing with the management of skin ulceration.
A hernia is a defect, usually in the abdominal wall, through which the contained contents such as bowel or omentum can prolapse abnormally as a result of increased intra abdominal pressure. When abdominal contents can move freely in and out of this hole in the abdominal wall we call this type of hernia a reducible hernia. If these structures are unable to be returned from the hernia sack back into the abdominal cavity we call this an irreducible hernia. Occasionally an irreducible hernia occurs in which the blood supply to the contents of the hernia is cut off. This is called a strangulate hernia.
Clinically hernias are characterised by the presence of an expansile swelling at the site of a recognised hernial orifice. A tender painful swelling at one of these sites may indicate a strangulated hernia. A strangulated hernia is a surgical emergency and needs urgent treatment.
The commonest sites for hernias to occur are in the groin (inguinal and femoral), at the umbilicus (belly button), and at the site of a surgical incision. Occasionally in the lower limb a muscle hernia can occur in which the calf muscles are squeezed out through a defect in the fascia of the lower limb. These hernias can cause calf pain on exercise and can be confused with intermittent claudication.
In general, it is desirable to repair hernias when they are symptomatic and before they become strangulated and require an emergency procedure. The follow procedures outline the repair of hernias at various sites.
Laparoscopic cholecystectomy is a procedure in which the gall bladder is removed using laparoscopic techniques. an associated procedure is operative cholangiography in which contrast is injected into the bile ducts and an x-ray is taken to exclude the presence of stones or other pathology in the bile duct system. Most frequently cholecystectomy is performed for the treatment of biliary colic, acute cholecystitis or chronic cholecystitis. Almost invariably these conditions are due to the presence of stones in the gall bladder.
This procedure involves the placement of four small incisions in the abdominal wall. The procedure is performed using a laparoscope and digital camera. The procedure takes about one hour and the length of hospital stay is 24 – 48 hours. The following video outlines the performance of laparoscopic cholecystectomy and operative cholangiography.
This is a video from YouTube
Carpel Tunnel Decompression
The carpel tunnel is an anatomical structure that occurs in the wrist. The carpel tunnel is formed by the bones of the carpus of the wrist which form an arch. This is held in its form by the transverse carpel ligament. The tendons of the forearm which work the fingers and the median nerve which supplies innervation to the thumb, first finger and second finger, and half the third finger travel through this tunnel. If the passage way through this tunnel becomes narrowed by arthritis of the carpel bones or swelling of the tendons then pressure on the median nerve can result. Carpel tunnel syndrome is characterised by pain in the hand due to pressure on the median nerve. This condition is diagnosed by the performance of nerve conduction studies and treated by surgical division of the transverse carpel ligament.
Appendicectomy is usually performed for inflammation of the appendix. This is called an appendicitis. Clinical presentation of an appendicitis is the development peri-umbilical abdominal pain which subsequently moves to the right iliac fossa and is associated with tenderness on palpation and rebound peri-toneal irritation. Several conditions can mimc appendicitis clinically. Mesenteric adenitis, salpingitis, ectopic pregnancy, ovarian pathology and other conditions can be confused with appendicitis. In general, the presence of right iliac fossa pain in females is considered to be an indication of early intervention, whereas in males the condition may be observed for a period of time. When a patient presents with right iliac fossa pain the patient may have MSU, blood tests, an ultrasound and CT scan in an attempt to identify the underlying condition. Ultimately, it may be necessary to perform a diagnostic laparoscopy with or without an appendicectomy to treat this condition.
Colectomy involves part or whole removal of the colon. The most common indication for this is the presence of colon cancer. Other indications for colectomy may be inflammatory bowel disease, benign polyposis, diverticular disease or in conjunction with other pathological processes that can involve the colon. Colectomy can be performed with primary anastomosis so that the colon remains in-continuity or with a stoma. A stoma may be temporary or permanent. A stoma is the opening of the colon on to the abdominal wall.