Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Department of Surgery
Document related concepts
no text concepts found
Transcript
Department of Surgery - THH New Services /Existing services • Breast: • • • ED Babu C. Kelley J. Kuriakose • Colorectal: • • • • Y. Mohsen S. Harris A. Prabhudesai A Myers • Vascular: • • • Prof. S. Das T Paes plus interventional radiology • Benign upper gastrointestinal • S. Harris • General - everyone • Emergency - everyone • Paediatric • Kelley and Kuriakose Colorectal service • • • • • • Laparoscopic Enhanced recovery programme Transanal endoscopic microsurgery (TEMS) Joined up with Mount Vernon Cancer Centre Colorectal Stent Pelvic Floor Laparoscopic colorectal surgery • Well-established • Offered by default • 4 surgeons • 50% last year • Estimate 70% this year • Less pain, faster return to function • Probably reduced length of hospital stay New technology Single port laparoscopic surgery (SILS, LESS, NOTUS etc) NOTES • Natural orifice transluminal endoscopic surgery • Transgastric cholecystectomy and appendicectomy Robotic surgery Old and cheap technology • Majority of laparoscopic surgery uses cheap, reusable instruments • Disposable staplers etc. expensive • Cost efficiency shown if length of hospital stay is reduced • Benefits may be difficult to measure Alexis wound retractor Trans-anal Microscopic Endosurgery • • • • • 44 year old female Few months pr discharge Very low anterior lesion, reaching very close to dentate line Colonoscopy otherwise normal Biopsies show high grade dysplasia TEMS Lower third rectal cancer • Chemo-radiotherapy with curative intent • Watch-and-wait • TEMS + Radiotherapy vs. Anterior Resection/Abdominoperineal Excision • Extralevator Abdominopernieal Excision of Rectum .Asynchronous avulsion of the rectum • Increased risk of local recurrence • Circumferential resection margin is crucial Enhanced Recovery Programme • • • • • • Multimodal intervention All designed to reduce trauma of surgery Key is pain control Fluid balance Intra-operative “goal-directed therapy” Avoidance of opiates • Pre-operative carbohydrate drinks • Avoidance of tubes and drains Doris, 79 • • • • • • • Very, very anxious 2WW referral Colonoscopy, CT, then MR pelvis Mid to upper rectal cancer No metastases, except indeterminate lung lesions Brought back to clinic Surgeon and CNS Pre-op visit • • • • On ward side room Information given Avoidance of bowel prep Stoma counselling, practice pack Laparoscopic low anterior resection • • • • 4.5 hours 8cm Pfannenstiel to deliver specimen 4 other ports RIF ileostomy • That evening, sitting up, drinking soup Day 1 • • • • Catheter out Avoid opiates Neutral fluid balance Out of bed, 3x50m walks • Progressively introduce diet • Stoma education • Home day 5 • 2 WW referral • Colonoscopy normal • What now? Pelvic floor dysfunction symptoms • Faecal Incontinence • Urgency • Passive • Post-defecatory soiling • Obstructive defecation • 2-27% of “constipation” • Pain/ altered sensation • Lump at the anal verge • Urinary symptoms • Gynaecological symptoms Pelvic Organ Prolapse Assessment: History • Let pt speak first about symptoms • Impact on QoL • Ask specifically • • • • • • • Digitation Incomplete evacuation Straining Laxative Use: what works, what doesn’t FI: Pads, Urgency/Passive/ PD soiling Obstetric history Investigation so far, fears about cancer Examination • Abdomen • Perineum: Left lateral, straining proctoscopy, haemorrhoids • Gynae chair Investigations • • • • • Exclusion of neoplasia mandatory Defecating Proctography, or MR with valsalva Transit studies Anorectal physiology Endoanal ultrasound Treatment • • • • • • Dietary modification Laxatives Constipating agents Weight loss Biofeedback physiotherapy Surgery Pelvic floor treatments • • • • Assessment Investigations Biofeedback physiotherapy Surgery Internal rectal prolapse or intussusception • • • • Some conditions moving back into realm of surgery Internal rectal prolapse now repaired Can improve OD, FI 80% have some improvement in Oxford series Laparoscopic Ventral Rectopexy STARR procedure • Stapled Transanal Resection Rectopexy • Established treatment for OD caused by IRP • Decreases rectal compliance, urgency may be worse Sacral Nerve Stimulator Pelvic Floor Surgery • • • • • Multidisciplinary approach Miss Vicky Cook, Cons Obstetrician Drs. Meer and Patel, Radiology Nurse specialists Aiming for in-house investigation, biofeedback and surgery
