Surgical Treatments

Banding of haemorrhoids

Rubber band ligation is the most widely used treatment for internal haemorrhoids. If symptoms persist, surgery may be considered.

A rubber band is placed around the base of an internal haemorrhoid cutting off the circulation. This causes the haemorrhoid to shrink, die and eventually drop off (usually within a few days to a week). Several haemorrhoids may be treated at the same time.

What to expect after banding of haemorrhoids (post-operative)

Bowel surgery

Bowel surgery is required to remove a segment of colon and is used to treat a number of conditions including:

  • colon cancer
  • polyp removal (not suitable for endoscopic removal)
  • Diverticular Disease
  • Crohn's Disease
  • Ulcerative Colitis
  • injury to bowel (eg. trauma, volvulus, ischemic gut)

There are several types of bowel surgery and is dependent upon the area of bowel to be removed. Surgery may be performed laparoscopically (key-hole or minimal incision surgery) or as an open procedure.

In consultation with you, Dr Doudle will advise the most suitable type of surgery or your condition and together formalise the best treatment plan.

Colonoscopy / Endoscopy

Colonoscopy
Under anaesthesia, a flexible tube with a video camera and light is guided via the anus to carefully examine the large bowel (colon). A colonoscopy is performed to look for cancer of the colon (bowel cancer) or colon polyps. If a polyp is found, it may be removed during the procedure.

A colonoscopy may be performed to find the cause of symptoms including:

  • rectal bleeding
  • blood or mucus in the stools
  • unexplained abdominal pain
  • changes in bowel habits such as unexplained diarrhoea
  • screening and surveillance for colorectal cancer.

What to expect after a Colonoscopy - Colonoscopy Information Sheet

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Flexible sigmoidoscopy
Also under anaesthesia and similar to a colonoscopy, a flexible tube examines the rectum and the sigmoid colon (last third of the colon). If a precancerous polyp is detected during the procedure, a full bowel examination by colonoscopy is usually required.

Gastroscopy
A gastroscopy (upper endoscopy) is a medical procedure that uses a flexible tube (endoscope) passed down the oesophagus to see inside the upper digestive tract, including the stomach and duodenum (the first part of the small intestine). A small camera on the endoscope transmits an image onto a monitor to allow close examination of the intestinal lining.

Gastroscopy can be used to determine the cause of abdominal pain, nausea, vomiting, swallowing difficulties, gastric reflux, unexplained weight loss, anaemia or bleeding in the upper digestive tract. Biopsies can be taken to exclude certain conditions including gastritis, helicobacter pylori (CLOtest), ulcers, cancer, acid reflux, coeliac disease and lactose intolerance.

Colostomy & Ileostomy

What is a Colostomy?
A colostomy is an opening in the abdominal wall that is made during surgery. Part of the colon (large intestine) is brought through this opening to form a stoma.

Colostomy surgery is done for many different diseases and conditions. Certain lower bowel problems are treated by giving part of the bowel a rest. A temporary colostomy is created so the bowel can heal. In time, the colostomy may be reversed and the bowel will work like it did before.

When part of the colon or the rectum becomes diseased and part of the bowel removed, a permanent colostomy is made.

What is an Ileostomy?
An ileostomy is an opening in the abdominal wall that is made during surgery. Part of the ileum (the lowest part of the small intestine) is brought through this opening to form a stoma, usually on the lower right side of the abdomen.

Ileostomy surgery is done for many different diseases and conditions. Ileostomy surgery is usually done when the bowel has disease or damage that cannot be treated by other methods. The most frequent reason for having surgery is inflammatory bowel disease (IBD) which includes Crohn's disease, ulcerative colitis or cancer surgery.

Certain bowel problems may be treated by giving part of the bowel a rest or with surgery to remove the damaged part. The bowel must be kept empty so it can heal. To keep stool from getting to the bowel, a short-term (temporary) ileostomy is created. For many patients, an ileostomy can be surgically reversed (removed) and the bowel will work much like it did before.

Fistula repair

To control the sepsis and hopefully achieve healing of the abnormal tract, surgery is required. Techniques available are:

Mucosal advancement flap - after clearing out the track, a flap cut into the rectal wall is made to cover the fistula internal opening. This is done to preserve the sphincter muscle.

LIFT (ligation intersphincteric tract) - a newer technique to divide the fistula and preserve sphincter muscle.

Fibrin glue and Collagen plug - a special glue made from a fibrous protein is injected through the fistula's external opening. The anal fistula tract can also be sealed with a collagen protein plug.

Despite surgical management, fistula surgery is not always successful.

Fistulotomy & Setons

Surgery is needed to treat a fistula and a fistulotomy is the most common type for repair. Once the course of the track between the anus and the skin is identified, the track is opened to allow the wound to heal. Some sphincter muscle may be divided.

A seton is a loop of flexible material that is placed along the track to maintain drainage.

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Haemorrhoidectomy

A haemorrhoidectomy is the surgical removal of haemorrhoidal tissue and is usually performed when banding or other treatments are not effective or the haemorrhoids are severe.

Open haemorrhoidectomy is usually performed when haemorrhoids are too large or complicated.

Stapled haemorrhoidectomy involves the use of a circular stapling device to remove the internal haemorrhoidal tissue only. This type of procedure is usually associated with less pain.

What to expect after a Haemorrhoidectomy

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Prolapse surgery

If a complete prolapse of the rectum occurs, then surgery is usually required to remove the part of rectal wall that is protruding outside the anus.

Delorme (perineal surgery) - some of the prolapsing lining of the rectum (mucosa) is removed and the muscle of the rectum is reinforced with stitches. As this is done via the anus, no external incision is needed.
This procedure is usually performed on frail patients who may have difficulties with abdominal surgery. There is a higher recurrence rate as opposed to Rectopexy.

Rectopexy (abdominal surgery) - the rectum is fixed with sutures and/or mesh to the sacrum. This is usually performed laparoscopically.

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Sacral nerve stimulation (incontinence)

Sacral nerve stimulation is a reversible treatment for patients with faecal incontinence, including leakage of gas, liquid or solid stool and is used where conservative treatments have been unsuccessful.

A small device (neurotransmitter) is surgically implanted under the skin in the upper buttock area. The device sends mild electrical impulses through a lead that is positioned close to the sacral nerves located in the lower back to influence the sphincter and the pelvic floor muscles.

Before the permanent device is implanted, an external stimulator and test lead are implanted and trialled for 7 - 10 days. At the post-operative appointment, the temporary equipment is removed. After this appointment the pre-existing incontinence problems will return.

If significant improvement is achieved and the patient wishes to proceed, a permanent lead and neurotransmitter are surgically implanted under the skin.

Eligibility criteria
Medicare Australia will only pay a benefit if the sacral nerve stimulator is used for the treatment of incontinence with an intact sphincter

Sphincterotomy

A sphincterotomy is a surgical treatment of anal fissures. During surgery, the lower part of the internal sphincter is cut to reduce spasm and facilitate healing. Sphincterotomy usually results in immediate relief of pain.

An alternative treatment is injection of Botox® into the anal muscle. The cost of the Botox® is not normally covered by Medicare or health funds.

Transanal surgery (minimally invasive techniques)

Transanal surgery is a minimally invasive procedure used in the removal of benign polyps and early stage cancers in the rectum. Specially designed instruments and camera systems allow for surgery to be performed through the anus. It requires no incisions on the outside of the anus or abdomen. Techniques available are (TEMS) Transanal endoscopic microsurgery and (TAMIS) Transanal minimally invasive surgery.

Some benefits to minimally invasive surgery are:

  • smaller or no incision
  • less post-operative pain
  • shorter hospital stay