Colorectal surgery

Areas of special interest include minimally invasive (keyhole) surgical procedures for benign and malignant colorectal conditions. This can lead to reduced post-operative pain and much shorter stays in hospital with a rapid return to full activities.

All of the surgeons are experienced endoscopists and Spire Dunedin provide state of the art equipment for colonoscopy and OGD (endoscopy).

The hospital provides top quality patient care from diagnosis to treatment and rehabilitation with a single-point of referral, short waiting times, and with appointment and treatment times to suit the patient. A further specialist area is proctology (conditions of the lower bowel and anus) and Spire Dunedin Hospital leads the way in the modern management of haemorrhoids, offering the HALO™ procedure (Haemorrhoidal Artery Ligation Operation) and it's variants: DGHAL, HAL-RAR, and the most recent advance – Trilogy for HALO. Trilogy for HALO provides surgeons with no-attachment wireless technology for the HALO procedure, promoting even greater patient comfort and even faster recovery. Mr Simon Middleton of The Colorectal Practice performed the first procedure in the UK using Trilogy for HALO in March 2014.

The hospital also benefits from on-site X-ray, MRI, CT and ultrasound and works closely with GPs to ensure they are kept up-to-date with the latest developments in treatment technology.

The treatments provided include:

Treatments for haemorrhoids

The hospital is at the forefront of treatment for haemorrhoids, using minimally invasive techniques including HALO to improve recovery and reduce the risk of complications.

Haemorrhoids, also known as piles, are enlarged and swollen blood vessels in or around the lower rectum and anus (the lower rectum is the final part of the bowel and the anus is the opening at the end of the bowel). Haemorrhoids are very common in men and women and often during pregnancy and immediately following childbirth. They are not life-threatening, but they can cause itching, bleeding and pain. Internal haemorrhoids develop in the lower rectum, a few centimetres above the opening of the anus. If they extend out of the opening of the anus, they are described as 'prolapsed'.

Haemorrhoids can often be successfully treated by simple measures such as eating more fibre and drinking more fluid. If these simple measures are unsuccessful, haemorrhoids can usually be treated successfully in a clinic. Local anaesthetic treatments include 'injecting' or 'banding' the haemorrhoids.

There are several surgical approaches to dealing with larger or resistant haemorrhoids that cannot be treated in the clinic or at home. The choice of treatment is dependent on the patient and their condition.

Injection

Injection is a common outpatient treatment for haemorrhoids. The advantages are that it has few side-effects, does not require hospital admission or anaesthesia and is frequently successful. The disadvantages are that it may require repeating as a course of injections (usually up to three) and that it can sometimes cause pain and bleeding.

Oily phenol is injected into the base of each pile to scar the blood vessels supplying the pile. Over time this can lead to shrivelling of the piles and a reduction in the symptoms they cause. Pain is generally uncommon and often does not occur immediately, though some discomfort may be experienced.

Banding

Banding is a common outpatient treatment for haemorrhoids. The advantages are that it has few side-effects, does not require hospital admission or anaesthesia and is frequently successful. The disadvantages are that it may require repeating as a course of bandings (usually up to three) and that it can sometimes cause pain and bleeding. Small rubber bands are applied to the base of the piles to cut off the blood supply. Over time this can lead to shrivelling of the piles and a reduction in the symptoms they cause. Pain is generally uncommon and often does not occur immediately, though some discomfort may be experienced.

Doppler-guided haemorrhoidal artery ligation (HALO, DGHAL and HAL-RAR)

The HALO technique and its modifications have revolutionised the treatment of haemorrhoids. Doppler-guided haemorrhoidal artery ligation utilises minimally invasive surgical techniques to treat the source of haemorrhoids without surgical excision, stapling or banding. It interrupts the blood supply to the haemorrhoid which allows it to shrivel away. As the procedure is far less painful than a conventional cutting haemorrhoidectomy it can be performed as a day-case operation and in most cases patients can return to work considerably quicker than after an open procedure. The very latest HALO innovation – Trilogy for HALO – provides surgeons with a no-attachments wireless technology for the HALO procedure, promoting greater patient comfort and faster recovery. Mr Simon Middleton performed the first procedure in the UK using Trilogy for HALO in March 2014.

Recto anal repair

Recto anal repair is an operation to control prolapsing haemorrhoids. Essentially it involves some dissolving stitches being inserted into the lining of the rectum, which then puts a pleat in the mucosa and draws the pile back up into the anal canal. The operation tends to be quite uncomfortable afterwards but generally the pain lasts for less than a week.

Stapled haemorrhoidopexy (PPH – procedure for prolapse and haemorrhoids)

In stapled haemorrhoidopexy a specially designed circular stapler is inserted into the rectum. It is used to cut out a strip of the tissue above the haemorrhoids in an area of the rectum that is not sensitive to pain. The operation helps to reduce the haemorrhoids. It also helps shrink the remaining haemorrhoids by reducing their blood supply and makes them less likely to extend out of the anus.

All of the 'work' of the operation is performed inside the anal canal, which is considerably less sensitive than the skin bearing area around the anus where the open procedure is performed. The other advantage of the operation is that' like the HALO procedure, it leaves the natural anal canal tissue behind, but in the correct position and much smaller.

As the procedure is almost pain free it can be performed as a day-case operation and in most cases patients can return to work considerably quicker than after an open procedure.

Bowel surgery

The hospital offers some of the latest and most innovative techniques including laparoscopic (keyhole) surgery for a number of bowel complaints including cancer, diverticular disease, Ulcerative Colitis and Cohn's disease.

Surgery may be necessary to treat bowel cancer. The aim of surgery is to remove the area of bowel affected by cancer and usually a small amount of healthy tissue either side, to ensure all the cancer cells are removed.

The bowel is a long tube. Bowel surgery usually involves removing the section of tube affected by cancer. The two ends are then joined together with stitches or staples. The amount of bowel removed depends on the position and size of the cancer and how advanced it is.

Lymph nodes near the bowel are usually removed as well. These are small bean-shaped organs that are part of the immune system. These are usually taken out to assess if the cancer has spread to them.

When a keyhole approach is possible this means that the stay in hospital may be as little as two days.

Colonoscopy

A colonoscopy is the most accurate way of looking at the large bowel to identify abnormalities. This is accomplished by inserting a flexible tube that is about the thickness of a finger into the anus, and then advancing it slowly, under visual control, into the rectum and through the colon. A high definition image is provided by a monitor. This test may be done for a variety of reasons. Most often it is done to investigate the finding of blood in the stool, abdominal pain, diarrhoea, a change in the bowel habits, or an abnormality found on colon X-ray or a CT scan.

A colonoscopy also allows the surgeon to take samples of tissue for further examination and to remove polyps (which are like small cherries) that can grow on the bowel wall. A small proportion of polyps may turn into malignant cancer over a period of years and removing them when benign reduces this risk.

Prior to the procedure the bowel is prepared with a special drink in order to empty the colon facilitating clear views for the endoscopist.

A colonoscopy is performed as a day case procedure. Colonoscopy is performed under sedation and a strong pain killer is also administered. Following a colonoscopy, patients are not permitted to drive for 24 hours.

Flexible sigmoidoscopy

Flexible sigmoidoscopy is a telescopic examination of the anus, rectum and the lower (sigmoid) colon. The flexible sigmoidoscope is a flexible tube 60 cm long and about the thickness of the little finger. It is inserted gently into the anus and advanced slowly into the rectum and the lower colon. It is an accurate and simple method of investigating the cause of rectal bleeding, change in bowel habit, and rectal symptoms such as pain and diarrhoea. Flexible sigmoidoscopy also is a part of colon screening and surveillance for colon cancer.

As well as identifying and photographing abnormalities of the bowel, samples can be taken and small procedures, such as polyp removal can be undertaken.

The procedure takes place on the day of admission without anaesthetic or sedation and patients normally go home on the same day. The procedure is usually painless, but sometimes there is 'wind' discomfort as gas is used to inflate the colon. Patients are given an enema upon arrival at the hospital to empty their lower bowels, facilitating this procedure.

Treatments for anal fissure

Anal fissures are cracks or tears in the anus and anal canal and may be acute or chronic (referring to the time that they have been present). The primary symptom of anal fissures is pain? during and following bowel movements. Bleeding, itching and a malodorous mucous discharge also may occur. They are often associated with a tendency to constipation. Anal fissures are easily diagnosed and evaluated by visual inspection of the anus and anal canal. On some occasions, flexible sigmoidoscopy or colonoscopy may be required.

Many fissures will heal by attention to the diet or with the use of laxatives. Plenty of fruit, vegetables and water in the diet will also help if other treatments are required. GTN is an ointment that is effective in healing a fissure but it involves a six week course and can cause headaches. An alternative is diltiazem, which doesn't cause headaches.

If these outpatient treatments do not work, then Botox injection into the internal anal sphincter may be offered. This aims to relax the involuntary sphincter muscle to allow tears in the anal margin to heal. It is carried out under general anaesthetic as a day case.

The traditional cutting operation (lateral anal sphincterotomy) is rarely carried out these days because of the small risk of incontinence to wind following the procedure.

Treatments for anal fistula

An anal fistula is a tunnel joining the skin near the anus to the inside of the bowel (either the anal canal or rectum). This means that the inside of the bowel is connected to the outside of the body through an additional opening. A fistula is usually the result of an infection or abscess in the anus.

There are many different kinds of fistula. Some have a single tract (route) running from the bowel to the skin. Others branch into more than one tract. Sometimes they cross the muscles that control the opening and closing of the anus (sphincters).

Anal fistulas may be uncomfortable and the skin around the anus can swell. The skin may also be itchy and irritated, and the fistula opening may be inflamed. Abscesses may occur. Surgical treatment is almost always necessary.

Anal fistula surgery is usually done under general anaesthesia but as a day case procedure. The exact operation will depend on the type of fistula you have and your surgeon will explain this to you in more detail.

Once the anaesthetic has taken effect, your surgeon will examine the fistula and decide the best way to treat it. Usually, the aim is to open up the fistula tract to the outside so that the wound can heal from the base upwards. Stitches are generally not used, but sometimes a piece of suture (thread used for stitches) is left in place if there is a danger of faecal leakage. This is called a seton which drains any infection away and cuts naturally through the tissues. Usually a further operation will be necessary two to three months later.

Pilonidal sinus

Pilonidal sinus is an inflammatory condition involving in-growing hairs in abscess cavities. It occurs most commonly in the natal cleft (between the buttocks at the base of the spine). The condition usually affects young adults but symptoms rarely persist beyond aged 30-40. The cause is not entirely clear and may involve hereditary or acquired factors. For some reason, the hair follicle enlarges and allows other hairs to grow in. This leads to a reaction like that of a foreign body with resultant inflammation or infection.

Half of all patients develop an abscess which may need surgical drainage. Most of the remainder present with an ongoing inflammation in the natal cleft, some of whom report a previous abscess. Up to a third of patients have very few symptoms, but if present these commonly include pain or discharge.

A simple examination confirms the diagnosis. There are a series of pits in the natal cleft, sometimes associated with discharge or thick inflamed tissue. Not all pilonidal sinuses need surgical treatment. In some cases, regular shaving is all that is necessary.

Surgery involves excision of the diseased tissue with the wound left open or closure of the wound with stitches. In some cases more complex surgery may involve excising the affected area and reconstruction with flaps of tissue. The operation usually takes place on the day of admission and some patients are able to go home on the same day.