service in

GENERAL SURGERY
I) ADVANCED MINIMALLY INVASIVE
LAPAROSCOPIC SURGERY
Laparoscopic Approach
why laparoscopy instead of the classical open approach of the abdomen
 less pain
 minimal use of analgesics – no narcotics three to six 5-12mm holes on the abdominal wall
 fewer complications closure of the holes with glue
 better postoperative lung function perfect cosmetic result
 full mobilization on the day of surgery
 faster oral intake
 shorter hospitalization
 faster recovery
 faster return to work
 better cosmesis – no scars

to treat (link)
heartburn – gastroesophageal reflux, hiatal hernia
oesophageal achalasia
morbid obesity (gastric banding, sleeve gastrectomy, gastric bypass)
benign large bowel disease (diverticulitis, inert colon-constipation, rectal prolapse)
malignant large bowel disease (colon cancer, rectal cancer)
gynaecological disease (ovarian pathology, womb pathology)
spleen pathology

Classical Open Approach of the Abdomen

when absolutely indicated

Diseases of the Anus

difficulties in opening the bowels (defaecatory problems)
constipation
obstructed defaecation
rectocele
enterocele
internal rectal prolapse
prolapse of mucosa
haemorrhoids – piles
link to “laparoscopy” “gynaecological disease”

GENERAL CONSIDERATIONS
Laparoscopic Approach
why laparoscopy instead of the classical open approach of the abdomen
 less pain
 minimal use of analgesics – no narcotics three to six 5-12mm holes on the abdominal wall
 fewer complications closure of the holes with glue
 better postoperative lung function perfect cosmetic result
 full mobilization on the day of surgery
 faster oral intake
 shorter hospitalization
 faster recovery
 faster return to work
 better cosmesis – no scars

Laparoscopy necessitates general anaesthesia. Complementary, and in case of a large operation such as
splenectomy, colectomy, or gastrectomy, epidural anaesthesia may be added. The abdomen is blown up
with gas (carbon dioxide), to achieve internal visualization. Duration of surgery varies from minutes to
few (no more than 31/2) hours depending on the sort of the operation. In general, duration of the
laparoscopic approach tends to be longer than the open one for the same operation. However, with
increased experience in the laparoscopic approach, differences in duration between the approaches are
not significant. Irrespective of the operation inside the abdomen, the patient who has a laparoscopic
approach can be mobilized in the afternoon of the day of the operation; he/she gets off the bed and takes
a few steps. In not contraindicated by the sort of the operation, the patient takes a light diet by mouth on
the next day of surgery. Also, the patient passes flatus or even opens the bowels on the next day of
surgery. Provided that there are no postoperative complications, the patient is discharged on the next to
4-5 days after surgery (more information about postoperative course see relative diseases at links).
link to “heartburn – gastroesophageal reflux, hiatal hernia”

“heartburn – gastroesophageal reflux, hiatal hernia”

general information
Gastroesophageal Reflux Disease (GOR) is the pathological condition at which juice of the stomach
that contains acid and possibly bile and pancreatic juice refluxes up into the oesophagus. Gastric juice
into the oesophageal lumen, if in excess and for long time, irritates the mucosa and produces heartburn
or even chest pain. Trivial reflux times and occasional heartburn is experienced in normal life by a
substantial proportion of the population. However, the disease of GOR is evident, if reflux occurs often
and in large amounts and medical advice is needed. Reflux may cause severe inflammation of the
oesophagus termed oesophagitis. If severe reflux persists for a substantial period of time, oesophageal
mucosa transforms to bowel mucosa in an effort to resist to injury by the refluxing material. This
transformation is termed “Barrett oesophagus”, a condition which may lead to oesophageal carcinoma.
When the refluxing material reaches high to the upper part of the oesophagus (regurgitation), there is a
risk of aspiration of the content into the larynx, trachea or even lungs, particularly when the patient is in
the supine position. This consequence causes the so called “respiratory complications”. Inflammation of
the larynx, trachea and bronchi is manifested with chronic cough, hoarseness, shortness of breath,
symptoms similar to those of asthma. Aspiration of gastric juice into the lungs is the most severe chest
complication and produces infection.
oesophagitis heart burn
chest pain

Barrett oesophagus heart burn settled

cancer of the oesophagus difficulty in swallowing

regurgitation acid or bitter sensation in mouth

gastric juice in mouth

aspiration chronic cough

respiratory complications hoarseness
laryngitis saliva hypersecretion
tracheitis shortness of breath

chest infection – pneumonitis high temperature

shortness of breath
GOR assumes a very severe form when associated with major abnormalities, such as severe impairment
of the lower oesophageal sphincter (LOS) function and hiatal hernia. When LOS is impaired shows a
lesser tone and allows gastric juice to reflux much more easily to the esophagus. Hiatal hernia is the result
of attenuation, loosening and dilation of the pillars of the diaphragm (hiatus), through which the
oesophagus crosses to join the stomach in the abdomen. The result of this anatomical disorder is the
protrusion of the upper stomach into the chest (hiatal hernia). Loss of LOS tone and hiatal hernia are
translated to excessive, in amount and duration, reflux and more severe symptoms.

how to diagnose GOR disease

In young subjects who have mild occasional heartburn the diagnosis can be safely made by swallowing a
pill that reduces gastric acid production and treats the sympotm. This medication is termed “Proton Pump
Inhibitor – PPI). When symptoms are more severe and constant upper alimentary endoscopy –
oesophagogastroscopy is indicated. By this test, which is performed under sedation, the severity of
oesophagitis, the presence and severity of Barrett’s oesophagus and the size of hiatal hernia are
assessed. If Barrett’s oesophagus is seen, biopsies for histology are taken to assess any risk for the
development of carcinoma (presence of dysplasia).
Complementary tests are the oesophagogatrogram, the oesophageal manometry, the ambulatory
24hour oesophageal pH monitoring and the ambulatory 24h oesophageal impendence monitoring.
These tests are indicated when there are atypical symptoms and the diagnosis is in doubt, when symptoms
do not respond to medication and when surgery for treatment is planned.

conservative-medical treatment
Approximately, 80 percent of the patients with GOR disease fall in the category of mild to moderate
severity. In this case, one or two PPI-pills every day are enough to control the symptoms. The exact dose
of medication is individualized according to the features of the disease. To maintain the good response,
additional measures, mostly concerning daily habits, are necessary: the subject should keep a normal
body weight, have small and frequent meals and avoid chocolate, pies, effervescent drinks (beer, gaseous
refreshments) and fatty meals. Also, in some cases use of two or cushions in bed are necessary to prevent
overnight reflux. Some novel endoscopic interventional techniques are currently available for the
control of symptoms in patients who otherwise would need indefinite treatment with PPS-pills. These
techniques aim to sharpen the joint oesophagus-stomach. At present, adequate data on the short and long
term efficacy of endoscopic intervention are not available.

surgical treatment
In general, surgical treatment is indicated in the severe forms of the disease, in which medication fails to
control symptoms or indefinite medical treatment in increased doses is necessary to maintain good
response. Usually, presence of a large hiatal hernia, loss of LOS tone, frequent regurgitations, Barrett’s
oesophagus and persistent chest symptoms signify a disease of great severity. Also, surgery is indicated in
young patients who are otherwise obliged to follow medical measures for life, or when the patient fails
to comply with long-term medication and measures.
aim of surgery
Surgery aims to correct the hiatal hernia, close the gap of the diaphragm and reinforce the LOS.
Reduction of the hiatal hernia is achieved by freeing the part of the stomach situated in the chest and by
pulling it back into the abdomen. The gap of the diaphragm is closed with stitches snuggly but loosely
around the LOS. Whoever these steps are not enough to abolish reflux and reinforcement of the LOS is
necessary. Several techniques have been described to achieve this goal, but only those that involve a wrap
of the upper part of the stomach around the LOS (fundoplication) are currently in use. The full 360o
floppy and short wrap (Nissen fundoplication) is the most popular, because it almost fully controls
reflux in long term. The efficacy of partial wraps [anterior partial fundoplication (Watson), posterior
partial fundoplication (Toupet)] in controlling reflux is not that sound, and may be indicated in specific
subsets of patients.

series of pictures:
 reduction of hernia
 suturing of hiatus
 fundolication
patient and surgery
After completion of the tests to fully assess the disease (recent endoscopy, oesophagogram, oesophageal
manometry, oesophageal pH monitoring metry), the patient is admitted in the hospital on the day prior to
surgery, or even on the day of surgery. The routine preoperative work includes full blood count,
assessment of blood clotting mechanisms, basic biochemical tests concerning liver and function, a chest
x-ray, an electrocardiogram and assessment by the anaesthetist. An overnight fast is necessary before
taking the patient to the operating theatre.
The operation is performed under general anaesthesia. The duration of surgery alone ranges between 30
and 60min, depending of the size of the hiatal hernia and the effort spent to free the stomach. After fully
awakening, the patient returns to bed, bearing a venous drip and sometimes a tube through the nose, and
approximately 6 hours later is encouraged to get off the bed and take some steps. Fluids by mouth are
allowed by the evening of the day of surgery. Non narcotic analgesics are usually given in the form of
suppositories, or by injection. With the exception of severe complication, the vast majority of the patients
is discharged the day after surgery. Instructions are given concerning oral diet and physical activity.
postoperative complications
Bleeding is the most common early complication closely related to surgery. However, bleeding that does
not cease spontaneously and needs re-operation occurs in much less 0.5 percent. Perforation of
oesophagus or stomach is much more rarely reported. Chest infection (atelectasis most usually) is by far
the commonest general postoperative complication. It is more commonly seen in smokers and patients
with past history of chest problems. However, chest infection is much less common after laparoscopy
than after open surgery, as a result of faster mobilization of the patient and less pain after the former
procedure. For the same reason urinary retention or infection and venous thrombosis of the legs are not
seen. Cardiac complications are only seen in patients with a history of heart problems, and can be
prevents by a thorough preoperative work out and treatment.
course after discharge
 The commonest complains after a Nissen fundoplication are dysphagia (difficulty in swallowing)
and sensation of fullness even after small amounts of food. Following dietary instructions, both
symptoms settle within a few weeks after surgery, because gullet and stomach adapt to the changes
induced by surgery. Persistence of those symptoms occurs in less than 1-3% and in this case they
are most usually the result of technical errors during surgery. In general, these complaints are much
less common after laparoscopy than open surgery.
 Recurrence of reflux symptoms are almost always attributed to technical errors at surgery. They are
seen very rarely after Nissen fundoplication even in the long term, but they reoccur in up to 20% of
the cases after partial fundoplication, few years after surgery. Heartburn, regurgitation and
aspiration should disappear after a well designed and executed antireflux surgery, and antireflux
medication should not be necessary. This is achieved by enough experience of the medical team
in correctly selecting the patient suitable for operation and by performing a technically
adequate antireflux surgery. Chest symptoms of the form of upper respiratory airways irritation,
such as chronic cough, hoarseness and shortness of breath may not disappear in up to 20% of the
cases, despite an operation that successfully controls reflux otherwise. In this case, chronic
inflammation with permanent changes of the upper airways is an obvious explanation. According to
current evidence, Barrett’s oesophagus without dysplasia tends to remain stable and not to develop
to malignancy.
 Other symptoms, such as abdominal bloating or diarrhoea, are not common and never troublesome.

Return to daily activities is feasible within few days after laparoscopic antireflux surgery. Heavy physical
activity is allowed at least 8 weeks later.

 Gastroesophageal reflux (GOR) is a common disease, usually treated with drugs that reduce
gastric secretion and settle heartburn.
 In the subset of patients with severe form of the disease (long standing daily symptoms requiring
indefinite medical treatment, presence of large hiatal hernia, loss of the tone of LOS) surgery is
indicated.
 Before surgery, investigation with specific tests is necessary to assess severity of the disease and
accurately design surgery.
 Nissen fundoplication is the most commonly performed antireflux operation.
 All types of antireflux surgery should be approached laparoscopy, after which recovery is
spectacularly fast, and the patient is discharged the next day of the operation.
 Return to normal physical activities and at work are possible within few days after surgery.
 A technically perfect antireflux operation abolishes reflux symptoms in the long term in the vast
majority of the patient.
link to “oesophageal achalasia”

general information
Oesophageal achalasia (OA) is a non-common disease of the oesophagus (one case/100000
population/year), with no specific age distribution, manifested with difficulty in swallowing, regurgitation
of non ingested food and saliva, and respiratory symptoms because of aspiration of the regurgitating
material into the respiratory airways. The cause of the disease is the destruction of the normal nerve
plexus of the oesophagus that results to a) loss of normal peristalsis and inability to propulse the food
bolus from the pharynx to the stomach and b) inability of the lower oesophageal sphincter (LOS) to relax
its increased tone and allow the bolus to pass into the stomach. As food and saliva stagnate in the
oesophagus, the body of the organ dilates and loses the normal configuration, while emptying of limited
amount of its content in the stomach is the result of gravity. Severity of the disease is graded according to
the appearance of the oesophagus at the oesophagogram: stage I: oesophageal diametre <40mm; stage II:
oesophageal diametre 40-60mm; stage III) oesophageal diametre >60mm; stage IV) loss of normal
configuration and assumption of an S-shape.
symptoms
Difficulty in swallowing (dysphagia) is occasional and not that severe at the early stages of the disease,
but aggravates by time in severity and incidence. At first, difficulty in swallowing may be present only in
fluids, but later appears after ingestion of solid food. Dysphagia is more commonly seen after swallowing
bread, pie, spaghetti or meat. However, loss of weight is rather uncommon. Also, at the first stages of the
disease the patient may complain of chest-substernal pain not related to food intake, mimicking a heart
attack, and possibly relieved by drinking water or nifedipine. Chronis food and saliva stagnation in the
lumen of oesophagus may irritate the oesophageal mucosa and cause oesophagitis. As a late complication
of oesophagitis, a small percentage of patients with non-treated achalasia may develop squamous cell
oesophageal carcinoma. At the supine position in bed, stagnated material regurgitates up to the mouth.
Patients usually complain of sticky foamy fluid or non ingested food in the mouth that wet the pillows.
When the regurgitating material is aspirated into the respiratory airways, respiratory complications
ensue: irritation of the upper airways (laryngitis, tracheitis, bronchitis) is manifested with hoarsness,
chronic cough or shortness of breath, and irritation of the lung causes pneumonia.

diagnosis
Symptoms of achalasia, dysphagia in particular, are very specific, but the disease must be differentiated
from carcinoma of the oesophagus, at which loss of weight is very common. The barium
oesophagogram and oesophageal manometry confirm the diagnosis. The oesophgogram also stages the
disease and excludes any other pathology. At oesophageal manometry, no oesophageal peristalsis is
detected and the LOS does not relax at swallow. Some unusual forms of the disease may be also detected
by manometry (vigorous achalasia etc). Oesophagoscopy is also mandatory to assess oesophageal
mucosa and exclude other pathology, carcinoma in particular.

There is no aetiological therapy of the disease, in the sense to reestablish nerve plexus
integrity of oesophagus. So all sorts of treatment are symptomatic, and practically
aim to reduce the tone of the LOS.

conservative treatment
Concervative treatment includes medication, injection of Botox to LOS and pneumatic dilation of the
LOS.
The most commonly medication in use are the calcium channel blockers. Nifedipine is the main
representative of this group of drugs. Nifedipine is given in the form of a pill under the tongue, and acts
within few minutes. Because of the short duration of action and the side-effects (headache, hypotension)
the drug is not given as a permanent treatment, but reserved for temporary relief prior to a more definite
treatment or to relieve substernal pain.
Botox injection to LOS is achieved with endoscopy and mild sedation on an outpatient basis. The
injection paralyses the LOS and swallowed food passes in the stomach if ingested at the upright position.
However, the duration of LOS relaxation usually does not exceed three months and dysphagia gradually
reoccurs. This sort of treatment id reserved for patients unfit to undergo any other more definite
treatment.
Pneumatic dilatation of the LOS is to standard treatment of achalasia. The treatment is undertaken by
endoscopy and with the patient under sedation, intravenous analgesics and fluoroscopic control. A wire
that bears a plastic balloon at its tip is introduced to the oesophagus, with the balloon situated along the
LOS. The balloon is inflated dilated forcefully with air at a specific pressure and diametre and for certain
duration. This maneuver aims to relief dysphagia and allow food to pass into the stomach by disrupting
the muscle fibres of the LOS and so reducing its tone to levels well below normal. The treatment relieves
dysphagia in approximately 60% of the cases. There is no solid evidence that repeat pneumatic dilation
improves this figure. The most severe complication of the procedure is rupture of the oesophagus that
necessitates hospitalization. Development of gastroesophageal reflux can also occur. The treatment is
ineffective in young patients (age<45years) and contraindicated in case of oesophageal deformity (stage
IV) or other anatomical abnormality of the area.

surgical treatment
patient and surgery
Heller’s myotomy is the surgical treatment of the disease performed by laparoscopy. Laparoscopy is not
only associated with the typical advantages of the minimally invasive approach but also offers better
visualization at the area and so meticulous and more complete division of muscle fibres of LOS.
Myotomy involves division of the circular fibres of the lower oesophagus at a distance of 4-6cm proximal
to the gastroesophageal junction and division of the oblique gastric fibres at a distance of 1-1.5cm on the
stomach. Usually, the operation is completed with and anterior Dor’s fundoplication to prevent
gastroesophageal reflux.

postoperative course
Perforation of the mucosa of the oesophagus below the myotomy occurs in less than 2-3% of the cases.
The surgeon should seek for any tiny perforation during surgery and ensure integrity of mucosa. A tiny
hole can be seen after infusion of blue dye through the nasogastric tube and stitched safely. Bleeding from
the site of operation is not really reported. If accounted, it usually comes form the sites of trocar insertion
on the abdominal wall. Chest infection (atelectasis most usually) is by far the commonest general
postoperative complication. It is more commonly seen in smokers and patients with past history of chest
problems. However, chest infection is much less common after laparoscopy than after open surgery, as a
result of faster mobilization of the patient and less pain after the former procedure. For the same reason
urinary retention or infection and venous thrombosis of the legs are not seen. Cardiac complications are
only seen in patients with a history of heart problems, and can be prevents by a thorough preoperative
work out and treatment.
The next day of the operation an esophagogram with a water soluble contrast is performed to ensure
integrity of the oesophago-gastric mucosa and passage of the contrast through the LOS to the stomach.
Then, the nasogastric tube is removed and the patient is discharged with instructions to consume soft
diet in small and several meals per day for the first 8 weeks after surgery and be in contact with the
surgeon. Return to daily activities is feasible within few days after surgery. Heavy physical activity is
allowed at least 8 weeks later.

course after discharge

The commonest complains after a myotomy is persistent of dysphagia (difficulty in swallowing). This
may be the result of an inadequate myotomy, oedema-swelling at the area of operation, ingestion of solid
food in large boluses or the advanced stage of the disease. If myotomy is inadequate re-operation is
mandatory. However, in experienced hands this rather unusual. Dysphagia due to oedema is temporary
and settles by time and after dietary restrictions. Sensation of fullness even after small amounts of food is
the result of the fundoplication and also settles within a few weeks after surgery.
The outcome of a technically adequate operation is considered successful when, after swallowing of
a well chewed bolus, the oesophagus empties in the stomach within 5min. Success depends on the
preoperative stage of the disease. Success rate is well over 90% in stages I and II, 80-85% in stage III and
less than 50% in
Development of reflux symptoms appears in less than 10% of the cases when anterior fundoplication is
added to myotomy. If not, the rate of reflux symptoms is over 20%. When heartburn is reported, an
ambulatory oesophageal pH monitoring will differentiate whether it is due to food stagnation and lactic
acid production or the true reflux of gastric contents into the oesophagus. In the latter case antisecretory
drugs (PPIs) are given.
follow-up
Because oesophagus may degenerate and dilate by time, as result of disease process and despite an
adequate myotomy and satisfactory good response, food stagnation in the oesophagus and dysphagia may
reoccur. For this reason, every year the patient should contact the surgeon and report on any changes in
symptoms. Also, an oesophagogram should be performed yearly and every time compared to the previous
ones. In general and according to current evidence, an initial good result is maintained for at least 10-15
years after laparoscopic myotomy. Further information will accumulate in the next years, but the
prospects are rather encouraging.
link to “morbid obesity (gastric banding, sleeve gastrectomy, gastric bypass)”
link to benign large bowel disease (diverticulitis, inert colon-constipation, rectal prolapse)

benign large bowel disease

There are benign diseases that at some time of their course may require surgery for treatment. The
commonest diseases of this sort are the diverticular disease, the inflammatory bowel diseases (ulcerative
colitis, Crohn’s disease), the rectal prolapse, and the slow transit constipation. Surgery involves
resection of a segment or of the total length of the large bowel, and can be performed by the laparoscopic
approach, thus exploiting the advantages of few complications and fast recovery.

diverticular disease
general information
A diverticulum is the protrusion of the mucosa through a weak point of the large bowel wall. They can be
found in more than 50% of the population of the western world aged more than 50 years, are numerous
and located at the left site of the bowel. Subjects with diverticular disease are usually without symptoms,
but diverticula may be aetiologically associated with chronic constipation. Occasionally, the diverticula
may bleed, and sometimes bleeding can be massive, requiring hospitalization. Rupture of a diverticulum
and leak of faecal material outside the bowel causes inflammation termed diverticulitis. The
inflammation may settle spontaneously, develop to local abscess formation, or spread in the abdomen
leading to peritonitis. In any case, hospitalization is necessary and assessment of the severity of the
disease is achieved with an emergency C/T scan.
Inflammation and small abscesses may resolve after antibiotic treatment and without any further
intervention, and this is the most usual outcome of diverticulitis. Larger abscesses can be drained with
tubes inserted under the guidance of ultrasound or C/T scanning and under local anaesthesia, without
operation. In case of peritonitis or lack of response to antibiotics, emergency surgical intervention is
mandatory. Occasionally, an abscess may drain spontaneously to nearby loop of small bowel (diarrhea),
or the urinary bladder (faces and air bubbles in the urine, urinary tract infection), or even the anterior
abdominal wall (discharge of faeces or air), resulting to a fistula (communication) formation. This
complication requires elective surgery. An attack of diverticulitis, initially treated successfully without
operation, may reoccur once or more.
elective surgical treatment
Elective surgery for diverticular disease (absence of active inflammation) is indicated in case of
recurrent attacks of diverticulitis initially managed conservatively, residual mass on C/T after
successful conservative treatment, presence or imminent internal or external fistula, particularly in male
subjects in whom development of a fistula between the bowel and bladder is more common than in
female ones.
The operation can be performed by the laparoscopic approach. An additional small suprapubic incision
may be required in case of a fistula to the bladder, in order to fix the opening. Basically, the operation
involves resection of the lower descending colon, the sigmoid colon and the upper rectum, parts that bear
the diverticula, and reestablishment of the continuity of the bowel by fashioning an anastomosis (joining
the two cut edges of the bowel with a use of stapling device). In the absence of inflammation, creation of
a colostomy or diverting ileostomy is not necessary.
picture of
surgery

After laparoscopic large bowel resection for diverticular disease, recovery is very fast. On the next day,
the patient is mobilized, bowels open, and oral diet is resumed. In the absence of severe complications,
the patient is discharged on the 4th-5th postoperative day. Complications are seen in much less than
10% of the cases. General complications include chest infection (atelectasis most usually), urinary
retention, urinary tract infection or deep venous thrombosis are really rare as result of the lack of severe
pain, fast recovery and mobilization of the patient after laparoscopy. Bleeding from the site of operation
is not usual and is managed conservatively in most of the cases. Anastomotic leak (disruption of the
anastomosis and leak of faecal material) clinically manifested occurs in approximately 5-8% of the cases.
This complication is managed conservatively by drainage of the collection under C/T scanning guidance.
If needed, a diverting temporary ileostomy is fashioned, until spontaneous seal of the leak.

inflammatory bowel diseases

Crohn’s disease is an inflammatory process most commonly of the terminal part of the small (ileum) and
the large bowel. The inflammation is of unknown aetiology and involves the full thickness of the
intestinal wall, the mesentery that suspends the bowel and surrounding structures in the abdomen. The
inflammatory process may also involve other organs than the bowel, leading to extra-intestinal
manifestations. The clinical picture of the disease is characterized by exacerbations and remissions.
Inflammation of the bowel wall may cause strictures manifested with signs of bowel obstruction, or
penetrate the wall resulting to phlegmon or abscess formation between the bowel loops. The abscess, if
not resolved, may spontaneously drain to adjacent loops of bowel, urinary bladder or abdominal wall so
to form fistulae.
Abdominal surgery may be necessary for the resection of a severely diseased small part of the small or
the whole of the large bowel. Depending on the presence of other complications, resection may be
associated with refashioning of a stricture of the bowel (stricture-plasty) to relieve obstruction, drainage
of an abscess, resection of adjacent structure to remove an internal or external fistula. Because multiple
surgical interventions may be necessary in Crohn’s disease and because the suffering subjects are young
and very much interested in their body image, laparoscopy is the approach of choice to undertake all
the above operations. The laparoscopic approach is associated with faster recovery after surgery, less
postoperative complications, shorter hospital stay and greater satisfaction of the subject with the cosmetic
result as compared to open surgery.
Ulcerative colitis is an inflammatory disease of the large bowel manifested with diarrhea, blood per
rectum and occasionally general symptoms including high temperature, loss of weight and bad general
condition. The treatment is medical at first with drugs including steroids and immunosuppressants and, if
necessary, support with parenteral nutrition.
Surgery is necessary in case of i) lack of response of an acute or even fulminant attack to intensive
medical treatment, ii) need of long term medical treatment to maintain the disease in remission iii) some
extracolonic manifestations of the disease that only respond to removal of the large bowel and iv)
development of dysplasia (precancerous condition) or even cancer. The operation of choice is removal of
the entire large bowel (total colectomy) with preservation of the anus and anastomosis of the terminal part
of the small bowel to the anus, after fashioning a pouch. (ileal-pouch – anal anastomosis). This operation
achieves removal of the whole of the disease large bowel but also preservation of the normal passage of
faeces through the anus. In long term, subjects with this operation experience 4-8 semi-solid bowel
motions per day, with good control of the sphincters and minimal or no soiling at all. The procedure can
be performed in one or two stages: in one stage (removal and anastomosis) in elective cases with a patient
in a stable condition and in two stages (first removal and some weeks later anastomosis) in the acute
phase of the disease.

This procedure can be performed by the laparoscopic approach. As the patients are young they are
highly motivated to undergo this approach. Laparoscopic total colectomy with ileo-anal anastomosis is an
extremely technically demanding and laborious procedure of 3-5 hours duration. However with acquired
experience and improvement of laparoscopic instrumentation, nowadays the operation is attempted
laparoscopically more often. According to current evidence, the laparoscopic approach is associated with
faster recovery, less complications, shorter hospital stay and better cosmetic result as compared to open
surgery, with similar long term outcomes. Irrespective of the approach –laparoscopic or open- the
anastomosis is usually protected with a temporary ileostomy, which is reversed 6-8 later.

also link to “difficulties in opening the bowels (defaecatory problems)”

“constipation”
“obstructed defaecation”
“rectocele”
“enterocele”
“internal rectal prolapse”
“prolapse of mucosa”
rectal prolapse
Rectal prolapse is the folding and protrusion of the upper and middle part of the rectum into the distal one
and finally through the anus to the outside. The protrusion that reaches the anus but does not protrude
outside is termed internal prolapse or intussusception. If the rectum protrudes outside and becomes
obvious is term total or overt rectal prolapse. The aetiology and pathophysiology of the condition is not
fully understood, but it seems to be associated with severe chronic constipation and excessive straining at
stool as seen for example in aged multiparous women. It is not known whether internal prolapse
deteriorated and develops to total prolapse in the same subject who remains severely constipated.

Intussusception is manifested with symptoms of obstructed defaecation, namely chronic straining,

incomplete evacuation of the rectum from faeces, interrupted defaecation, passage of small pellet stools,
vaginal or anal digitation to facilitate defaecation, deep vague perineal discomfort or pain, and passage of
blood per rectum in case development of a solitary rectal ulcer. The investigation to confirm the diagnosis
includes the defaecogram, anorectal manometry, anorectal physiological tests and anal ultrasound. At the
defaecogram, a mixture of 150ml of mashed potatoes with barium sulfate, simulating faeces, is
introduced into the rectum and the vagina is coated with radioopaque paste, while the loops of the small
bowel are also opacified after ingestion of 500ml of barium sulfate. Then the subject sits on a commode
and is asked at first to squeeze the perineum and then to strain in order to empty the rectum, while the
whole procedure is filmed. The investigation demonstrates the intussusception and also depicts some
coexisting abnormalities which should also be taken into account when planning the treatment. These
abnormalities include the rectocele, the perineal descent, the enterocele or the sigmoidocele.

Treatment should be individualized and is at first conservative. Softening of stools, usually with high
fibre diet, and retraining-reeducation of the patient in the process of straining and bowel opening are
measures with good response rate in the majority of the cases. Conservative treatment usually fails in case
of a large intussusception associated with an enlarged anterior rectocele that entraps stools at straining. In
this case surgery can be applied. Currently, the procedure mostly in use to correct intussusception is the
Stapled Trans Anal Rectal Resection – STARR. The procedure is performed under general anaesthesia,
with the patient in the gynaecological position, so to gain access to the anus. Excision of the protruding
rectum and joining up of the cut edges of the rectum is achieved with specific stapling devices, introduced
through the anus. At surgery, caution should be taken not to include the posterior vaginal wall to the
resection-staple line. Any bleeders at the suture line are easily stitched. The duration of the procedure is
less than 30min. Pain after surgery is minimal. Recovery is fast and the patient is usually discharged on
the next day. It is common the patient to experience perineal discomfort, urge to defaecate or several
small bowel motions per day for the first 4-6 first postoperative weeks. These symptoms are the result of
oedema at the site of resection, which is perceived as a rectum full with faeces. The condition settles by
time and after following specific dietary and defaecatory measures. Symptoms of obstructed defaecation
disappear or significantly improve in most of the patients. Persistent symptoms may respond to additional
training in the defaecatory process in the form of biofeedback.

STARR operation

If the defaecogram shows that rectal intussusception is associated with enterocele or sigmoidocele,
STARR procedure is not expected to relieve symptoms. In this case, surgery through the abdomen that
permanently reduces intussusception and enterocele is mandatory. Currently, the most popular operation
applied to treat this condition is Ventral Rectopexy. The procedure is performed by laparoscopy and
involves unfolding and fixation of the rectum with prosthetic material, placed between rectum and
posterior vaginal wall, to prevent refolding and to obliterate the space occupied by the prolapsing loops of
small bowel. The patient is discharged on the next day of the operation. Initial reports on the symptomatic
outcomes are very encouraging.
operation of ventral
rectopexy

Total rectal prolapse shares the same pathophysiology with rectal intussusception. The condition seems
to be associated with severe chronic constipation and excessive straining at stool as seen for example in
multiparous aged women. It can be also seen in younger patients, in whom congenital anatomical
abnormalities, such as impaired fixation of the rectum, are implicated. The patient with total rectal
prolapse complains of protrusion of the bowel during straining at defaecation or increased abdominal
pressure, mucous discharge form the anus, soiling, irritation of the skin around the anus, chronic
constipation, or even symptoms of obstructed defaecation. Blood discharge is not unusual, as a result of
mechanical injury of the protruding bowel or development of a solitary rectal ulcer. In approximately two
thirds of the patients, true faecal incontinence coexists.
The investigation, not only to confirm the diagnosis but also to assess the extent of the disorder and
identify additional abnormalities, includes the defaecogram, anorectal manometry, anorectal
physiological tests and endo-anal ultrasound. At the defaecogram, a mixture of 150ml of mashed potatoes
with barium sulfate, simulating faeces, is introduced into the rectum and the vagina is coated with
radioopaque paste, while the loops of the small bowel are also opacified after ingestion of 500ml of
barium sulfate. Then the subject sits on a commode and is asked at first to squeeze the perineum and then
to strain in order to empty the rectum, while the whole procedure is filmed. The investigation
demonstrates the intussusception and also depicts some coexisting abnormalities which should also be
taken into account when planning the treatment. These abnormalities include the rectocele, the perineal
descent, the enterocele or the sigmoidocele. Anorectal manometry and endo-anal ultrasound provide
information about the degree of anatomical and physiological integrity of the perineal-anal sphincters.
Also, colonic transit studies and barium enema are considered necessary to design the therapeutic
approach and choose the appropriate procedure.
 OPERATIONS TO CORRECT RECTAL PROLAPSE
transabdominal operations
anterior prosthesis rectopexy (Ripstein)
posterior prosthesis rectopexy (Wells)
posterior suture rectopexy
resection – suture rectopexy
ventral prosthesis rectopexy
resection of abundant rectosigmoid

transanal procedures
Thiersch loop
resection of rectosigmoid (Altemeir)
rectal mucosectomy – muscular plication (Delorme)
Stapled Trans-Anal Resection of Rectum (STARR)

The condition and resultant symptomatology can be treated only by surgery. There are several procedures
designed and applied to correct the abnormality, the choice of the optimum one depending on the
particular case. In, general they are divided into categories: the trans-anal and the trans-abdominal
ones. The trans-anal procedures are indicated in rather debilitated patients, unfit to undergo general
anaesthesia or any big trans-abdominal procedure. The most popular of them are the rectal mucosectomy
with muscular placation (Delorme’s procedure) and the resection of rectosigmoid (Altemeir’s
procedure) that protrudes with colo-anal anastomosis, fashioned trans-anally with stitches or a circular
stapling device. Both procedures can be completed in an hour or so and are associated with a rather fast
recovery and hospital stay of few days, depending on the general condition of the patient.
Of the trans-abdominal procedures, prosthesis-or-suture anterior-or-posterior rectopexies are indicated
in patients with prolapse associated with diarrhoea and non-redundant sigmoid colon on the barium
enema. These procedures implicate mobilization and fixation of the rectum upon the sacrum either with
stitches or with the use of a prosthetic material that covers the rectum either anteriorly or posteriorly.
Resection rectopexy is indicated in patients with rectal prolapse associated with constipation, redundant
sigmoid colon, slow transit of the bowel or presence of diverticulae at the sigmoid colon. The procedure
involves mobilization of the rectum, resection of the redundant sigmoid colon, anastomosis of the
descending colon to the rectum with the use of a circular stapling device and fixation of the rectum to the
sacrum with stitches. Ventral prosthesis rectopexy is a modification of the prosthesis anterior rectopexy,
indicated in patients with prolapse and associated large rectocele or enterocele. At this novel technique,
the rectum is completely mobilized anteriorly and behind the posterior wall of the vagina and deep down
to the level of anal sphincters. The deep, redundant peritoneal sac (Douglas pouch) is excised, a strip of
the prosthetic material-mesh is sutured along the anterior aspect of the mobilized rectum and the posterior
vaginal wall and the mesh is pulled upwards and fixed on the sacral promontory, so to reduce the
prolapse, suspend the rectum and obliterate the space occupied by the enterocele (small bowel loops). All
trans- abdominal procedures are approached laparoscopically. If resection and anastomosis of the
bowel is not included in the procedure, the patient is discharged within one or two days after surgery. In
case of resection of the bowel, the patient recovers fast, is mobilized on the day of surgery, resumes oral
feeding the day next to surgery and is usually discharged on the 4th-5th postoperative day.
 schematic and laparoscopic representation of all procedures.

long-term results
Trans-anal procedures, Delorme’s procedure in particular, are associated with significant rate of prolapse
recurrence. Furthermore, Altemeir’s and Delorme’s procedures are usually associated with rather poor
functional results, possibly because the capacity of rectum as a reservoir of faeces is abolished. This is
translated in urgency to defaecate, small and frequent motions and soiling. Also, faecal incontinence may
deteriorate, if pre-existing, or appear de novo, as a result of dilatation of the anus during the procedures.
Prosthesis-or-suture anterior-or-posterior rectopexies are associated with recurrent prolapse in rates
around 10%, much less than after the trans-anal procedures. Long term results, concerning defaecatory
habits vary and are unpredicted. A substantial proportion of the patients complain of urgency to defaecate,
unproductive straining or frequent and small stools, because the rectum becomes stiff and incompliant as
a result of irritation or inflammation by the prosthetic material.
Resection rectopexy is associated with the best long-term results. Recurrence of prolapse is seen in less
than 5% of the cases. Bowel habits become normal within few weeks after surgery. Preexisting
constipation is treated in the majority of the cases, while faecal incontinence is cured in approximately
two thirds of them. Results of ventral prosthesis rectopexy are promising, particularly in correcting
enterocele, but current evidence is limited at present.

slow transit constipation

Slow transit constipation or colonic inertia is a hereditary condition manifested with very severe
constipation in young female. Although hereditary, the condition is manifested at puberty, or at a young
age after a stressful situation (appendicitis, severe infection, etc). Constipation deteriorates by time and,
soon after onset, bowels are open after use of cathartics. Months or years later, cathartics fail to work and
only enemas may be of some relief. Abdominal distention, discomfort and pain are also reported. The
diagnosis is confirmed by assessing the colonic transit of radio-opaque markers or the polyethylene
glucole test. Both tests are easy to perform and give reliable results.

The condition is treated by surgery. Segmental resections of the colon, based on the observation of faecal
stagnation at a specific part of the large bowel, do not correct constipation and are not indicated. The
operation is the subtotal colectomy with anastomosis of the terminal ileum to the rectum which is not
resected. The operation is performed by laparoscopy and, therefore, recovery, mobilization and food
resumption are expected to be fast, complication are few and insignificant and hospital stay is short. At
long term, constipation is cured in more than 90% of the cases. Usually the patient experiences 2-4 semi-
solid bowel motions every day. In few patients bowel motions are more frequent exceeding 10-12 per
day, impairing quality of life. Persistent constipation is accounted in less than 8% of the patients after
surgery, but in any case less severe than before with 1-2 bowel motions per week. A proportion of
patients that exceeds even 50%, particularly after the open approach, experiences attacks of bowel
obstruction. Although hospital admission may be necessary, these attacks settle after conservative
treatment, and in the end disappear. The vast majority of the patients are very satisfied with the outcomes
of the procedure.
link to “malignant large bowel disease (colon cancer, rectal cancer)”

malignant large bowel disease (colon cancer, rectal cancer)

general considerations
In the western world, cancer of the large bowel is the commonest cancer after that of the skin in both
sexes. As a general rule, the treatment of choice is surgical removal of the segment of the colon that bears
the cancer, with adequate proximal and distal margins and removal of the mesentery that corresponds to
the segment, so to achieve a so called “oncologically correct resection”. After removal of the segment of
the bowel an anastomosis is usually fashioned between proximal and distal stumps, so to reestablish
continuity of the bowel. If the operation is oncologically correct, good outcomes, in terms of local
recurrence of the disease and survival, are expected.

treatment
In case of cancer located at the rectum (last 10-12cm of the colon-large bowel) which is locally advanced,
(assessment by an MRI of the pelvis) combined radiotherapy and chemotherapy (neo-adjuvant treatment)
is recommended prior to surgery in order to improve outcomes. At surgery, the part of the rectum that
bears the cancer, along with at least 20cm proximal and 2cm distal clearance, and the whole of the
mesentery of the rectum (total mesorectal excision – TME) are removed. An anastomosis between the
colon and the distal rectal stump or anus can be fashioned, provided that removal of anal sphincters is not
mandatory in order to achieve oncological clearance. This is usually the case in a tumour located at a
distance of no less than 3cm from the anal verge. If the distance is shorter and sphincters should be
removed, an anastomosis is not feasible. The operation that involves removal of rectum and sphincters is
termed “Abdomino-Perineal Resection of Rectum – APR”.

Schematic representation of rt and

left colectomy, LARR and APR

laparoscopic colectomy for cancer

All colectomises (right, left, total, subtotal, low anterior resection of rectum with TME – LARR-TME and
APR) are classically performed by the open approach, but recently can also be approached by
laparoscopy. The main contra-indications for the laparoscopic approach are i) large tumours (>8cm),
tumours located at the transverse colon (extremely technically demanding procedure, jeopardized
oncological adequacy) iii) tumours invading adjacent organ but a curative removal can be expected, iv)
lack of adequate training and experience with the particular approach and colorectal surgery and v) lack
of a high quality hardware incomplete instrumentation. Advanced age of the patient, impaired
cardiovascular and chest condition (category ASA III, IV), previous abdominal operations and obesity are
not contra-indications for laparoscopy.
For specific anatomical reasons and because extended surgery is required to cure a cancer, laparoscopic
colectomy is very technically demanding. LARR-TME is even for difficult to accomplish. It is usually
argued that for this reason the latter procedure should be attempted only by open, at present. However,
supporters of laparoscopy claim that the novel approach is superior to open, in particular in the obese
male patient, because of a better visualization deep in the pelvis. Understandably, good training and
overcome of the steep learning curve are prerequisites to operate of colonic cancer by laparoscopy. The
operation is achieved by creating 4-6 holes on the abdominal wall for the trocar insertion. By the end of
the operation, the wound at a trocar site (left loin or just above symphisis pubis) is elongated to
approximately 4cm, to remove the resected specimen in bag, to protect the abdominal wall from
contamination. In general duration, of the laparoscopy is long than by the open approach, but difference
diminishes as experience increase. For several local (tumour characteristics), general (poor cardiovascular
response at surgery), mechanical (hardware failure), operational (surgeon’s inability to cope with)
reasons, conversion of the laparoscopic approach to open may be necessary. The most common reason is
the tumour characteristics that preclude laparoscopy, but have been missed at the preoperative staging
work out. If conversion is early, no addition impact on patient outcome is expected. However, if
conversion is decided after having spent hours in attempting to accomplish the operation by laparoscopy,
higher morbidity (complications) and mortality (deaths) are seen, as compared to a totally open or totally
laparoscopic approach.

Video of all colectomies

short-term outcomes
According to current evidence, laparoscopic colectomy is associated with all the advantages of the
approach over open surgery. The patient is mobilized on the day of the operation, oral feeding is resumed
and bowels usually open the first day after operation. Pain is minimal and non-narcotic analgesics may be
given for 2-3 days. In the uncomplicated cases, hospitalization is short and the patient is discharged on the
4-6 postoperative day. Local complications (bleeding, leak from the anastomosis, abdominal sepsis) are
seen in similar rates between the two approaches. Wound infection and hernia are much less common
after laparoscopy than after open. Similarly, pulmonary complications and deep venous thrombosis are
less common after laparoscopy than after open, apparently because of less pain and conceivably better
respiratory function and faster mobilization after the former approach.

long-term outcomes
Local recurrence of cancer, survival, and quality of life are the parametres that characterize long-term
outcomes after colorectal surgery for cancer. Although current literature on this issue is still limited and
more is expected to appear soon, there is evidence that laparoscopy is associated with at least similar
rates of local recurrence and survival to the classical open approach. Quality of life is also favourably
compared between the two approaches. The fear of increased recurrence of cancer at the sites of
abdominal trocar-wounds, expressed the early days of the approach, is not substantiated by current
evidence, and, in fact, it may be less common than recurrence of cancer on the abdominal wound after the
open approach.
link to “spleen pathology”

general considerations
Occasionally, the spleen, which is situated below the left part of the diaphragm and on top and left of the
stomach, should be removed electively, because of some haematological diseases. These include
idiopathic thrombopenic purpura (ITP) sickle cell anaemia, or hairy cell leukaemia. Other pathology
necessitating elective removal of the spleen is rare. The classical open approach is achieved through a
large incision on the abdominal wall across the left subcostal margin. Because of this long wound,
postoperative pain is severe, necessitates narcotic analgesics administration, impairs depth of breath
resulting in chest infection, and conceivably prolongs hospital stay.

laparoscopic approach
To tackle disability and slow recovery after open splenectomy, the laparoscopic approach is
recommended. The contraindications to attempt laparoscopic splenectomy are emergency condition
(acutely bleeding spleen) and enlarged spleen (greatest dimension 25cm). The operation is accomplished
through 3-4 trocars along the left subcostal margin and one 5th at the umbilicous for the optique. The
spleen is freed from its attachments and the blood vessels (splenic artery and vein) are ligated and divided
with the use of specifically designed vascular stapling devices. Duration of the operation is less than
60min.

video of laparoscopic
splenectomy

As usual after laparoscopy, pain is minimal as is use of analgesics. Patient is mobilized and fed on the
afternoon of the operation day. The patient is discharged on the 2nd-4th postoperative day, provided that no
respiratory complication develops. In any case respiratory complications, such as lung atelectasis,
pneumonia, or left pleural infusion, are much less common than after the open approach.
link to “haemorrhoids – piles”

II) HAEMORRHOIS - PILES

general considerations
The haemorrhoidal cushions (haemorrhoids-piles) are anatomical elements consisted of clusters of small
veins and covered by mucosa of a trasitional type, situated at the lowermost part of the rectum and at the
proximal orifice of the anus. They contribute to continence and control of defaecation. Chronically
increased and sustained effort at defaecation and hard stools may lead to enlargement, bleeding and
protrusion of the piles outside through the anus. Protruding-prolapsing piles may also be strangulated,
resulting in thombosis (clot formation) manifested with swelling at the area and severe pain, or even
necrosis of the covering skin and ulceration.

schematic representation of
haemorrhoids at all degrees

Severity of haemorrhoidal disease is graded as follows: 1st degree: enlargement of the cushions and
bleeding, no prolapse; 2nd degree: prolapsing piles at straining and spontaneous reduction after the end of
the defaecatory process; 3rd degree: prolapsing piles at straining and manual reduction after the end of the
defaecatory process; 4th degree: permanently prolapsing piles, impossible to reduce. Bleeding, irritation
of the skin and discomfort at the area may be present at any degree of the disease. In general, symptoms
severity parallels the severity of the disease.

treatment
Conservative treatment consists of simple measures that aim to soften the stools and relieve topical
discomfort (tepid baths, application of local anaesthetic ointments). If respond is poor, symptoms are
bothersome and bleeding significant, interventional therapy, including also surgery, is indicated. There
are numerous methods of varying degree of invasion designed to treat piles. The approach is not
unanimous between surgeons. However, it is generally accepted that treatment should be individualized,
primarily considering the severity of disease, as expressed by the degree of presentation.
1st degree piles: Sclerosing injections or rubber banding of the piles is usually indicated. Treatment is
applied through a proctoscope at an outpatient basis. Injections are painless is properly performed. Re-
injections may be required if bleeding reoccurs. Rubber banding of piles is more effective in controlling
bleeding but is associated with some complications, if not properly applied. Usually one pile is treated at
a time. Complications include, pain, ulceration and bleeding of the strangulated by the band pile and local
sepsis. Some surgeons recommend the THD method for the treatment of 1st degree piles, as it is
associated with superior results, less complications and much less pain than rubber banding.
2nd degree piles: A novel technique is nowadays recommended for the treatment of 1st and particularly 2nd
degree piles. According to the method, the branches of the haemorrhoidal arteries that supply the piles
with blood are identified just above their entrance into the piles with the aid of an ultrasound probe
mounted at the tip of a specific proctoscope. After identification, the arterial branches are ligated with
stitches introduced through the proctoscope. This method is termed as “Transanal Haemorrhoidal
Dearterialization – THD”, according to company that provides the market with the instrumentation. The
method is applied on an outpatient basis and under mild sedation. As relative literature is limited at
present, there is no sound evidence on the results of the method. It seems that bleeding is controlled in
more than 80% of the cases. Similar are the rates of reduction of prolapse. THD is applied on an
outpatient basis, is practically painless and can be repeated if bleeding reoccurs. Some discomfort may be
reported in some patients for the first few days after the procedure.

pictures of THD
3rd degree piles: Another novel method is currently been advocated for the surgical treatment of 3rd
primarily, but also 2nd degree, haemorrhoids. The method carries the term “Procedure for Prolapsing
Haemorrhoids - PPH” and has been introduced into practice by A. Longo. Through a specific anal
retractor, a threat is fashioned at the rectal mucosa above the haemorrhoidal cushions in a circular purse-
string manner. Then, a specifically designed circular stapler is introduced through the rectractor, the rectal
mucosa is pulled into the chamber of the stapled and the device is fired. As a result of this, a 2cm wide
ring of rectal mucosa and submucosa above the piles is excised and the mucosal stumps are automatically
and at the same time approximated and anastomosed with staples. By this method, first the haemorrhoidal
arteries that supply the piles with blood are ligated and divided and secondly the prolapsing part of piles
is pulled and reduced above the anus. The procedure is performed under epidural, spinal or general
anaesthesia. The method is painless, if correctly applied. Bleeding from the staple-line is not that common
with the new generation of stapling devices and can easily be controlled with stitches. Some severe
complications, such as rectal perforation or pelvic sepsis, have appeared in the literature as case-reports.
If the surgeon is adequately trained and method is meticulously applied, complication rate is not
significant and is of very mild severity. The patient is usually discharged on the next day after surgery.
Postoperative discomfort may last for few days, but true pain is not usually a problem. Also, adequate
training and correct application of the method by the surgeon are the prerequisites for good functional
results. In general, bleeding is controlled and prolapse is reduced in more than 85% of the cases. There is
no substantial evidence that repeat PPH is indicated in case of relapsing piles. The method precludes anal
intercourse.
4th degree piles: The classical surgical technique of “Milligan – Morgan” is indicated in case of 4th
degree piles, or recurrence of piles treated with the PPH method. The method is performed under general,
epidural or spinal anaesthesia. The piles are dissected from outside and towards the base of the
haemorrhoidal cushions and ligated and transected. The only severe drawback of the procedure is the
severe postoperative pain and discomfort which lasts for at least 5-7 days after surgery. Pain can be eased
with warm baths and application of local analgesics. Also, injections with local anaesthetics may be of
help. If dissection and ligation is achieved with new sources of energy (ultrasound, bipolar diathermy)
postoperative pain is significantly reduced as opposed to the situation after the application of the classical
monopolar diathermy and stitches. In any case, the classical method of “Milligan – Morgan” is the one
associated with the best long term results. Recurrence of bleeding or prolapse of piles is well less than
5%.