Conditions & Procedures

I am a laparoscopic colorectal and general surgeon, I offer laparoscopic surgery for bowel cancer, inflammatory bowel disease, laparoscopic surgery for all types of hernia operations other than hiatus hernia.

I am a high-volume cancer surgeon having done more than 800 procedures with minimal complications. I perform high quality endoscopies with fantastic outcomes. My endoscopy list on the NHS is a therapeutic list where I take away large polyps. I am one of the few colorectal surgeons who offer this routinely.

My special interest is in proctology. I offer a number of surgical options for haemorrhoids : Haemorrhoidal artery ligation with Mucopexy ( HALO), Stapled Haemorrhoidectomy and open Haemorrhoidectomy. I have extensive experience with fistula in ano procedures and surgery for pilonidal sinus. I am very happy to see patients with perianal skin tags wishing to have it excised privately.

I am an expert hernia surgeon. I can offer keyhole surgery for all abdominal wall and groin hernias. I have had extensive experience in excision of lesions, lumps and bumps under a local anaesthetic.

Anal Fissure

An anal fissure is a tear in the lining of the anal canal. A common reason for developing this is due to passing hard stools. There are also a number of other conditions which can cause a fissure. An underlying pelvic floor dysfunction can predispose to recurrent fissures, which can be difficult to treat. In the majority of patients because of poor blood supply to the front and rear of the anal canal these fissures do not heal on their own. The anal canal muscle may then go into spasm further reducing the blood supply and impairing healing.

The treatment for this is very patient dependent. This may just be life style changes, medications to relax the muscle and improve the blood supply, laxatives or invasive procedures like injection of botox to relax the sphincter muscles transiently, cutting the muscle surgically or advancement flaps. I will discuss the various options after examining the patient.

For more detailed information on anal fissures, please visit:
www.patient.info/anal-fissure

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Anal Fistula

An anal fistula is an abnormal connection between the anal canal and the outside skin. In a lot of patients this develops after having an anorectal abscess. This is precipitated by infection of an anal gland and the tract usually travels through the sphincter complex and that can make it a difficult condition to treat. Diagnosis would usually involve a digital examination and may need an MRI scan.

Surgery would either be laying open of the fistula if the damage to muscle is small, otherwise we may have to put in a stitch called a Seton, which runs along the fistula tract and allows it to drain from the inside out. These stitches gradually cut through the muscle and in some patients the fistula can then become a low fistula which can be safely laid open.

I will discuss the options after eliciting the bowel and continence function, doing a digital rectal examination, proctoscopy to rule out associated conditions, possibly a rigid sigmoidoscopy to rule out inflammation and assess the tone of the anal canal and check the postion of the internal opening if palpable.

For more information on anal fistula, visit:
www.nhs.uk/conditions/Anal-fistula/Pages/Introduction.aspx

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Banding

Banding of haemorrhoids: Banding involves using a proctoscope and a banding gun or instrument to put a rubber band at the base of the haemorrhoid and above the dentate line where there is no sharp pain sensation. This reduces the blood supply to the haemorrhoid. It also bunches up the lining and fixes it to prevent further prolapse.

What to expect: Banding can be undertaken in the outpatient setting or in the endoscopy department. The actual procedure only takes a few minutes to complete. I will insert a proctoscope and band above the dentate line. The procedure should not be very painful. Some patients can have a Vaso vagal attack after the procedure, so I always ask patients to wait in the treatment room or waiting room for 20 minutes before leaving or driving. Ideally it would be advisable to have someone with you who can drive you back. It is advisable to take a couple of painkillers (Ibuprofen or similar) about 90 minutes before the procedure.

After the Procedure: You may experience some discomfort or a feeling of fullness in the anus for a day or so after the banding. You can return to normal activities as soon as you feel comfortable, usually the next day. It is advisable to keep strenuous activities to a minimum for a few days. You can take regular painkillers like Paracetamol if needed. If you are on medications to thin your blood, I will give you advice on when you can restart it. You can expect some bleeding for a week to ten days after the procedure. The bands should fall off in about 5-10 days. The area heals over during the following 3-4 weeks. Rarely patients get more profuse bleeding when the raw area gets infected, or the scab falls off. You will need medical advice if that happens, and you should contact us at the hospital. I will do a follow up appointment in about six weeks after the procedure to see if that has helped or you need surgical intervention.

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Colonoscopy

Introduction: A colonoscopy is a procedure where a long flexible tube is inserted through the anal canal and will help me visualise the whole bowel and in some indicated cases the last part of the small bowel. I can remove polyps, take biopsies and perform a few other interventions like dilatation of strictures, argon therapy, banding during the procedure.

Indications: There are number of indications for a colonoscopy. The common ones are to diagnose bowel symptoms, screen some one with a positive bowel cancer screening test or family history of bowel cancer and surveillance after bowel cancer operation, previous polyp excision and in inflammatory bowel disease.

Preparation for the Test: Prior to having a colonoscopy, the bowel must be cleared with strong laxatives like Moviprep or Picolax. There is also a diet restriction on the day before the procedure. I will organise for the bowel prep, diet sheet and the admission details to be sent out. Some patients with chronic constipation or diabetics may need extended bowel prep. That would involve a low residue diet for a week before the test along with laxatives like Movicol, Senna or Lactulose. Please do let me know if you are a diabetic or on blood thinners or on anti-hypertensive medication as I may need to stop or modify medication. A colonoscopy may not be suitable for everyone especially elderly patients with multiple comorbidities. I can discuss alternative investigations in those patients.

What to expect on the day: The test is undertaken in the endoscopy department. You can choose to have the procedure done with sedation and pain killers through a needle, gas and air (Entonox) or without any medication. You will be able to watch the procedure and I will talk you through it if you so desire. The procedure usually takes about 30 minutes to do. You may be part of a list, so please be prepared to spend half a day in hospital. There are small risks associate with the procedure like perforation, bleeding (Especially if large polyps are excised), side effects from sedation or an incomplete scope. I will go through the risks and limitations during consultation. I am a high volume endoscopist with excellent outcomes.

After the procedure: You will feel slightly bloated and windy after the procedure. This will settle down quickly. You can eat and drink normally after the procedure. I will be able to tell you the results straight away. Biopsy results may take about a couple of weeks to be available. If you haven’t had sedation you can leave soon after and potentially drive yourself home. If you have had sedation you may need to stay longer, you will need a responsible adult to take you home and stay with you overnight. There are other restrictions for 24 hours. You should not:

Drive
Undertake jobs like, operate machinery, working at heights, carrying hot objects
Drink alcohol or take sleeping tablets
Sign documents

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Haemorrhoidal Artery Ligation

Haemorrhoidal artery ligation operation is a minimally invasive procedure that can be used to treat haemorrhoids in selected patients. The procedure is under a general or spinal anaesthetic. It involves detecting the blood vessels that supply the piles using ultrasound and ligating their blood supply. This causes the piles to shrink. This is often combined with a mucopexy to deal with the mucosal prolapse. Some benefits of haemorrhoidal artery ligation include reduced pain and incontinence as the procedure does not require any incisions.

Patients are given an enema before surgery on the ward by the nurses. I will explain the procedure and the risks in clinic. Post operatively you will be sent home with pain killers, antibiotics and laxatives.

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Polyps

What are Polyps: Polyps are small growths that arise within the lining of the bowel. Most polyps don’t cause any issues. Some polyps, but not all, can turn into cancer if left. The timescale is usually years. It is for that reason excision of some polyps for analysis and prevention of cancer is advised. The risk is higher in polyps larger than one cm, multiple polyps or abnormal looking polyps. In most patients, we don’t know why polyps happen. Some of the predisposing factors are age over 50, smoking, obesity, family history of bowel cancer or polyps or rare genetic conditions. Most polyps don’t cause any symptoms. They are picked up incidentally during endoscopy, a positive faecal occult blood test or during investigations like CT colonoscopy.

Removal of polyps: Most colon polyps are small and can be removed during a colonoscopy. They can be removed by or a snare or forceps. Very often I will inject fluid underneath the polyp to lift it up from the bowel wall, use a snare with diathermy in technique is known as endoscopic submucosal resection. Large polyps may need to be removed piece meal. This type of procedure may be associated with greater risk of bowel perforation or bleeding. I will discuss this with patients beforehand. Removing polyps in itself does not cause any additional pain but can prolong the procedure. The excised polyp is then sent for analysis. Based on that surveillance may be recommended.

In some cases, polyps may be too large, be in a difficult location or there may be concerns that the polyp is in fact a cancer. In such cases I may recommend an operation or other modalities of treatment.

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Pruritus Ani

Pruritus ani is itching around the anal canal which can significantly affect the quality of life in some patients. In the majority of patients there is an underlying cause and my role as a Colorectal Surgeon is to try and find the underlying cause. Very often it is due to microscopic leakage of faeces due to a number of conditions. It is uncommon for personal hygiene to be the cause of this as patients who suffer from this are usually quite aggressive with their personal hygiene, which might make the whole situation worse. The mainstay of treatment would be to eliminate irritants, which contain harsh chemicals. This might mean stopping using toilet paper, bubble baths, using hypoallergenic laundry products and only using water for cleansing. Certain food products can also cause this the commonest culprits being coffee, tea, energy drinks, spicy food, citrus foods and sometimes dairy products; eliminating these from the diet by trial and error methods can sometimes help. Barrier creams like Sudocrem can be used after cleaning. Very rarely drug therapy maybe needed.

The investigation would usually consist of at least a digital rectal examination, proctoscopy and may include further investigations like a flexible sigmoidoscopy or colonoscopy. I will discuss this with you after taking a history and examining you.

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Skin Tags

Skin tags are excess skin around the anal opening. They are often mistaken for haemorrhoids. They could be associated with fissures. When the fissure is irritated it can cause bleeding, pain and swelling of the skin tag which can mimic haemorrhoids. They may also be a sequelae of haemorrhoids. They can be associated with other conditions like Crohn’s disease or a fistula.

Skin tags can cause issues with hygiene, itching, soreness and bleeding. They are not dangerous on their own but if they change in appearance, develop ulceration or cause any red flag symptoms, then you should seek medical attention.

I will need to do an external and internal digital examination, examination of the anal canal with a proctoscope or a rigid sigmoidoscope. I may recommend a flexible sigmoidoscopy or a colonoscopy to rule out other underlying conditions.

Skin tags can be excised surgically. It would usually necessitate an anaesthetic in theatre by the anaesthetists. It is a day surgical procedure. Depending on the number and size they are either suture with absorbable suture or more commonly left to heal on their own.

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Stapled Haemorrhoidectomy

What is a stapled haemorrhoidectomy: PPH or stapled haemorrhoidectomy is a minimally invasive procedure used to treat haemorrhoids. It can be used in selective patients as an alternative to open haemorrhoidectomy or HALO. Its main advantage is that there is less post-operative discomfort and complication than after an open haemorrhoidectomy. The principle is to use a stapling technique is used to pull the swollen blood vessels back into their normal position and then remove excess haemorrhoidal tissue. The staples used in the PPH procedure are made of titanium and are tiny and are MRI competent. This procedure is not suitable for patients indulging in penetrative anal sex. It is usually a day surgical procedure performed under general anaesthetic or spinal anaesthesia

Recovery: You will usually be sent home on pain killers, antibiotics and laxatives to take for a week or so after the surgery. You can have some spotting after surgery which will bet better with time. Most people usually resume normal activities within a few days of surgery.

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