Thursday, September 23, 2010

7.7 Appendectomy, Cholecystectomy, Hernia and other Surgery

Physician's Notebooks 7  - - See Homepage

7. Appendicitis and Other Abdominal Surgery–  Update 22 December 2018
Acronym S/P or s/p for status post, eg, s/p appendicitis, for post-op appendicitis.

   An abdominal surgery ought to be carried out in
Gallbladder surgery
Inguinal Hernia 
Furor Operandi (A Rage To Operate) 
Blood Transfusion during Surgery 
Endnote: Cases of furore operandi 
The most frequent emergency – appendicitis - evolves in 24 hrs from first pain to where Doctor pokes you and says, “Get on a cutting table!” But if you are thinking “appendicitis!” as soon as you feel pain in abdomen, you’ll get the diagnosis made before appendix rupture and you’ll have time to select the best team. Diagnosis of Acute Ap is best made using ultrasound or other imaging of the abdomen with a clinical picture of acute lower right abdominal pain. “Team” means the hospital where your surgery is done, the surgeon and assistant, the anesthetist, nurses, lab techs, operating room staff and availability of self blood transfusion. Do not take surgery lightly; it is the point where you may come closest to losing life or having medical mistake that ruins life. In 2019 almost all appendectomy is done by laparoscopic technique that requires a mini-incision and 1 to 2 days in hospital. 
   An abdominal surgery ought to be carried out in university medical center because at such a place you'll get a surgeon on salary and he will have no economic stimulus for unnecessary surgery. At such a place, a high level of training and skill come from continuing medical education, and there is peer review, so a mistake cannot be hidden. Also a full range of specialists to certify need for surgery, to suggest best procedure and to be at once available should problem arise your surgeon cannot handle.
General anesthesia puts you to sleep by an IV injection and/or gas; and with major surgery above the navel, general anesthesia must be used. But for major surgery below the navel which can be completed in an hour or less, spinal anesthesia is an alternative.
Gallbladder surgery
is a question when one discovers gallstone on ultrasound or x-ray. If solitary and not causing trouble, leave stone alone. Multiple small stones or stones with symptoms should have gallbladder out. If question, get 2nd opinion. The surgeon who operates should be experienced in hundreds of gallbladder surgeries because it is a tricky operation and if it goes wrong the patient will be cursed for life. Attempts to shatter gall stones by ultrasound or dissolve by prolonged chemical treatment have not worked well.
Inguinal Hernia
Besides being visible and palpable, the abdominal, inguinal hernia ought to bulge out more on cough or strain, and to get smaller or disappear from view on lying flat in bed relaxed.
The groin hernia develops slowly due to muscle defect and weakness from birth. What brings it out is sudden physical stress that ups pressure inside abdomen, eg, weight-lifting or chronic cough or, with constipation, straining on a toilet seat to push out a hard piece of feces. (Can be prevented by a habit of digital rectal removal of feces) A groin hernia in adult develops over years and one day you notice it because you see the bulge or because of discomfort. Hernia should be repaired by world class hernia surgeon. Hernia repair tends to fail years later. I had a left hernia that came into my scrotum and was repaired in 1982. I thought it a good job till one day in 1998 when – Oops, there was that bulge again! And soon after, it was back in my scrotum. Finally (I hope) I had it re-repaired in Jan. 2001 by world-class surgical team using a plastic mesh and so far so good.
   After bilateral groin hernia repair, A man may notice his scrotum feels abnormally cool for months. This is due to sensory nerve cutting but it disappears as other nerves take over.
   The groin hernia happens more to men, and a botched surgery could badly hex sex if the surgeon makes mistake of tying what he thinks is a blood vessel bundle but actually contains a vas deferens (tube that passes sperms) and the nerve that effects erection. In good hernia surgery, this bundle should be carefully pulled out of the surgical field.
   Now, what follows is a situation with hernia where knowing a maneuver can avoid lots of trouble. Say you’re a jet setter far from home, and just after landing in Tokyo or Timbuktoo you notice a frightening enlargement of  your groin hernia that for years you put off having surgery on – you just had let it slide and now, after the 12-hour jet with low pressure in aircraft and overeating and constipation, it really did slide – right into your scrotum. So you arrive in hotel and strip for sleep. And - Lo! - you note the enlarging bulge where your left ball (testicle) normally is! And you can’t push it back. Your hernia has incarcerated in scrotum. It is a soon emergency because unless you get it back into abdomen, it may become gangrenous and sudden surgery will be needed in foreign country with HIV contamination a possibility.
   What to do? Lie down on sofa or bed, arranging your body so the buttocks are on the sofa arm or bed edge and shoulders on the floor and your upper torso is sharply angled downward. After 10 or more minutes try to push the hernia out of your scrotum, back into your abdomen cavity, and it should go easily. You succeed in reducing such a hernia by the lying down maneuver because it creates negative pressure in the abdominal cavity, from your intestines; and then your stomach following gravity and pulling away from the lower abdomen into the upper abdomen, creates more abdominal space which pulls the hernia out of the scrotum. And, with your hand pushing, you may return what you could not previously return into your abdomen cavity. Then you should fly home for hernia repair. And use well applied ace bandaging to prevent return of the hernia and do not strain at stool or lift anything on the flight home. If the hernia goes back in the scrotum, replace it again.
Furor Operandi (A Rage To Operate)
is pseudo Latin and refers to the frenzy that seizes a patient who is informed he has cancer or other disease that may be cured by surgery.“Out with it at once” describes it. All rational planning is junked and he well may accept an operation from the first personable “have knife, will cut” doctor, and angrily refuse advice to get 2nd opinion.
  Except where acutely discomforting and immediately life-ending condition forces emergency, no surgery, should be rushed into without careful consideration based on expert alternative opinion. Even with the worst operable cancer, waiting a week between the diagnosis and a potentially curative surgery makes no difference except to improve outcome when the time is used to get more data for making good decision on When? Where? How? And By Whom? The way to save time is to act quickly if you get sign or symptom and to make rapid, accurate diagnosis. Then, if expert opinion agrees, you can proceed to world-class, permanently curative, psychologically and spiritually satisfying surgery. Mostly a patient wastes time not acting on sign or symptom, which has been noted a long time before getting him anxious, and then stumbles about and gets shoddy examination and testing before the diagnosis stares him in face and forces ill-considered furor operandi. Where an operation is concerned, intelligent delay is the speediest course to cure.
Blood Transfusion during Surgery
Because of risk of deadly infection (eg, HIV, hepatitis virus) or allergic reaction, a strong effort should be made to avoid receiving blood donated by a not-DNA-related, or not previously known other person. In major medical center you can donate your own blood during or within 4-weeks before the surgery. Assuming you are not anemic, you may donate blood as frequently as every 3 days until 72 hrs before surgery. Since abdominal surgery may result in unexpected blood loss, you should plan to self-donate as soon as surgery is scheduled. So before you have a doctor surgerize you, be sure his hospital has self-blood donation. Alternatively and if possible, convince a healthy DNA-related potential donor to donate the blood you may need. If not, find a good surgical center that assists self or DNA-related donations. Availability of self-donation is as important as surgeon or hospital, and also to cultivate close family relatives (children, parents) as donors.

Endnote: Cases of furore operandi: In spring 2007 a woman had persistent cough and, after the chest x-ray, a CT of chest was done and a 7-cm diameter kidney tumor was seen below right lung base. It was solid. The size sparked fear it was cancer and her doctor advised surgery and the woman agreed readily and signed permission for right kidney removal if surgeon deemed it necessary. On opening the abdomen the tumor was noted to be very vascular so a biopsy was not done and, because of the large size, the surgeon elected to remove the tumor with all of right kidney. Afterward, the pathologist report revealed the tumor to be a benign lipoma (fat tumor). So the woman ended up unnecessarily losing a normal kidney because she complained of a cough. (Lipomas are not cancerous and grow very slowly so there was no need to rush. Treatment options of such a lipoma, range from doing nothing to local artery embolization to careful surgical resection that removes the tumor and preserves the kidney. A 2nd surgical opinion should have been sought before embarking on treatment)
  In another case, an 83 y/o woman had a chest x-ray for cough which revealed a 5-cm round tumor of right lung in its middle lobe. A CT scan suggested carcinoid tumor (hormone producing benign tumor). The chest surgeon advised thoracotomy (chest opening) surgery to remove the tumor and the patient signed permission. The surgery was done but the woman never regained consciousness and died in nursing home 2 months later after prolonged, expensive post op coma. (Again as in the 1st case, a benign tumor was rushed into the operating room with even more tragic result. In this case the appropriate approach should have been a 2nd opinion consultation on appropriate safest treatment of benign lung tumor in an 80+ year old. Most top chest surgeons would have opted for thoracoscopic biopsy)
A third case saw a 70 year-old man who noted blood in urine and had a quick diagnosis of right kidney cancer. It was operable for cure and the doctor rushed him into agreeing for surgery and, only a few days after the diagnosis was made, he had his right kidney removed and 2 days later he dropped dead on first day out of bed in hospital from an acute coronary artery block that caused the heart attack and sudden death. The lesson here is, again, Never rush into surgery. This man should have got a 2nd opinion and also - especially because age 70 - a careful medical check to be sure he had no reason to delay the surgery. In his case it might have revealed a narrowed coronary artery that could have been easily and quickly dilated and stented and then he could have safely got his surgery with better outcome. Never rush into surgery!
  Never rush into surgery! Never rush into surgery! Never rush into surgery!
END OF CHAPTER. To read next now, click 7.8 Taking Care of Anus and Rectum

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