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Common Operations
 HYPERHIDROSIS & THORACOSCOPIC SYMPATHECTOMY
WHAT IS HYPERHIDROSIS?
Hyperhidrosis is excessive sweating. All of us sweat. When it is hot, or we are embarrassed or anxious, we sweat more. This is normal and it is only when the sweating is excessive and causes ruined clothing or extreme social embarrassment that it is called hyperhidrosis. Generalised hyperhidrosis may be the result of systemic disease such as chronic infection or an overactive thyroid. Localised sweating confirmed to the armpits or hands is not usually associated with any generalised disease.
WHERE DOES SWEAT COME FROM?
There are thousands of little glands in the skin that produce sweat. Sweat is one of the ways which the body uses to cool itself. The amount of sweat depends on how hot it is and on stimulation of the sweat glands by the nerves that supply them.
DO I NEED TREATMENT?
Excessive sweating us not harmful in itself. Therefore treatment is only required if the sweating is so severe that is causing embarrassment or difficulties at work.
WHAT TREATMENT IS AVAILABLE?
You may initially be prescribed a strong antiperspirant called aluminium chloride. This is applied at night and washed off in the morning. Antiperspirants work better in the armpits than on the hands. If the medical treatment is unsuccessful in controlling the sweating then an operation to divide the nerves that supply the sweat glands may be needed (thoracoscopic sympathectomy).
WHAT IS A THORACOSCOPIC SYMPATHECTOMY?
The nerves that supply the sweat glands in the armpit and palms can be cut to reduce the amount of sweating. These nerves lie deep in the neck and chest close to the spine and the traditional operation to divide them, using a neck or armpit incision, left a sizeable scar and was often accompanied by complications. The operation was therefore only done in very severe cases. However, thanks to the development of 'keyhole surgery', the nerves can now be cut through 2 or 3 tiny holes in the chest usual special instruments. This procedure is called a thoracoscopic sympathectomy.
HOW IS A THORACOSCOPIC SYMPATHECTOMY CARRIED OUT?
You will have a general anaesthetic for the operation. When you are asleep, a small hole is made in the upper chest. The lung, on the side being operated on, is allowed to collapse a little to make some working room. Meanwhile your other lung is capable of doing all the work. A camera on a thin telescope is then put into the chest to find the nerves to be divided. One or two other small holes may be made to put in instruments that divide the nerves. The lung is then re-expanded and the instruments removed. Sometimes a small drain (plastic tube) is left in the chest for a few hours to make sure that all the air is removed from the chest cavity.
HOW LONG DO I HAVE TO BE IN HOSPITAL?
Although it is possible to have this operation as a day case, in most cases you will be kept in overnight after the operation. Occasionally, if the lung is slow to expand again, you may have to stay in hospital a little longer.
HOW SUCCESSFUL IS THORACOSCOPIC SYMPATHECTOMY?
This operation usually gives a satisfactory reduction in sweating in over 90% of patients and in nearly all cases the results are permanent. The operation is usually more successful for sweating of the palms than the armpits. Sometimes the palms are so dry after the operation that moisturising cream is needed to prevent cracking of the skin.
Stopping the palms and armpits sweating may result in extra sweating elsewhere. This 'compensatory' sweating usually occurs on the back below the shoulder blades but may occur anywhere. It occurs in more than half the patients undergoing thoracoscopic sympathectomy and sometimes can be unpleasant.
ARE THERE ANY SPECIAL COMPLICATIONS OF THORACOSCOPIC SYMPATHECTMY?
The only particular complication is a drooping of the eyelid on the side of the operation due to damage to the nerves in the root of the neck. This is rare with thoracoscopic sympathectomies (less than 1 in 50), and usually resolves itself. Sometimes, where the telescope was inserted into the chest, the ribs are sore for a few weeks and hurt on breathing in deeply or coughing. This is due to bruising of the ribs and gradually improves. You should be able to return to normal activities as soon as you are quite comfortable, normally within a week or two.
Rarely, bleeding can occur within the chest which may require an operation.
INTERMITTENT CLAUDICATION
WHAT IS INTERMITTENT CLAUDICATION?
Pain you feel in your legs on exercise is called intermittent claudication.
The reason for it is as follows. There is a narrowing or blockage in the main artery taking blood to your leg. This is due to hardening of the arteries (atherosclerosis). Over the years, cholesterol and calcium build up inside the arteries. This occurs much earlier in people who smoke and those who have diabetes or high levels of cholesterol in the blood.
The blockage means that the blood supply is reduced. The circulation is sufficient when you are resting but when walking, the calf muscles cannot obtain enough blood and cramp occurs. This is made better by resting for a few minutes. If greater demands are made on the muscles, such as walking uphill, the pain comes on more quickly.
DOES THE BLOCKAGE EVER CLEAR ITSELF?
No, unfortunately not, but the situation may improve due to opening up of smaller arteries (collateral circulation) which carry blood around the blockage. Many people notice some improvement as the collateral circulation opens up, within six to eight weeks of the onset of claudication.
HOW CAN I HELP MYSELF?
There are several things you can do which may help. The most important is to stop smoking, take regular exercise and lose weight.
SMOKING
If you are a smoker, you must make a determined effort to give up completely. Tobacco is harmful on two counts.
Firstly, it speeds up the hardening of the arteries, which is the basic cause of the trouble.
Secondly, it clamps down the small collateral vessels and reduces the amount of blood and oxygen to the muscles.
The best way to give up is to choose a day when you are going to stop completely, rather than trying to cut down gradually. If you do have trouble giving up, please ask your doctor who can give your advice on nicotine gum and patches or put you in touch with a support group.
DIET
It is very important not to put on weight because the most weight the legs have to carry around, the more blood they will need. Your doctor or dietician will give you advice with regard to a weight reducing diet. If your blood cholesterol is high, you will need a low fat diet and may also require cholesterol lowering drugs.
EXERCISE
There is good evidence that people who take regular exercise develop a better circulation. Do not stop as soon as the pain starts. The chemicals that produce pain may also help to open up the collateral circulation. Try to walk a little further each day and you will almost certainly find that the distance you can manage without pain, slowly but steadily increases.
WHAT ABOUT TREATMENT?
Most people with intermittent claudication do not require intervention but if your symptoms are very severe, or if they do not improve, further treatment may be necessary. An X-ray of the arteries (arteriogram) is usually performed first, to see what can be done. Short blockages can be stretched open with a balloon (angioplasty) in the X-ray department. This is usually done under local anaesthetic and often involves an overnight stay in hospital.
Longer blockages are bypassed using a plastic tube or vein from the leg (bypass graft). This is a major operation under general anaesthetic and involves being in hospital for a few days.
The decision about intervention is usually one for you to make yourself after the likelihood of success and the risks involved have been explained.
DO DRUGS HELP?
Although there are quite a number of proprietary tablets and drugs on the market,
There is very little evidence that they actually help: drugs will not unblock the artery. Perhaps your doctor has already tried one of these drugs in your case so you can judge for yourself. Aspirin is commonly prescribed because it makes the blood less sticky.
A Statin is often prescribed even if cholesterol is normal as this may improve the circulation.
WHAT IS THE RISK OF LOSING MY LEG?
Very few patients with intermittent claudication end up with an amputation if they stop smoking. The most important thing is that you improve your lifestyle.
Keep walking, lose weight
& stop smoking!
LAPAROSCOPIC CHOLECYSTECTOMY
Laparoscopic cholecystectomy is the removal of the gallbladder through a laparoscope (telescope). The main advantages of the 'keyhole' technique are a shorter hospital stay, earlier mobilisation, shorter convalescence and less discomfort. However, as with all operations there are complications which are described later.
The gallbladder acts only as a reservoir for bile produced by the liver, and will not be missed once removed. Bile will continue to be produced. It breaks down fats as they pass through the digestive system. Gallstones are extremely common, and occur in all shapes, sizes and numbers. They may cause no symptoms at all, or they may cause pain and discomfort after eating, especially if the food contains fat. In certain circumstances they may cause jaundice.
The operation usually takes place on the day of admission. You will probably be home the day after your operation.
There is a 5-10% risk that it will not be possible to complete the operation via the laparoscopic (keyhole) route. This may be due to the gallbladder being badly inflamed or due to the presence of abnormal blood vessels. The surgeon is always guided by safety, and if he considers it unsafe to proceed laparoscopically he will convert it to an open procedure (this will entail a slightly longer stay and recovery period, although four weeks after the operation it does not matter which way you had it performed).
ON THE DAY OF YOUR OPERATION
You will not be allowed to eat or drink for about 6 hours before the operation (this may vary depending on the time of your operation).
You will be asked to wear a hospital gown and anti-embolism stockings (to help your circulation).
You should remove any make-up, dentures, contact lenses, jewellery, (wedding rings can be taped over), and any other prostheses.
You may be given a pre-anaesthetic medication on the ward, approximately one hour before the operation, and a ward nurse will then accompany you to theatre. The operation takes 30-60 minutes.
FOLLOWING THE OPERATION
You will go to the recovery area and then return to the ward, where you will be helped off the theatre canvas and made comfortable. A nurse will check your blood pressure and pulse regularly until stable.
You will have three or four very small wounds on your abdomen. Each will be covered by a small dressing. You will be allowed to drink when you are fully awake, and build up to a light diet as tolerated. The nursing staff will provide painkillers for any abdominal discomfort, or referred shoulder or back pain you might have, and will also provide anti-sickness medication is required.
DISCHARGE ADVICE
Wound Care/Stitches:
You can bath the day after the operation.
Activity:
It is advisable to take it easy for 2-3 days and then resume normal activities gradually as you feel able. Heavy lifting should be avoided at first. You will probably need a week to ten days off work, depending on the nature of your job. If your operation was converted to an open procedure, you will be given additional information regarding your convalescence.
Medication:
Painkillers such as paracetamol are usually sufficient to relieve discomfort at home. If any other medication is required then this will be supplied by the ward.
Driving:
You will probably be fit to drive after a week. Please check with your insurance company, and make sure you can do an emergency stop comfortably before you resume driving.
Medical Certificates:
The ward can provide a sick certificate to cover your hospital stay and convalescence.
Diet:
You may have been advised to follow a low-fat diet before your operation, but once the gallbladder has been removed this will no longer be necessary. However, for general health reasons it is advisable to limit dietary fat intake.
Complications:
Laparoscopic cholecystectomy is a very safe operation with few complications. There is a risk of infection of the port sites and minor bleeding from them. There can be leakage of bile past the clips or an accessory duct and this complication may require an operation. The most serious complication occurs when there is damage to the bile duct. This happens only rarely (in less than 1% of cases) but does require an operation to correct the problem.
LEG ULCERS
WHAT IS A LEG ULCER?
A leg ulcer is simply a break in the skin of the leg. The immediate cause is usually a minor injury that breaks the skin. In most people such an injury will heal up without difficulty within a week or two. However, if there is an underlying problem the skin does not heal and the area of breakdown may even increase in size. This is a chronic leg ulcer.
WHAT CAUSES LEG ULCERS?
The most common underlying problem causing chronic leg ulcers is disease of the veins of the leg. There are less common causes for leg ulcers such as disease of the arteries, diabetes or rheumatoid arthritis as well as a number of even rarer conditions. In some cases two or more conditions may be causing damage at the same time. Your doctor will examine you and do some tests to see what sort of ulcer you have.
The following advice applies to venous ulcers and may not be
appropriate for other sorts of ulcers.
HOW DOES VENOUS DISEASE CAUSE ULCERS?
The veins in your leg are tubes that carry the blood back from the foot towards your heart. They contain one way valves that should allow flow up the leg and not back down the leg. However, these valves are not very effective in some people or can be damaged by thrombosis (clots) in the veins. If the valves are damaged, blood can flow the wrong way down the veins which results in a very high pressure in the veins when standing up. This abnormally high pressure is transmitted to the tissues and the skin and leads to damage and ulceration.
HOW WILL I BE TREATED?
Treatment of a venous leg ulcer is aimed firstly at controlling the high pressure in the leg veins and secondly at the ulcer itself. The mainstays of treatment are compression bandaging or stockings and elevation of the limb:
ELEVATION OF THE LIMB
The higher the leg, the lower the pressure in the leg veins. If the foot is elevated above the heart then the pressure in the foot drops to a normal level. Put your legs up whenever you can and as high as you are able - the arm of the sofa is good. Elevate the lower end of your bed (6 inches or so) so that when in bed your feet are a little higher than your head.
COMPRESSION BANDAGING OR STOCKINGS
In order to keep the pressure in the leg veins at the ankle low when you are standing up, you will be treated with compression bandaging or stockings. Several layers of bandages, usually four, may be required to get the necessary pressure to control the veins.
Once the ulcer is healed, compression stockings are necessary to prevent the ulcer from returning. These stockings need to be specially fitted and are much stronger than ordinary "support tights". If you have difficulty putting on your stockings then you can buy a special stocking applicator.
DRESSINGS
The nurse will use a number of different dressings under the bandages depending on the state of the ulcer itself. These dressings may well change as the ulcer progresses.
SURGERY
An operation may be necessary if your ulcer is due to varicose veins. It is not necessary to get the ulcer healed before an operation. The combination of surgery and then ongoing compression can be very effective.
HOW LONG WILL IT TAKE THE ULCER TO HEAL?
It has usually taken many years for the venous problems to cause the ulcer, so it is not surprising that ulcers may take a fairly long time to heal. Although most venous ulcers will heal up in 3-4 months, a small proportion will take considerably longer. Don't despair! Even in these resistant cases treatment is eventually successful.
HOW CAN I STOP THE ULCER COMING BACK?
Once your ulcer is healed, it does not mean that your problems are over. Although the skin is intact the underlying problem with the veins remains and you must take precautions to prevent the ulcer recurring.
- Wear compression stockings at all times during the day.
- Elevation of the legs whenever possible.
- Keep the skin in good condition by using plenty of moisturising cream to prevent dryness.
- Weight loss, fresh fruit, exercise and stopping smoking are also vital to help heal your ulcer as well as for your general health.
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