Consultant surgeon speaks about keyhole surgery for the abdominal cavity.

Nobody wants to discuss their piles – unless boasting about piles of money – but they are a common ailment, which counts for about 50% of routine surgical procedures. “Patients are embarrassed to disclose they suffer from haemorrhoids or incontinence, unless the doctor susses it out with targeted questions; patients suffer in silence and this can make their life miserable, causing not only physical but also psychological problems,” St. Bernard’s Hospital colorectal and laparoscopic consultant surgeon Ehab Mansour says. And they are afraid of surgery, because this operation is still commonly regarded and dreaded as the ‘most painful on the whole planet’, with tales of patients hospitalised for weeks in terrible pain, as it was the case years ago. But it is no longer so, the surgeon reassures us, despite your grandparents having perhaps told you horror stories about it. Indeed they were, but fortunately it is a thing of the past and it no longer needs to be that way since the day-hospital procedure known as HALO was introduced.

The angelical name is actually the acronym for the self-explanatory mouthful ‘Haemorrhoid Artery Ligation Operation’, a procedure that almost takes longer to speak out than to perform, and that can drastically improve the sufferer’s life quality within days. “Haemorrhoids are not considered a disease in itself, but the reflection of other conditions, like constipation, when the vascular cushion lining your entrails is prolapsed and inflamed, sometimes as severely as thrombosed, causing discomfort, pain and unnecessary stress in your daily life. In the old days, they used to cut off part of your back passage,” Mr Mansour explains, “and this was almost torture, but today we can ligate the blood vessels and hence starve the piles with minimal invasion and immediate relief.”

With the help of a camera or Doppler ultrasound instruments, the artery’s exact position is detected. “Arteries make a characteristic chugging pulsating noise, so we can isolate them and selectively tie the ones feeding the piles using a suture akin to a hair scrunchie to starve the inflammation.” This procedure surely is a big improvement to the hospital’s waiting list, but Mr Mansour, a fellow of the Royal College of Surgeons, doesn’t stop here in his bid to revolutionise tummy surgery locally, with the aim of curtail the need to refer patients overseas. Together with the physiotherapist, urologist and gynecologist consultants, he is setting up an integrated pelvic floor support group and is inviting patients to join a forthcoming program targeted to repair, improve and of course prevent the pelvic blunders that are ‘oh so awkward’ when you are on the ugly side of fifty. “Being unable to control your bowel movements is a frustrating way to live, but please don’t suffer in silence. Come forward and help us help you.”

Of course, Mr Mansour’s main specialty is major surgery, minimally invasive keyhole surgery that is, which he has researched since his days as a medical student at the University of Alexandria of Egypt. His medical degree is about colon mobilisation and bowel dissection: his 1996 thesis studied the recurrence of bowel tumour after it was surgically removed through keyhole surgery, then in its infancy, assessing whether it carried a higher risk of breaking down during extraction and catching to the abdominal wall with disastrous consequences like metastasis. “This risk was later proven to be only an academic concern, with no validation in real clinical cases.”

St. Bernard’s Hospital colorectal and laparoscopic consultant surgeon Ehab Mansour

In his late twenties, Ehab moved to the UK and Ireland where he became a senior lecturer and assistant professor at the Royal College of Surgeons Ireland RCSI, Trinity College Dublin TCD and an overseas MRCS examiner. But his longest and most productive spell was his eighteen-year clinical practice , research and consultancy in Dublin and UK Hospitals; “I was lucky I could spend a few weeks of clinical attachment with an Egyptian consultant there, so we shared our common culture and this helped me with the initial cultural shock. Irish people are warm and friendly and they hardly discriminate against foreigners; if they deem you a good professional they accept you for what you are, but still sometimes in the very early days, I had trouble with their accents before I mastered the differences between Irish counties. During my training, I spent five years in one hospital where I researched the advantage of keyhole surgery for and with colorectal professors pioneering the discipline.”

He continues: “We researched the advantages, potential complications and survival projections for laparoscopic surgery compared to ‘traditional’ invasive surgery and we found that keyhole surgery yields higher chance of disease-free survival and of course shorter convalescence, which positively affects costs. Yes, keyhole surgery theatres may be costly to set up, but in the medium term they become cost-effective in the number of ‘working-hand’ hours spared to social grants and sick pay, when the patient can be dismissed within two-three days from the operation, versus the week or two of traditional surgery, and back to work in a week or two.”

Furthermore, keyhole surgery avoids large scars and is pivotal in diagnostics: scars are virtually the size of a dot, while one of the largest stretches to about three centimetres, enough to pull the entire colon out of it. Appendectomies are carried out this way, with the advantage that further investigation can be applied in case the appendix is found undisturbed and the cause of pain originates elsewhere, for example from the ovaries. “And the ladies, especially young ones, love the idea that the scar is invisible!” Ehab says. “From a clinical point of view, large scars may cause adhesions, incarcerations and incisional hernia, which may turn chronic, with an unsightly and painful bulge in the tummy area.”

Endocavitary surgery is also a precious tool to diagnose other ailments of the abdominal cavity, which are benign in most cases, but still need addressing. “We can break down and extract polyps for example. The camera allows to explore what is going on inside and be able to plan a topical intervention, avoiding excess scarring.” Mr Mansour works within a team that includes dietitian, physiotherapist, anaesthetist and intensivist. They pre-assess the patient and devise a customised strategy to minimise the impact on his or her general health and lifestyle, while maximising the success rate of the surgical procedure, and hopefully zeroing the chance of relapse.

As a general surgeon, he also deals with skin conditions and highlights the importance of checking your moles: “We do remove malignant moles, but for aggressive ones like melanoma we still have to refer patients overseas. Never underestimate a suspicious mole as skin-deep: the skin has several layers and if the mole penetrates them all, it can spread cancerous cells through the bloodstream or the lymph nodes, so it is important you voice your concerns with your GP, and get quickly referred to a specialist.”

Ehab arrived in Gibraltar last June to set up the keyhole surgery suite, upgrading to modern practice standards according to guidelines for minimally invasive surgery. “People are genuinely friendly in Gibraltar, and the weather and landscape remind me of my native Alexandria, a Mediterranean port like Gibraltar, so I feel welcome here. This is my alternative hometown. And yes, sometimes there is a language barrier to knock down when I visit Spanish-speaking patients, but they usually come with relatives who can translate, or my nurse will in any case. On the plus side, I am growing in popularity with Moroccan patients, who can describe their symptoms in Arabic to me, notwithstanding the small differences in pronunciation.”