General+Surgery+Referral+Guide

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 * If a patient has had surgery with one of our surgeons in the past please note this in the referral. We try to have the patient return to their original surgeon unless another request is made. We do not have cardiothoracic, neurosurgery or vascular surgery (to name the most common mistaken referrals) within CCHS and these patients need to be referred externally.**

**Hemorrhoids/ perianal disease**
– for any hemorrhoidal surgery to be covered by insurance, the patient needs to have been on medical therapy (diet changes and a bowel regimen) for 6 weeks and this should be documented in the record. If the surgery is done emergently for acute significant bleeding, this does not apply. If a patient has a fissure, suspected fissure or suspected fistulae, do NOT try to do an anoscopy or even DRE. It will hurt a lot. A patient with a fissure will say that they have a knife like pain with defecation and for some time afterwards. For a fissure or fistulae, you simply need to look at the anus while retracting the buttocks to the sides. All surgeons perform hemorrhoidectomies and other peri anal procedures. Also note, the diagnosis is important to clarify, as malignancies such as rectal cancer can mimic benign anorectal disease. So these patients can also be referred to surgery for this reason, as an exam under anesthesia or other evaluation may be indicated.

**Inguinal hernias**
– if demonstrated on physical exam, you do not need to image them. If the patient complains of inguinal discomfort but a hernia is not palpated on exam, consider imaging with focused US of the inguinal region with Valsalva,. If bilateral, and patient wants them done concurrently, they are likely best done laparoscopically. If the hernia is recurrent and was originally done open, re repair is best done laparoscopically. If original surgery was done laparoscopically, re repair is best done open. Drs. Berguer, Gynn and Lo perform laparoscopic inguinal hernia repairs.

**Ventral hernias**
– if demonstrated on physical exam, you do not need to image them unless the patient has had a ventral hernia repair before or has a thick abdominal wall which is difficult to examine completely. Then consider a CT prior to their surgery appointment**.** All surgeons perform ventral hernia repairs (open and/or laparoscopic)

**Cholelithiasis**
– patients with gallstones but without symptoms do not need to have their gallbladder removed. Approximately 10% of patients with gallstones will eventually require a cholecystectomy. Patients with asymptomatic cholelithiasis become symptomatic at a rate of about 2% per year. They should be given emergency precautions. If they develop right upper abdominal pain especially with nausea/vomiting or fever, they should be seen in the ER or a same day appointment.

**Symptomatic cholelithiasis/biliary colic/chronic cholecystitis**
– please make sure they have a RUQ ultrasound and if done at an outside hospital, the report has been scanned into CC link. These patients should also be given ER precautions as they wait for their surgery consultation. All surgeons perform laparoscopic and/or open cholecystectomies.

**Lumps and bumps**
– if amenable to excision with local, please refer directly to minor procedures. The general surgeons do not routinely do procedures in their consult clinics do to the volume of patients. There is not an absolute size cut off for what can and cannot be done under local. Fairly large lipomas of the trunk can be done under local. Pilonidal cysts almost always need to be excised in the OR although they are I&Dd with local commonly. The location is also important. Minor procedures clinic providers can manage cysts of the face as well as atypical nevi or small BCC/SCC of the face. Distal nose lesions, large face lesions and large ear lesions should go to plastics. If SCC or BCC on the dorsum of the hand, these may be done in minor procedures. If you are unsure whether a lesion can be done in minor procedures, you may contact any of the minor procedures staff (Eve Cominos, Michel Sam, John Lipson or Dave Solomon). The minor procedures staff will use their judgment and occasionally will refer a lesion to a surgical subspecialty if beyond their scope. //Please note that minor procedures clinic has its own referral in ccLink//. If it is on the neck and superficial (dermal cysts or nevi), it possibly may be done in minor procedures. If it is on the neck and deep or suspicious, refer to either ENT or general surgeon, Dr. Mohebati. If it is a ganglion cyst of the hand or wrist, it needs to be referred to plastics/hand. If it is a bony mass, it needs to be referred to ortho.

**Thyroids and parathyrods**
– for thyroid disease, the patient should have had TSH with reflexive FT4, thyroid US and a thyroid uptake scan if there is a dominant nodule. If there is a dominant nodule, you may refer to general surgery concurrently with ordering the uptake scan and an ultrasound guided FNA biopsy (done by radiologist). For parathyroid disease, most commonly hyperparathyroidism, a PTH level, Calcium and creatinine (or a basic metabolic panel with PTH) is most helpful for the biochemical diagnosis. A sestamibi (or parathyroid nuclear study in ccLink terminology) can be ordered by the referring physician or the surgeon. The general surgeons who do thyroid and parathyroid surgery are Drs. Gynn, Mohebati and Weiss.

**Varicose Veins**
– the patient should have already tried medical therapy (walking for exercise, graded compression stockings, elevation when at rest). We do not offer surgical therapies for spidery varicosities. The surgery offered here is vein stripping usually of the greater saphenous (medial leg) so if the patient has large painful varicosities of the greater saphenous and they have failed medical therapy, they are a candidate for surgery here. They should have a bilateral venous Doppler prior to seeing the surgeons to r/o chronic DVT which would make saphenous stripping contraindicated.

**Nissen fundoplication**
– Drs. Berguer, Gynn, and Lo perform these laparoscopically. The patient should have failed medical therapy for their reflux**.** They need to have had an EGD showing severe esophagitis or Barrett’s esophagus. An UGI series is helpful to plan the surgery. The surgeons will order an esophageal manometry if indicated. The other indication for this operation is a paraesophageal hernia, which presents more with dysphagia and chest pain than reflux symptoms. The evaluation is similar to above and can include a CXR or CT scan of the chest and abdomen to evaluate the extent of the stomach in the chest.

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