Posts Tagged ‘surgery’

Costs of surgical procedures and operations

Saturday, January 30th, 2010

If you are due to go into hospital to have surgery then you might be interested in how much it costs regardless of whether you are going NHS or private.

In can be hard to find out what your treatment actually costs but I’ve found out that many of the major health insurance companies publish lists of how much they will pay your hospital for your surgery.

As the health insurance companies have special deals with the hospitals the prices they list will be a lot cheaper that it would be if you paid for the surgery yourself, but it will give you an idea of how much your treatment actually costs the hospital.

You can even compare how much each insurer pays for your treatment. This is because a standard classification of procedures has been created by the Clinical Coding and Schedule Development (CCSD) group.

If you know the code of your procedure then you can compare prices using the insurers schedule of fees. However note that some of the schedules just list the surgeon / anaesthetist’s fees, whereas other include the total cost including hospital fees.

You can easily search for your surgery using either the CCSD code or just by typing in the procedure name.

For example W8520 is the code for a type of arthroscopy of the knee. Currently Cigna would pay up to £575 for the surgeon’s fee and £250 for the anaesthetist’s fee. This is a total of £850 for the surgery.

If you paid for this surgery privately then it could cost you around £3000 – but note that this price includes all your hospital fees as well (and of course some profit for the hospital!).

Knee pain, physio, MRI scans and lateral release surgery

Thursday, September 3rd, 2009

I’ve been having problems with my knees for many years. I get pain when I am in a seated position. I do a desk job which means I am in pain for much of the day. Sitting in a cinema, restaurant or car will cause me pain as well. I don’t have pain when I’m standing, walking, lying down or exercising. The pain is mostly in my right knee – coming from the area under the knee cap – but there is also some pain in my left knee.

Physiotherapy

I first had physio on the NHS about 7 years ago and have since had multiple courses of private physiotherapy as well. If you have read my nhs vs private physio post you’ll know what the differences are with between NHS and private treatment. In total I’ve seen four different physiotherapists.

My first physiotherapist diagnosed the problem as patellofemoral pain syndrome, and all the other physios I’ve seen have used the same name for the problem. Patellofemoral pain syndrome is not in fact a diagnosis at all. It is just a generic name that means ‘knee pain’. Pretty useless really! I know I have knee pain and giving it a fancy name does not help!

What is important for your physio to do is to properly diagnose why you have pain in your knee. There is a very good guide to patellofemoral pain on the KNEEguru website which also contains detailed information on all kinds of knee related issues. Before having a course of physiotherapy it is worth reading about the basic anatomy of the knee and the leg. If you know some of the names of the bones, muscles, and how the knee joint works you’ll be better placed to understand what you physiotherapist tells you.

In my case the physios have always believed that my knee cap (patella) is in the wrong position. It is not centred in the patellar groove which causes more pressure to be put on one side than the other. The pain comes on when I sit down because in this position the knee cap is pulled into the side of the patellar groove which puts pressure on it.

My treatment has consisted of four main part.

1. Stretching the outer muscles of my leg

In my case the outer muscles and connective tissues of my right leg are tight. This has the effect of pulling my knee cap away from the centre of the groove. By stretching these muscles the pull on the knee cap should slowly reduce.

2. Strengthening the inner muscles of my leg

I was given exercises to strengthen the inner quad muscles of the leg. By strengthening these muscles the knee cap should be pulled towards its correct position.

3. Deep tissue massage

A painful type of massage was carried out on my outer thigh to try to stretch out the muscles and other connective tissues. This helps to reduce the pulling forces on the knee cap.

4. Taping of the knee cap

The stretching and strengthening exercises slowly help to reposition the knee cap but a more direct re-positioning effect can be achieved by taping the knee. After assessing the position of my knee cap the physiotherapist showed me how to attach surgical tape over the knee to pull it into the correct position. For me the taping had an almost immediate effect on my knee pain.

Orthopaedic consultant

My knee pain went up and down over the years and I started new physio courses when my pain got worse. During my last course of physio my knee pain actually got worse which is when my physiotherapist recommended that I see an orthopaedic consultant.

Upon visiting the consultant he asked me a few questing and quickly looked at my knee. He said that my knee cap did look like it was further off centre than it should be. He gave two recommendations.

He could either have a look at what was going on inside my knee and possibly treat any problem by doing an arthroscopy. An arthroscopy is a keyhole surgery operation where a camera and light source is inserted into the knee through a very small incision. A liquid is pumped into the joint which helps to expand the joint so it easier to see and navigate around. Surgical tools can then be inserted through a second or third hole to probe or treat any problems.

The second option was to send me to have an MRI scan done of my knee after which I might need an arthroscopy to treat any problems found.

I picked the MRI scan as there wasn’t any disadvantage to having it done. It never hurts to have as much information as possible before considering surgery.

MRI scan

I was told to remove anything metallic from my person and put it in a locker outside the MRI room. I was then taken in and made to lie down on the machine’s bed. I have one metal crown in my mouth but this was not a problem.

The technician secured my leg into place and gave me some headphone to wear. She asked what kind of music I wanted to listed to. She suggested pop, and I was fine with that. I was given a button which I could press if I needed to contact her.

She then left the room and a few minutes later I heard her voice through the headphones. She said that they were going to start the machine. They started the music as well. It sounded like an old compilation of really bad pop songs.

The machine started up and rumbled into life. It was surprisingly noisy and seemed to vibrate intensely like a piece of industrial machinery. Even with the headphones on your can’t ignore the fact that this large machine is roaring around you!

The machines roared for about a minute and then stopped. After about 30 seconds it started roaring again. After a few minutes of this the technician’s voice came back on the headphones. She told me that I wasn’t keeping my knee completely still. This was annoying as I was keeping it as still as I could. It is hard to remain completely still for so long. If I’d known how long it would take I would have asked for my leg to be more securely fastened in place.

Previously I’d only had X-Rays taken of my body and anyone who has them taken knows that they are very fast – like taking a photo. An MRI scan is more like a very slow exposure. This is because many images are being taken at slices across whatever it is they are scanning.

knee mri scan front

The machine could take 20 images slices through my leg. It can take the images in any direction as well. They took images from top to bottom, left to right, and along my leg. Each time the machine would rumble for about one minute and then stop for about 30 seconds before starting again.

knee mri scan patella

The whole process took about 20 minutes during which I had to endure music such as Cyndi Lauper’s Girls Just Wanna Have Fun. I was glad when it was all over!

Afterwards they told me to wait outside whilst they put my images on a CD. The CD ended up having around 100 images on it from various angles. Some scans had been done several times – probably because I hadn’t managed to keep as still as they wanted me to. After I’d been given the CD I was free to go. I’d see the consultant again in a week for him to discuss the MRI images and recommendations.

knee mri scan side

Consultant recommendations

A week later I went back to see the consultant. He told me that internally the knee looked healthy. The bones and ligaments seemed in good condition.

The only problems were that my knee cap was tilted as you can see from the below image, and that my knee cap was higher than it would usually be.

knee mri scan cross section

He gave two options. Either I could try some further physio – now with the extra knowledge of how my knee cap was positioned – or he could perform lateral release surgery on my knee.

The consultant told me that a lateral release of the patella was a very safe procedure. It would take 30-45 minutes, be done under general anaesthetic, and I’d be able to walk out of the hospital and go home a few hours later. I should be able to do exercise such as running after a month, I’d be able to do high impact exercise such as karate two months after the operation. He said that main risk was deep vein thrombosis but even that was extremely rare. This appointment lasted less than 15 minutes and this included the time where he was explaining the MRI scans.

I told the consultant that I’d prefer the surgical option as I’d been having physio for so long.

My own research into lateral release surgery

When I got home and thought about it more I felt that I didn’t really understand what it was the consultant wanted to do to me knee. This is probably not surprising given that I spent less than 15 minutes with him. I wanted to be able to do my own research to better understand the surgery.

I did some research on Google into arthroscopy surgery and lateral release surgery. I phoned up the consultant to confirm the name of the procedure, and that it was the lateral retinaculum which was going to be cut. This at least allowed me to find specific information on the surgery.

Lateral release surgery is an operation which is supposed to allow the knee to rest in the correct position by cutting through the tight lateral retinaculum. This lateral retinaculum is a type of tissue which hold the kneecap on the outer side of the leg. The procedure uses arthroscopy techniques rather than open knee surgery. There is a quick description of the surgery on about.com and there was a really excellent article on arthroscopy surgery on KNEEguru. You’ll still find lots of individual accounts of the surgery on KNEEguru and on Google by using the search boxes.

Obviously the internet does not provide a balanced view of the success of surgery. People with bad experiences are much more likely to share than people who have had no problems. Still I was very alarmed by the large number of accounts of people who have said that lateral release surgery has made their knees worse. In some cases people have been saying that this surgery has left them with permanently reduced mobility or in agony. Some people say it has ruined their life. Strong words indeed. Other people talk about the long recovery times to get mobility back up to normal. There are of course people who say it has greatly benefited them and who had no complications.

Even if the people who have had complications are just a minority it does show that the surgery can have real complications. I was worried that these complications hadn’t been properly explained to me by the consultant. An appointment lasting under 15 minutes is just not sufficient to explain the MRI results, the surgery and the risks. I got an explanation of the MRIs, a very brief description of the surgery and hardly any detail of the risks.

I decided to cancel the surgery. Even if the risks are small I didn’t consider it worth risking my mobility for the sake of pain – which although can be quite painful – is something that I can live with. Especially now that I know the internals of my knee (bones, ligaments) are healthy I didn’t want to risk the health of my knee by having surgery. I was also put off by my previous experience of surgery where a simple lipoma/cyst removal surgery turned into 6 weeks of pain and inconvenience.

Even if the surgery made my right knee better I’d still have some pain in my left knee.

I decided to continue with the physio. Previously there has always been an element of guess work with the physio as the physiotherapists have always been diagnosing the problems from the outside of the knee without any knowledge of what is going on inside. Now that I have the MRI scans of my knee, and can see more precisely what the problem is I hope that they physio can be better targeted at what the problem is.

Lipoma and cyst removal surgery

Monday, August 3rd, 2009

About 5 years ago I started developing a lump on my leg – on my thigh. It grew to the size of a small marble. It was below the surface of the skin and seemed fairly firm and quite spherical.

lipoma cyst on leg

Lumps growing under your skin can be bad news so I went to see my doctor. He told me it was a lipoma – a harmless build up of fat under the skin. He said I could have it removed if I wanted to but that it would do no harm if I left it.

I lived with this odd lump for 5 years and it didn’t cause me any trouble. A year ago I spotted that it had grown larger. It had now reached the size of a large marble under my skin. I went back to the doctor and this time we decided to get it removed. He wrote me a referral and told me that I should expect an appointment letter from the St. Mary’s hospital in about 6 weeks.

My appointment letter arrived. It told me that I would be a day patient – i.e. no need for an overnight stay – and that the surgery would be carried out under local anaesthetic. I was told the date and time to report to the small surgery unit. Apart from that there were no special instructions.

The surgery

On the day I reported to the St. Mary’s Hospital small surgery unit’s reception and had a simple form to fill in. A little later a nurse came in and told me to change into the hospital robes. I did this and waited some more.

Another nurse arrived and took me upstairs to another waiting area. This waiting area was full of other people in surgical robes – either waiting for their surgery to begin, or sitting there under observation after their surgery was complete.

More waiting was involved, until the surgeon appeared and lead me to another room. This room was like a doctor’s room. It had a movable bed (plastic, not fabric covered), and lots of cupboards. Another nurse was in the room as well preparing some equipment.

The surgeon asked some questions and took a look at my lump. She explained what she was going to do. Seemed simple enough, give me the aesthetic, cut a slit in the leg, remove the lipoma and then stitch the leg back up.

I had to sign a form saying that I understood what was going to happen and that I understood that I would be left with a scar.

She had me lie on the bed and positioned my leg. She shaved the area and then using a marker pen drew a few lines onto the lump where she was going to cut. She then swabbed some liquid (I’m guessing it was iodine) onto the area to sterilise it.

Next was the anaesthetic. I had assumed that this would involve a single injection to the area – wrong! She told me that the injections were usually the worst bit of the surgery. She would inject into the surrounding area multiple times. She warned that the injections would feel like bee stings.

The injections did definitely sting. She started out with about 4-5 injections around where the lump was. She then poked the area and asked if I could feel anything. I could. She then gave me another 4-5 injections – I wasn’t watching but I think that as well as them being around the lump they were also at different depths into the skin. Clearly each injection only numbs a very small area. More injections followed until finally she was satisfied that the area of my leg would not feel anything.

As I was lying down I fortunately couldn’t see exactly what she was doing. I saw her holding a scalpel blade. I don’t know exactly when she started cutting into my leg. This is obviously a good thing and meant that the injections were working!

She spent some time doing what I assume was cutting. It is a very odd feeling to be lying down whilst someone uses a scalpel and surgical scissors to cut into your skin. Every so often she’d ask the nurse for some help of a new piece of equipment. A few times she needed a new scalpel.

After what was about 10 minutes she told me that she could see the lump and said that it wasn’t actually a lipoma which is what my doctor had diagnosed it as. It was a harmless benign cyst. The surgeon said that this made it a bit more tricky as she needed to remove it in one piece. If she couldn’t get it out intact then there was a risk that a piece could get left behind which would start growing again.

She also told me that it was quite firmly attached at the bottom so it would require a lot of cutting to remove. She continued cutting and snipping for another 15 minutes. I didn’t feel any of it. All I could feel from my leg was a numb feeling caused by the anaesthetic. Similar to the numb feeling you might get from a dentist anaesthetic.

Finally she announced that it had been removed!

She checked that there were no pieces left and then got ready to sew me back up. Doing the stitches (or sutures as medical people call them) seemed to be straightforward. She used 6 stitches in the area. She told me that they usually have the ends cut short but in my case she’d leave them long so they didn’t come undone. There was a risk as the incision was in a mobile part of my leg.

On top of the main stitches she stuck some paper stitches down – so the main stitches wouldn’t move about. I had a look at the wound at this point and the sight was not great. It was as if someone had cut a one inch hole into my leg and then sewn it back up – which of course is what had happened.

She then put a giant plaster over the stitches and finally wrapped a bandage tightly round my leg.

She told me that I should take it easy today, and warned that my leg could be very painful once the anaesthetic wore off. I could take some standard pain killers if I needed them. I was to take it easy for the next few weeks but there was no need for me to avoid walking. No running, sports or anything stressful for my leg, but normal walking would be fine. In two weeks I should go to a nurse at my doctor’s practice to get the stitches removed. I was also told not to get the wound wet. I could shower if I kept my leg away from the water, but definitely no baths.

It all sounded like it had gone very smoothly. Little did I know that the surgery was only the start!

Before I left the operating room she showed me the cyst in a bottle. It was white, quite spherical and the size of a large marble. It looked a bit like an eyeball!

Afternoon recovery

After the surgery I was told to sit down in the waiting area and have a drink and a biscuit. 10 minutes later I was allowed to leave.

It was quickly apparent that walking with an anaesthetised, stitched up leg was to be a slow affair. I made it to be bus and managed to get home.

Once home I sat with my leg up and tried to rest it as much as I could manage. For several hours the area of my leg that had been operated on remained very numb. Slowly the numbness started wearing off, to be replaced with a sharp painful stinging sensation.

I’d been told that I could take painkillers if I needed them. The problem is that you don’t know how much the pain is going to increase by. I decided not to take any pain killers unless the pain got really bad.

For another few hours the anaesthetic wore off. The pain did increase but it was manageable. It was most noticeable when trying to move or walk.

I had to sleep on my back that night as my leg was too painful (and too fragile given that it had new stitches in it) for me to put any pressure on that leg.

The next day

The next morning the pain had died down considerably. I was able to hobble around, but my limp was obvious.

I continued to rest my leg as much as possible as I knew that I needed to give my wound a chance to heal.

Recovering

Over the next two weeks the pain reduced more. I was able to take the bandage off in the first week but the large plaster remained covering my wound. I had no idea what was happening underneath, but I was hoping that the hole was closing up.

after cyst lipoma removal surgery

It was no longer painful when sitting or walking, but the pain was there if any pressure was applied to the area. I still couldn’t sleep on my side.

As the days wore on I could walk more and more normally. I thought it must be getting better.

Visit to to the nurse

Two weeks after my surgery I visited the nurse to have the stitches removed. I couldn’t visit the nurse at my doctor’s practice as they were dealing with a mice infestation, so I went to the Soho Walk-In Centre. You don’t need an appointment to go here, but you do have to be prepared to wait. On this visit I arrived after work and after filling in the form they gave me, I had to wait nearly two hours before I was seen.

The nurse was very friendly and after questioning me asked me to sit on the bed. First she removed the giant plaster and then started removing the paper stitches. I was watching as she did this.

The paper stitches are stuck onto the skin (like match stick wide pieces of masking tape). The adhesion is fairly strong so a bit of ‘pull’ is needed to remove them. As she took them off it became very obvious that my wound was still completely open. Only the main stitches were holding each side of my skin together.

She spotted that one of the longs ends of one of the stitches was sticking inside my leg. Perhaps this was making it harder for the wound to heal. She re-positioned the end part of the stitch and told me that it was clearly too early for the stitches to be taken out. She put some new paper stitches in place, and put another giant plaster over the wound. She told me to come back in a week.

Before I left I did find out that in order to avoid a two hour wait it would be a good idea to get there just before 8am when it opened.

A week later

A week later I went back to the Soho Walk-In Centre. As suggested I got there before 8am. There were already a few people waiting. At 8am the door was opened and we were let in. I filled in the form and after about 10 minutes was collected by another nurse.

She removed the giant plaster, and then the paper stitches. The wound looked pretty similar to a week ago. It still wasn’t closing up.

The nurse told me that she would have to remove the stitches anyway. She said that there was a limit to how long they could be left in. She removed the stitches – which is very quick and painless by the way – and then cleaned up the wound.

She put new paper stitches on to try to hold the two edges of skin together and then put another giant plaster over the top. She gave me some giant plasters so I could replace the plaster a few times and told me to come back a week later.

lipoma cyst removal scar 2

The next two weeks

Over the next two weeks I visited the Soho Walk-In Centre three more times. Each time my wound would be examined, cleaned and be re-dressed. Each time when I saw the wound again it didn’t appear to be much better. Each time I was told to come back in 3-5 days.

One one occasion to save me a visit one of the nurses gave me a dressing kit so that I could re-dress the wound myself the next time. And I was given a supply of the Mepore giant plasters so I could change them every few days.

dressing pack

mepore giant plaster

On another of the visits a gel was squeezed into the wound which was supposed to encourage the healing process.

intrasite gel

A breakthrough

It was now four weeks since my surgery and the wound was still not closing. I was wondering if the wound could be infected. In fact one of the nurses had wondered this but after getting a second opinion had decided it wasn’t.

On visit number 6 to the Walk-In Centre the nurse I saw told me she believed the wound was infected. She explained that this was why it wasn’t healing up. She cleaned and re-dressed the wound. Over the actual wound she put an inadine sheet. This is a small piece of fabric which is soaked in iodine. Iodine helps to kill bacteria. She also gave me a prescription for Flucloxacillin – an anti-biotic which is similar to penicillin. I was to take this three times a day for the next week.

inadine

The Flucloxacillin caused me no problems apart from one day when I had a lot of chest tightness. On my 7th visit to the nurse I mentioned this side-effect but was just told to keep taking it.

On my 8th visit I saw real improvement to the wound. It looked like the anti-biotic had killed the infection and allowed my wound to heal. The wound had almost closed up. Rather than putting a giant plaster over the wound the nurse put a thin see-though skin-like layer over the top of it. She said this would help the scab that was over the wound to break down and would speed up the healing process.

duoderm layer

The end

Six weeks after my surgery I made my 9th visit to the Soho Walk-In Centre. My wound was now fully closed up. The nurse took off the skin-like layer, cleaned the wound and put another one of the skin-like layers over the top. She told me to leave this layer on for another week. She told me that there should be no need to come back!

Indeed this was my last visit to the nurse, after taking the final skin-like layer off I was able to leave the wound exposed. It still had a large scar over the area, and there was a indent where the cyst had been but at least I could have normal baths, and showers again.

Over the next 6 months the scar did reduce. It still hasn’t disappeared and the indentation is still there but it is good to have got rid of the lump – even though the whole experience was a lot more hassle than it should have been.

lipoma cyst removal scar 3