• Providing quality
    and compassionate
    care in the Santa Monica
    and West Los Angeles
    medical community
    for over 25 years

  • Board Certified
    General Surgeon

    Specializing In

    • Minimally Invasive Laparoscopic Procedures
    • Hernia Surgery
    • Gallbladder Surgery
    • Abdominal & Breast Surgery
  • Second Opinions
    To Determine
    Surgical Necessity

    Get an Honest Second Opinion

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Colorectal Surgery

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hernia

Description:

Over half a million hernia surgeries are performed annually in the United States. A hernia is an opening or weakness in the wall of a muscle, tissue, or membrane that normally holds an organ in place.  If the opening or weakness is large enough, a portion of the organ may be able to push through that area.  If you can imagine an inner tube poking through a hole in an old tire - that is what a hernia is like.

Inguinal (groin) hernia: Making up 75% of all abdominal wall hernias and occurring up to 25 times more often in men than women.  These hernias occur in the groin area.  These hernias get their name from the inguinal crease which is where the top of the thigh joins the torso.

Femoral hernia:  The femoral canal is the path through which the femoral artery, vein, and nerve leave the abdominal cavity to enter the thigh.  A femoral hernia causes a bulge just below the inguinal crease in roughly the mid-thigh area.

Umbilical hernia:  These common hernias (10% - 30%) are often noted at birth as a protrusion at the belly button (the umbilicus).  This type of hernia is more common in women.  Umbilical hernias can appear later in life or in women who are having or have had children.

Incisional hernia:  Abdominal surgery causes a flaw in the abdominal wall.  This flaw can create an area of weakness where a hernia may develop.  Even after surgical repair, incisional hernias may return. 

Hernias by themselves are not usually life-threatening, but nearly all have a potential risk of having their blood supply cut off, therefore, becoming strangulated.  If this happens, it becomes a medical and surgical emergency.

Symptoms:

For inguinal, femoral, umbilical, and incisional hernias, symptoms may include:

  • An obvious swelling beneath the skin of the abdomen or the groin; it may disappear when you lie down and may be tender.
  • A heavy feeling in the abdomen that is sometimes accompanied by constipation or blood in the stool.
  • Discomfort in the abdomen or groin when lifting or bending over.

What to Expect if Surgery is Required

Surgeries to address most types of hernias are similar to other laparoscopic procedures. General anesthesia is given, and a small minimally-invasive incision is made in or just below the navel. A thin, lighted scope called a laparoscope is inserted through the incision. Other instruments to repair the hernia are inserted through additional small incisions in the lower abdomen. Mesh is then placed over the defect to reinforce the abdominal wall.

Most people who have laparoscopic hernia repair surgery are able to go home the same day. Post-operative discomfort is usually mild to moderate.  Frequently, patients will require pain medication and/or a device called "On Q" catheter.  The "On Q" pump is filled with a local anesthetic toward the end of the surgical procedure.  It is connected to one or two small gauge catheters, which are placed into the intra-operative site. The “On-Q” is a pain management system designed to provide patients with post-operative pain relief for up to three days and is separate from the administration of anesthesia for the surgery.  The "On Q" is very effective in lessening post operative discomfort and promoting a quick recovery.

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Recovery

Recovery time is about 1 to 2 weeks. Patients are encouraged to engage in light activity while at home after surgery.  Dr. Cole will determine the extent of activity, including lifting and other forms of physical exertion.

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Aftercare

Aftercare should include constant icing of the incision site.  This is very therapeutic and hastens recovery.  Most patients are able to get back to their normal activities within seven days after surgery. 

Breast Surgery

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breast surgery med

Description:

Breast changes are common.  From the time breast begin to develop through menstruation and menopause, women may experience various kinds of breast pain and other breast changes such as breast lumps and tenderness.  Lumps within breast tissue are usually found unexpectedly during test procedures or during a routine monthly self-examination.  Most lumps are not cancerous but represent changes within the breast tissue.

Your breast is composed of several glands and ducts that lead to the nipple and the surrounding colored area called the areola. The milk-carrying ducts extend from the nipple into the underlying breast tissue like the spokes of a wheel. Under the areola are lactiferous ducts which fill with milk during lactation after a woman has a baby. When reaching puberty, changing levels of hormones cause the ducts to grow and cause fat deposits in the breast tissue.  The glands that produce milk (mammary glands) may extend to the armpit area (axilla).

There are no muscles in the breasts, but muscles lie under each breast and cover the ribs. These normal structures inside the breasts can sometimes make them feel lumpy. Such lumpiness may be especially noticeable in women who are thin or who have small breasts.

Symptoms:

Breast pain is a common breast problem mostly in younger women who are still having their periods, and happens less often in older women. About two-thirds of women with breast pain have a problem called cyclic mastalgia. This pain typically is worse before your menstrual cycle and usually is relieved at the time your period begins. The pain may also happen in varying degrees throughout the cycle. Because of its relationship to the menstrual cycle, it is believed to be caused by hormonal changes. This type of breast pain usually happens in younger women, although the condition has been reported in postmenopausal women who take hormone replacement therapy.

Breast pain that is not associated with the menstrual cycle is called noncyclic mastalgia. It occurs less often than the cyclic form. It typically occurs in women older than 40 years and is sometimes linked to a fibrous mass (fibroadenoma) or a cyst.  Although breast pain is a concern, it is rarely the only symptom of breast cancer.  Most breast cancers involve a mass or lump.

Breast pain or tenderness may also occur in teenage boys. The condition, called gynecomastia is enlargement of the male breast which may occur as a normal part of development, often during puberty. Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous.

Lumps or abnormalities in the breast are often detected by physical examination, mammography, or other imaging studies. However, it is not always possible to tell from these imaging tests whether a growth is benign or cancerous.

If an abnormality is not felt during examination, there are additional signs that indicate the need for medical attention. These include:

  • Severe breast pain.
  • Changes in the size of a breast or the nipple.
  • Changes in the shape of both breast or nipple.
  • Pitting, dumpling or redness of the breast skin.
  • Nipple redness, irritation, or inversion.
  • Changes in the pattern of veins visible on the surface of the breast.
  • Some types of nipple discharge.

To determine the condition of the mass, a breast biopsy may be required.  The biopsy is removal of breast tissue for examination by a pathologist. This can be accomplished surgically, or by withdrawing tissue through a needle. Image-guided needle biopsy is not designed to remove the entire lesion, but most of a very small lesion may be removed in the process of biopsy.

The type of biopsy will depend on whether the area can be felt, how well it can be seen on mammogram or ultrasound, and how suspicious it feels or appears. Specialized equipment is needed for different types of biopsy and availability may vary. Generally, needle biopsy is less invasive than surgical biopsy. It is appropriate for some, but not all situations and some surgeons feel it is far less accurate. These are some of the more common biopsy procedures:

  • Fine needle aspiration(FNA), which uses a very small needle to extract fluid or cells from the abnormal area.
  • Core needle (CN) which uses a large hollow needle to remove one sample of breast tissue per insertion.
  • Vacuum-assisted device (VAD) which uses a vacuum powered instrument to collect multiple tissue samples during one needle insertion.
  • Wire localization, in which a guide wire is placed into the suspicious area to help the surgeon locate the lesion for surgical biopsy. 

What to Expect if Surgery is Required

If the abnormality is not felt, a needle localization must be done before the actual surgery. After local anesthetic is administered, a fine wire is placed in the area of concern. Either x-ray or ultrasound guidance is used. The patient is awake and usually sitting up.

There are two types of surgical breast biopsies considered here, excisional and incisional. An excisional biopsy is a procedure where the entire area of concern and some surrounding tissue is removed. It is usually done as an outpatient procedure, in a hospital or surgery center. The patient may be given a light anesthesia which will speed recovery time in comparison to a general anesthesia.

If a mass is very large, an incisional biopsy may be performed. In this case only a portion of the area is removed and sent for analysis. The procedure is the same as an excisional biopsy in other respects.

A surgical breast biopsy will require the patient to have nothing to eat or drink after midnight before the scheduled surgery date.  This even applies to brushing your teeth the morning before surgery - DO NOT swallow the water.

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Recovery

Recovery time depends on the type of procedure and will vary from patient to patient. In cases of biopsies, the skin opening for a needle biopsy is minimal. It may be closed with thin, clear tape, called a steri-strip, or covered with a small gauze bandage. The patient can return to her usual routine immediately after the biopsy. Strenuous activity or heavy lifting is not recommended for 24 hours. Any bandages can be removed one or two days after the biopsy.

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Aftercare

After a surgical biopsy, the incision will be closed with stitches, and covered with a bandage. The bandage can usually be removed in one or two days. Stitches will dissolve in the next 2 weeks.  You should make a follow up appointment with your doctor, 7 days after the surgery.  Depending on the extent of the operation, normal activities can be resumed in approximately one to three days. However, vigorous exercise may be limited for one to three weeks.



Gallbladder Surgery

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 gallbladder orig

Description:

The most common treatment for gallbladder symptoms is a surgical procedure referred to as a cholecystectomy.  This procedure used to require a large abdominal incision to remove the gallbladder. However, this procedure is now commonly performed laparoscopically (minimally invasive).  There are still rare cases where an open incision must be used. The minimally invasive laparoscopic procedure can be performed at a surgery center and requires only very small incisions.  Laparoscopic procedures promote a speedy recovery time and, in most cases, the patient does not experience much pain.

Symptoms:

Generally, gallbladder symptoms are referred to as an "attacks" because they occur suddenly. Gallbladder attacks often follow the intake of a fatty meal, may occur during the night and can be accompanied by excessive vomiting. The typical gallbladder attack includes:

  • Steady, severe pain in the upper abdomen that increases and can last  several hours.
  • Pain in the back between the shoulder blades.
  • Pain under the right shoulder.
  • Nausea or vomiting.
  • Abdominal bloating.
  • Intolerance of fatty foods.
  • Excessive belching / gas.
  • Chronic indigestion.

Additionally, the following symptoms are indications of more serious conditions, and you should seek medical care immediately:

  • Sweating.
  • Chills.
  • Severe abdominal pain.
  • Low grade fever.
  • Yellowish tint of the skin or whites of eyes.
  • Clay colored stool.

What to Expect if Surgery is Required

Surgeries to address most types of gallbladder removal surgeries are similar to other laparoscopic procedures. General anesthesia is given, and a small minimally-invasive incision is made in or just below the navel. A thin, lighted scope called a laparoscope is inserted through the incision. Other instruments to remove the gallbladder are inserted through additional small incisions in the lower abdomen.

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Recovery

Post-operative discomfort is usually mild.  Rarely, patients will require pain medication. Dr. Cole will determine your individual recovery time at the seven day post-operative visit.

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Aftercare

Patients are encouraged to engage in light activity while at home after surgery. Most patients are able to get back to their normal activities within seven days after surgery and are able to fully resume their regular lifestyle after one month.

Skin Cancer Excisions

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melanoma orig

Description:

Melanoma is a form of cancer that begins in melanocytes (cells that make the pigment melanin). It may begin in a mole (skin melanoma), but can also begin in other pigmented tissues, such as in the eye or in the intestines. 

 

Melanomas that have not grown deeper than the epidermis are referred to as “Stage 0”. They are usually treated by a surgical wide excision to remove the melanoma and a margin of about 1/2 cm.  If the edges of the removed sample contain cancer cells, a repeat excision of the area may be done. 

 

Stage I melanoma is treated by wide excision and its margins.  The amount of normal skin removed depends on the thickness of the melanoma, but no more than 2 cm of normal skin needs to be removed from all sides of the melanoma. Wider margins make healing more difficult and have not been found to help people live longer.

 

Some doctors may recommend a biopsy.  This is an option that you and your doctor should discuss to determine if a biopsy is the right choice.

 

Stage II melanoma is treated by a wide excision.  The amount of normal skin removed depends on the thickness of the melanoma, but it should be no more than 2 cm (4/5 inch) around all sides of the melanoma.  Because the melanoma may spread, many doctors will recommend a biopsy of you lymph nodes.  For some patients doctors may advise treatment with interferon, other drugs or perhaps vaccines to reduce the chance the melanoma will come back.

 

Stage III melanomas have already reached the lymph nodes when the melanoma is first diagnosed.  Surgical treatment required a wide excision along with the removal of lymph nodes.  It may be recommend to be treated with interferon or radiation therapy to the areas where the lymph nodes were removed, especially if many of the nodes contain cancer.

 

Stage IV melanomas are very hard to cure, as they have already spread to distant lymph nodes or other areas of the body. Surgical removal is recommended followed by radiation therapy, immunotherapy, or targeted therapy.  The treatment of widespread melanomas has changed in recent years as newer forms of immunotherapy and targeted drugs have been shown to be more effective than chemotherapy.

Symptoms:

  • You may notice any symptoms in the early stages of melanoma. Skin cancers may be sore, itch or bleed. These skin cancers may start as a new skin growth on unmarked skin and change color, shape, or size. These types of changes are an early sign that the growth is melanoma. But melanoma can also develop in an existing mole or other mark on the skin. Or it may look like a bruise that isn't healing or show up as a brown or black streak under a fingernail or toenail.
  • Melanoma can grow anywhere on the body. It most often occurs on the upper back in men and women and on the legs in women. In older people, the face is the most common place for melanoma to grow. And in older men, the most common sites are the neck, scalp, and ears.

What to Expect if Surgery is Required

We will phone in prescriptions for you to have on hand after surgery.  We will prescribe a pain reliever and possibly an antibiotic.

 

You should have nothing to eat or drink after midnight the night before surgery. This includes candy, water, coffee, and gum. If there are any medications that you take on a regular basis and are concerned about taking them the morning of surgery, please call Dr. Cole to discuss this with him.

 

Dr. Cole may recommend that you see your primary care doctor or other specialists involved in your care to obtain a surgical clearance.

 

Please bathe or shower prior to surgery. Remove all makeup, jewelry, hairpieces and false eyelashes. Do not use lotions or oils after bathing.

 

Wear comfortable clothing that is easy to put on and remove.

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Recovery

Dr. Cole recommends bed rest once you arrive home on the day of surgery.  Dr. Cole will suggest that you stay indoors and take it easy the first 3 days after surgery.  Once Dr. Cole sees you in the office for your 7 day follow up it will be determined the extent of your activities and physical exertion.

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Aftercare

•After every surgery there will be swelling, which is a normal tissue response. Bruising may also be seen under the incision.  Again, ice will help significantly.

•You may sit on a sofa, or at your desk, but minimize your activity

•No heavy lifting greater than 15 pounds for approximately 6 weeks after surgery

•A ridge of firm tissue will develop beneath your incision. This is part of the normal healing process and will resolve over the next few months

•Massage with Aloe Vera gel for the next 2 – 3 months, 2 – 3 times per day. This will help to break down the scarring process

•Should you develop a fever or the wound becomes very swollen, tender and/or red, contact Dr. Cole immediately

Follow-Up

•Please call Dr. Cole the following morning to check-in and make an appointment within 7 – 10 days

 

 

On-Q PainBuster Catheter

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on-QPain Relief After Surgery

Pain relief after surgery is an important part of the recovery process. When you're not in pain, you move around sooner, have a better appetite and return to normal quicker. Dr. Cole has performed hundreds of surgeries involving the On-Q PainBuster Catheter, and he feels it's the best way to for patients to manage post-operative pain and discomfort.

There are two primary methods of relieving pain after surgery. The most familiar is the use of narcotics like morphine. These drugs can cause unpleasant side effects such as nausea, drowsiness, constipation and difficulty breathing. They may also be habit forming. Medical science has developed a new way of relieving pain that can cut down or even stop the need for these drugs. This important new type of pain relief is called ON-Q PainBuster.

The New Choice for Post-Surgical Pain Relief

Narcotic Pain Relief

  • Common narcotics are morphine and codeine. They may be taken in pill form or given through an injection or an IV. Narcotics affect the entire body and may slow the recovery process. They can make you sleepy or groggy. Narcotics may also cause nausea, vomiting, constipation and possible breathing problems.

Continuous Pain Relief at the Surgical Site

  • Doctors have used local anesthetics during different types of surgeries for years. Now these medicines are used to relieve pain after surgery. The local anesthetic is infused directly at the surgical site and relieves the pain even while you're up and moving around.

 

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What You Should Know About the On-Q PainBuster

The ON-Q PainBuster uses a ballon-type pump filled with local anesthetic medication. The pump is automatic and completely portable and may be clipped to your clothing or placed in a small carrying case.

The pump is attached to a very thin tube (catheter), which is placed by Dr. Cole at the end of your surgery. You may wear the ON-Q PainBuster for 2 - 3 days or until the "ball" is flattened.  After the dressing is removed, gently pull the catheter out (approximately 4 - 6 inches).  Once the catheter is removed, place a sterile dressing (bandage) over the catheter exit site.  You can take a shower (NO BATH) on the fourth post-operative day, 24 hours after the catheter is removed.

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Things to be Aware of When Using the On-Q PainBuster

Immediately report any of these symptoms to your doctor (close the clamp on the pump tubing to stop infusion)

  • Increase in pain
  • Redness, swelling, pain, and/or discharge at the catheter site
  • Dizziness
  • Light headedness
  • Blurred vision
  • Ringing, buzzing in your ears
  • Metal taste in your mouth
  • Numbness and/or tingling around your mouth, fingers or toes
  • Drowsiness
  • Confusion