General Surgical Conditions and Surgery

General surgery is a broad discipline covering many regions of the body. At Nis Clinic's General Surgery department, diagnosis, preoperative preparation and surgical treatment are delivered across the following main areas:

• Endocrine surgery: Thyroid nodules, goitre, thyroid cancers.
• Breast surgery: Breast cancer, fibroadenoma, cysts and other benign breast conditions.
• Upper digestive system: Gastric cancer and benign surgical conditions of the stomach, gastro-oesophageal pathologies.
• Lower digestive system: Small intestinal conditions and bowel obstruction, colorectal tumours, surgical complications of inflammatory bowel disease such as ulcerative colitis and Crohn's disease.
• Anorectal surgery: Haemorrhoids, anal fissure, perianal fistula, pilonidal sinus, anorectal tumours.
• Hepatobiliary surgery: Benign and malignant liver tumours and cysts, obstructive jaundice, gallbladder and bile duct stones and tumours.
• Pancreas and spleen: Acute and chronic pancreatitis, pancreatic cysts and tumours, surgical conditions of the spleen.
• Abdominal wall surgery: Inguinal hernia, umbilical hernia, epigastric hernia and incisional hernias arising from previous surgical wounds.
• Soft tissue pathologies: Skin and subcutaneous infections, benign and malignant soft tissue tumours, lipoma and cyst excisions.

No single surgeon is expected to work with equal intensity across all these areas; in clinical practice, the patient's profile, the nature of the condition and the surgeon's area of expertise are all weighed together. At Nis Clinic, cases that cross specialty boundaries — for example, thyroid conditions requiring endocrine assessment, or breast cancer requiring oncology referral — are managed through multidisciplinary consultation as a standard part of the care pathway.

Thyroid and breast surgery occupy an endocrine and oncological crossroads within general surgery. Although they are distinct areas, the clinical logic is closely aligned: in both, assessment is built on the triangle of imaging + fine-needle biopsy + clinical examination, and surgery is considered only when this triangle points towards it.

Thyroid conditions can present across a wide spectrum — from a palpable neck nodule or an incidental ultrasound finding, to hoarseness or difficulty swallowing. Approximately 85–95% of thyroid nodules are benign; however, 5–15% require further investigation. The result of a thyroid fine-needle aspiration biopsy (FNAB) is interpreted according to the Bethesda classification:

• Bethesda I–II (non-diagnostic / benign) → clinical surveillance in most cases.
• Bethesda III–IV (atypia / suspicion of follicular neoplasm) → multidisciplinary review, surgery if indicated.
• Bethesda V–VI (suspicious for malignancy / malignant) → surgical planning.

In thyroid surgery, preservation of the recurrent laryngeal nerve and the parathyroid glands is paramount. Intraoperative neuromonitoring is used to help protect vocal cord function. Postoperative calcium and thyroid hormone monitoring is routine.

Breast surgery rests on distinguishing benign conditions (fibroadenoma, cyst, intraductal papilloma) from malignant ones (invasive ductal/lobular carcinoma, in situ pathologies). Breast cancer treatment extends well beyond surgery; the plan is established jointly by a team comprising a breast surgeon, medical oncologist, radiotherapist, pathologist and radiologist. The main surgical options are breast-conserving surgery (lumpectomy) and modified radical mastectomy; sentinel lymph node biopsy is a standard staging step. At Nis Clinic, patients diagnosed with breast cancer who require oncology or radiotherapy at a more advanced stage are referred to partner centres, with follow-up continuing here.

Digestive system surgery covers the entire anatomical tract from the stomach onwards — stomach, small intestine, large intestine, rectum and anorectal region. Patients most commonly present with abdominal pain, weight loss, changes in bowel habit, rectal bleeding, bloating and persistent nausea.

For gastric conditions, gastroscopic (upper GI endoscopy) evaluation is central to diagnosis; for colorectal pathologies, colonoscopy plays the same role. General surgery addresses the forms of these endoscopic findings that require operative intervention:

• Gastric cancer and complications of peptic ulcer requiring surgery (perforation, massive haemorrhage, gastric outlet obstruction).
• Small intestinal tumours, ileus (bowel obstruction), Meckel's diverticulum, small bowel ischaemia.
• Colorectal cancers — right/left hemicolectomy, anterior resection, abdominoperineal resection.
• Inflammatory bowel disease (ulcerative colitis, Crohn's disease) — surgical complications such as stricture, fistula and fulminant colitis.
• Acute appendicitis — one of the most common emergency surgical diagnoses in Northern Cyprus (TRNC).

Anorectal conditions are among the most frequent reasons for attending a general surgery outpatient clinic. Haemorrhoids, anal fissure, perianal fistula and pilonidal sinus are generally benign conditions, yet they significantly reduce quality of life. The treatment range is broad:

• Haemorrhoids: Medical treatment, rubber band ligation or haemorrhoidectomy (open or stapled), depending on grade and symptoms.
• Anal fissure: Topical treatment and lifestyle modification for acute cases; lateral internal sphincterotomy for chronic presentations.
• Perianal fistula: Fistulotomy, seton placement, or sphincter-sparing techniques such as LIFT or VAAFT in selected cases.
• Pilonidal sinus: Open or closed excision techniques; recurrence rates vary according to technique and patient compliance.

Given the sensitive anatomy of this region, preserving sphincter function is a priority when making surgical decisions; recurrence, continence impairment and wound healing time are all topics that must be discussed with the patient.

Surgical conditions of the right upper abdomen involve structures including the gallbladder, bile ducts, liver and pancreas. The most common pathology in this area is gallstones — they affect an estimated 10–15% of the population across the Mediterranean and Middle Eastern region, including Northern Cyprus, and the majority are asymptomatic. Most asymptomatic stones are monitored; the decision to operate is based on clinical symptoms combined with a demonstrated risk of complications.

Classic symptomatic presentations:

• Biliary colic: Right upper abdominal pain lasting 30 minutes to two hours after meals, often radiating to the back.
• Acute cholecystitis: Fever, raised white cell count, prolonged pain and a positive Murphy's sign.
• Choledocholithiasis: Stone migrating into the bile duct, causing jaundice and elevated liver enzymes.
• Pancreatitis: Gallstone-induced pancreatitis, one of the causes of an acute abdomen.

Laparoscopic cholecystectomy (keyhole gallbladder removal) is today's gold standard. It is performed through four small incisions (typically 5–10 mm), and the majority of patients are discharged the same day or the following day. Conversion to open surgery is required in approximately 2–5% of cases; this rate varies with the surgeon's experience and the patient's anatomy.

Obstructive jaundice (mechanical icterus) results from bile flow being blocked by a stone, tumour or stricture. In this setting, ERCP (endoscopic retrograde cholangiopancreatography) is the primary diagnostic and therapeutic tool; surgery is planned when ERCP is insufficient or when obstruction is tumour-related.

Liver cysts and tumours and pancreatic pathologies are the areas most often requiring a multidisciplinary approach. Hepatic hydatid cyst remains an endemic parasitic condition in Northern Cyprus and Türkiye; treatment options range from the PAIR method (percutaneous aspiration) to open cystotomy and liver resection. For pancreatic cysts and tumours, advanced endoscopic (EUS) and imaging (MRI/MRCP, contrast-enhanced CT) evaluation is a prerequisite for the surgical decision. For complex cases of this kind, the department works in consultation with advanced hepatobiliary surgery centres.

Abdominal wall hernias are the most common reason for planned (elective) surgery in general practice. They occur when intra-abdominal structures (omentum, small or large intestine) protrude through a weak point in the abdominal wall, forming a sac. The most common types are:

• Inguinal hernia: More common in men, but occurs in women too. Both direct and indirect forms exist.
• Femoral hernia: More common in women, with a higher risk of strangulation.
• Umbilical hernia: In adults, associated with obesity, pregnancy and raised intra-abdominal pressure.
• Epigastric hernia: Small midline hernias above the navel.
• Incisional hernia: Weakness at the site of a previous surgical incision — can become large and has a tendency to recur.
• Rarer forms such as Spigelian and lumbar hernias.

Hernias do not resolve spontaneously. Surgery is the only definitive treatment. Delaying surgery creates risk at two critical points: incarceration (the hernial sac becoming trapped) or strangulation (loss of blood supply). Strangulation demands emergency surgery, and bowel resection may be unavoidable in delayed cases.

Modern hernia surgery uses two main approaches:

• Open repair (Lichtenstein and other tension-free mesh techniques): The standard technique. Can be performed under local or general anaesthesia. Rapid recovery; low recurrence rate (1–3% in experienced hands).
• Laparoscopic repair (TEP/TAPP): A keyhole approach using mesh placed from within the abdomen. Particularly advantageous for bilateral inguinal hernias and recurrent hernias; for unilateral primary hernias, outcomes are comparable to open repair.

For incisional hernias, abdominal wall reconstruction is the priority; advanced techniques such as component separation are considered for large defects. Mesh repair has become standard, although biological mesh or mesh-free approaches are considered in the presence of wound infection, contaminated fields or certain patient groups.

After hernia surgery, patients observe a three-to-six-week restriction on heavy lifting; return to activity is gradual. The risk of recurrence cannot be reduced to zero, but with the correct surgical technique and patient compliance it is kept to a minimum.

Emergency surgery is an unplanned but critical surgical discipline. It encompasses acute appendicitis, complicated cholecystitis, perforated peptic ulcer, incarcerated hernia, acute mesenteric ischaemia, complications of acute pancreatitis and abdominal trauma. The time from presentation to clinic, accurate rapid diagnosis and — where necessary — a timely decision to operate directly influence the outcome.

Emergency surgical care follows a three-phase workflow:

1. Resuscitation and stabilisation: Intravenous access, fluid resuscitation, commencement of antibiotics, pain management.
2. Diagnostic workup: Clinical examination combined with laboratory tests (white cell count, CRP, lactate) and imaging (ultrasound, CT) to reach the surgical decision.
3. Surgical or conservative management: If the surgical indication is clear, the operation is planned; in cases that can be monitored, close observation is maintained.

At Nis Clinic, patients who may require emergency surgery benefit from in-building consultation with other specialties. Cardiology review, anaesthesiology pre-assessment and internal medicine support are all available within the same floor — a small but important advantage that accelerates preoperative preparation for elderly patients or those with multiple comorbidities.

Abdominal trauma may be blunt (road traffic collision, fall) or penetrating (sharp instrument, firearm). In blunt trauma, the priority is stabilisation followed by selective imaging; in penetrating trauma, emergency exploratory laparotomy is sometimes necessary. Trauma management is not the remit of a single specialty; orthopaedics, vascular surgery, anaesthesiology and, where required, neurosurgery all work together.

Intensive care monitoring is required for selected patients postoperatively. Sepsis risk, haemodynamic instability and the early postoperative period following major resections are all managed in the intensive care unit. Team coordination, modern operating theatre equipment and postoperative intensive care capacity — these three factors together determine the outcome in emergency surgery.