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Achalasia is a motility disorder of the muscles of the esophagus (gullet/foodpipe). Due to inability of the lower part of the gullet to relax the patient will experience the following symptoms: progressive difficulty in swallowing, regurgitation of food, weight loss and occasionally chest pain. The diagnosis can usually be made by a barium (contrast) swallow or manometry (pressure testing) of the gullet. Different treatment options are available. Oral medication, pneumatic dilatation of the lower part of the gullet and Botox injections all have limited success. It is widely accepted that surgical treatment offers the patient the best chance of long term cure. The procedure done to treat achalasia is called a Heller’s myotomy. The aim of the procedure is to divide the thickened muscle layer of the lower part of the gullet without perforating the lining of the gullet. An anti-reflux procedure (see below) is also added. This procedure should be performed in a minimally invasive manner (laparoscopically) and can be done with minimal morbidity.
This condition is characterized by spasm of the muscles of the upper part of the gullet (the cervical esophagus). Because of this the patient experiences difficulty in swallowing (dysphagia) and gradually a pouch (diverticulum) can form in the neck at the weakest point of the gullet (Killian’s triangle). The diagnosis is confirmed with a barium (contrast) swallow and manometry (pressure testing). This condition needs surgical treatment. The aim of the procedure is to decrease the pressure in the upper gullet by dividing the muscle layer. Depending on the size of the diverticulum this can either be done through a neck incision or with the use of a special stapling device introduced through the mouth.
Gastro-esophageal reflux disease is a common condition affecting millions of people worldwide. In healthy individuals there is a very effective one-way valve mechanism between the gullet and the stomach which prevents gastric acid from entering the gullet. Due to variety of factors the valve mechanism can fail which will lead to the lining of the gullet being exposed to acid and the patient experiencing the symptom of heartburn.
The risk factors for developing GERD are:
If left untreated GERD can lead to the following complications
The diagnosis of GERD can de made based on the history and if necessary performing a esophagogastroscopy or 24 hr pH (acid) monitoring test. Not all patients will need a gastroscopy, definite indications for a gastroscopy are:
The mainstay of GERD treatment is medical therapy with a PPI (protonpump inhibitor: a type of drug highly effective in suppressing the secretion of gastric acid). The majority of patients will experience complete relief of their heartburn after initiating PPI therapy. Surgical therapy is indicated in the following scenarios:
Anti-reflux surgery (if done for the correct indications) can produce excellent long- term relief of heartburn without the hassle and expense of taking daily medication. There are a variety of surgical procedures available to treat GERD of which the “Nissen fundoplication” is the most widely used. All of the currently available procedures are based on the same principle though: restoration of the normal barrier to gastric acid reflux while exposing the patient to the minimum risk of morbidity and mortality. Except in the presence of a clear contra-indication, all anti-reflux procedures should be done in a minimally invasive / laparoscopic manner.
Risks or complications following anti-reflux surgery include:
The esophagus (gullet/foodpipe) normally passes through a small hole in the diaphragm (breathing muscle) to enter the abdomen. The size of the hole plays an important role in the effectiveness of the anti-reflux barrier preventing gastric acid entering the esophagus (and causing heartburn). Due to a variety of factors (advancing age, obesity, constipation, chronic cough, etc.) the hole in the diaphragm can enlarge and lead to a hernia developing. This condition is mostly asymptomatic, but can lead to the development of heartburn and/or regurgitation of food. Occasionally these hernias can become quite large and a part of or even most of the stomach can herniate into the chest. Most patient with small hiatus hernias and heartburn will respond well to medical therapy. Large symptomatic hernias will mostly need to be surgically corrected. These procedures involve the mobilization of the stomach out of the chest cavity, resection of the hernia sac, closure of the diaphragmatic opening and performing an anti-reflux procedure. Hiatal hernia surgery should be performed via a laparoscopic approach to minimize morbidity, but can be very challenging.
Peptic ulcers most commonly occur in the duodenum or the stomach. Ulcers occur as a result of an imbalance between the amount of acid secreted and the amount or quality of the (normally) protective mucus secreted by the lining of the stomach / duodenum.
Causes of peptic ulcer disease include the following:
Peptic ulcer symptoms can vary greatly from patient to patient. Typical symptoms can include any of the following:
The diagnosis is usually suspected based on the patient’s history and can be confirmed by doing a gastroscopy. At the time of the gastroscopy a tissue sample will also be taken to determine whether Helicobacter pylori needs to be eradicated and to exclude the presence of cancer if clinically indicated.
Treatment of peptic ulcers has been revolutionized with the introduction of proton pump inhibitors (a specific class of drugs that effectively inhibit gastric acid secretion) and our understanding of the role of Helicobacter pylori. Medical treatment (1 month of a PPI and 2 of the following antibiotics: Amoxicillin 1gm bd, Clarithromycin 500mg bd or Metronidazole 400mg bd) will heal >90% of all ulcers. Surgical treatment for peptic ulcers is rarely performed these days and are mostly reserved for the complications of peptic ulcers:
Bile is produced in the liver and plays a central role in the digestion and absorption of fat. Bile is stored and concentrated in the gallbladder and then released in response to a meal. The body also uses bile to get rid of excess cholesterol. Cholesterol in bile is kept soluble by the presence of bile salts. Any imbalance of the cholesterol:bile salt ratio can lead to the precipitation of cholesterol and the formation of cholesterol stones.
Gallstones are a common problem, increasingly so with advancing age. Fortunately gallstones will remain asymptomatic in the majority of patients. When gallstones do produce symptoms it can be any of the following:
Surgery is indicated as soon as gallstones become symptomatic. A cholecystectomy, performed in a minimally invasive (laparoscopic) manner as soon as any of the above complications develop is the standard of care.
Major cholecystectomy complications are minimal:
Small bowel obstruction usually occurs as a result of some mechanical factor and should be differentiated from a paralytic ileus where the small bowel dilates due to a loss of peristalsis secondary to sepsis or a metabolic derangement.
The following are some of the most common causes of small bowel obstruction:
The patient will usually present with a combination of some or all of the following symptoms:
Treatment depends on the suspected underlying cause of the obstruction. When bands are suspected and the patient is otherwise stable, a period of conservative management might be undertaken. For all other cases surgery will be necessary in order to relieve the obstruction, make a diagnosis and restore intestinal continuity. minimally invasive(laparoscopy).
Diverticula of the colon form due to our western diet leading to constipation and therefore an increase in the pressure needed to propel stool through the colon. The wall of the colon has weak areas where blood vessels penetrate the muscle layer of the colon. It is through these weak areas that the inner layer (mucosa) of the colon can herniate and form diverticula. With advancing age most people will develop some degree of diverticular disease. Fortunately in the majority of people this condition is completely asymptomatic.
The following complications can however occur secondary to diverticular disease:
Diverticular disease is quite common and when completely asymptomatic it requires no treatment. Once complications occur some form of treatment is usually indicated. Simple diverticulitis usually responds well to antibiotics (either as in- or outpatient). In recent years the treatment of diverticular abscesses has moved away from aggressively resecting the involved segment of bowel (which led to high rates of colostomies) to a more conservative approach where drainage (percutaneous, laparoscopic or open) of the abscess would first be attempted and surgery (if still indicated) can then be delayed and a colostomy avoided. A fistula or stricture will be treated by resecting the diseased portion of bowel and a primary anastomosis to restore intestinal continuity. Surgery for bleeding is controversial and depends on many factors
A volvulus occurs when any part of the gut ‘twists’ on itself. This usually has 2 potentially disastrous effects: the organ twists and the tube that is the gut is twisted shut leading to bowel obstruction; the mesentery or base of the organ containing the blood supply is also twisted shut leading to ischaemia, necrosis and potentially perforation.
A volvulus usually occurs in the presence of an anatomic defect that renders the organ more susceptible to twisting. Any part of the GIT can be affected, but the sigmoid colon is by far the most common site involved.
Treatment centers on whether the affected organ is still viable. If the organ is viable it can be ‘untwisted’ and the underlying anatomical defect can be fixed to prevent future re-occurrence. Once necrosis has occurred the patient is usually toxically ill and very unstable. Surgery in this scenario is potentially life saving. The compromised organ is resected and restoration of continuity is left for a later procedure if the patient survives.
Appendicitis most commonly occurs in the 10 – 19 yo age group, but can occur at any age. The underlying problem is obstruction of the appendix lumen (opening) by either a faecolith (hardened stool) or glandular enlargement. Appendicitis classically presents with colicky (cramping) peri-umbilical pain followed by nausea. Low-grade fever and loss of appetite can also be present. Within 24 hrs the pain then localizes to the right lower aspect of the abdomen.
Diagnosing appendicitis can be easy in patients with a classic history and the typical clinical finding of severe tenderness (peritonism) in the right lower quadrant. However, when there is any doubt as to the diagnosis further imaging in the form of an ultrasound or CT scan will be necessary.
Once the diagnosis has been confirmed treatment should occur promptly in order to avoid the complication of appendix rupture with subsequent generalized peritonitis or abscess formation. The patient is started on antibiotics immediately and is taken to theatre on an urgent basis for removal at the appendix. In most cases this will be done in a minimally invasive / laporoscopic manner. This approach has the advantages of:
If a normal appendix is found at the time of the surgery it is mostly still removed in order to avoid diagnostic uncertainty in future.
Rectal prolapse occurs secondary to weakening of the pelvic floor. It is most common in females over 60 years of age. It frequently coexists with other findings such as constipation (two thirds of patients), incontinence, vaginal prolapse or a cystocele.
Rectal prolapse develops gradually. First there is a reducible protrusion through the anus with a feeling of incomplete evacuation of stool. The extent of the protrusion increases gradually until rectal mucosa is exposed externally. This leads to mucous discharge and soiling and may progress to mucosal bleeding and ulceration. With advanced disease faecal incontinence will occur secondary to stretching of the anal sphincter.
Appropriate selection of treatment options will be guided by the following factors:
Treatment options are as follows:
Haemorrhoids (Piles) occur commonly. ‘Anal cushions’ are normally present in the anal canal. For a variety of reasons these cushions can enlarge and then protrude through the anal opening. The following conditions can predispose to the development of haemorrhoids:
Haemorrhoids can occur internally (inside the anus) or externally (outside the anus). Internal haemorrhoids develop 2-4cm above the opening of the anus. They can be classified depending on their size and severity. Internal haemorrhoids are classified as follows:
Haemorrhoids that are associated with external blood clots beneath the skin are known as perianal haematoma. They are less common than internal haemorrhoids and develop on the outside edge of the anus.
Haemorrhoids can lead to the following symptoms / complications:
Treatment of haemorrhoids depends on the size of the haemorrhoids and the symptoms they produce:
Conservative treatment typically consists of nutrition rich in dietary fiber, uptake of oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest. Ointments and creams such as Anusol HC or Sheriproct can be beneficial for relief of symptoms.
Sclerotherapy is reserved for early (1st and 2nd degree) haemorrhoids and involves the injection of a substance that causes shrinkage of the pile.
Rubber band ligation relies on the tight encirclement of the base of a pile by a rubber band. This is indicated in all degrees of internal haemorrhoids and should be virtually painless if done correctly. Bleeding can occur on day 7-10 when the necrotic pile sloughs off
These procedures are done in theatre, usually under full anaesthetic. They involve the removal of all haemorrhoidal tissue (internal and external). The wounds can then be left open or closed with a suture. These procedures lead to painful wounds and patients generally take 2 – 4 weeks to recover fully. Historically these have been the most commonly performed procedures for haemorrhoids following the failure of conservative management. However with the introduction of Doppler guided minimally invasive procedures such as the THD (discussed later) into my practice, the use of excisional surgery has greatly decreased and is nowadays seldomly indicated.
Transanal Haemorrhoidal Dearterialization (THD), http://www.thdamerica.com/, uses a doppler probe to locate the terminal branches of the haemorrhoidal arteries. Once the artery is located the surgeon uses an absorbable suture to ligate or “tie-off” the arterial blood flow. The venous “out flow” remains to “shrink” the cushion. This is done without excision of tissue. If necessary the surgeon will perform a hemorrhoidopexy to repair the prolapse of the anal canal/anal cushions. Again, this is done with suture and no excision of tissue is done. This repair restores and “lifts” the tissue back to its anatomical position. The entire procedure is performed above the dentate line (an area with no sensation) so that there is minimal discomfort. The procedure takes about 20 minutes and is offered as a day case surgery. Lean more about the procedure by watching these videos.
The THD procedure is as effective as excisional surgery, but avoids the postoperative pain and prolonged period of wound healing associated with excisional surgery. Postoperative complications are rare and may include temporary mucous discharge and urinary retention (inability to pass urine). No serious complications have so far been reported with the THD procedure.
An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. An anal fissure may occur when a hard or large stool is passed during a bowel movement. Anal fissures typically cause severe pain and bleeding with bowel movements. The fissure may also lead to spasm of the ring of muscle at the end of the anus (anal sphincter). These spasms will decrease the blood supply to the area of the tear leading to impaired wound healing. The pain associated with the act of passing stool can lead to the patient avoiding stooling and subsequent constipation developing. Passing a large, hard stool will in turn worsen the fissure and so a vicious cycle can ensue leading to a chronic fissure. Anal fissures are very common in young patients but can affect people of any age. An anal fissure usually heals on its own within four to six weeks. If it doesn't, medical treatment or surgery usually can relieve discomfort.
Medical treatment: Anal fissures often heal within a few weeks if steps are taken steps to keep stools soft, such as increasing the intake of fiber and fluids. Soaking in warm water for 10 to 20 minutes several times a day, especially after bowel movements, can help relax the sphincter, improve blood supply and promote healing. If the above measures fail the following treatments might be indicated:
Surgery: If the anal fissure has become chronic and is resistant to other treatments, or if the symptoms are severe, surgery may be recommended. Surgery usually involves cutting a small portion of the anal sphincter muscle to reduce spasm and pain and promote healing. Surgery has a small risk of causing incontinence.
Anal fistula, or fistula-in-ano, is an abnormal connection between the surface of the anal canal and the perianal skin. Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula. Abscesses can recur if the fistula seals over, allowing the accumulation of pus. It then points to the surface again, and the process repeats. Anal fistulas are not dangerous but can be very painful from time to time and can be quite irritating because of the continuous drainage of pus. Additionally, recurrent abscesses may develop. Surgery is considered essential in the decompression of acute abscesses; repair of the fistula itself is considered an elective procedure that many patients elect to undertake due to the discomfort and inconvenience associated with the draining tract. Surgery:
There are several options:
A length of suture material or rubber looped through the fistula which keeps it open and allows pus to drain out. In this situation, the seton is referred to as a draining seton. A drainage seton can be left in place long-term to prevent problems. This is the safest option although it does not definitively cure the fistula.
This option involves an operation to cut the fistula open. Once the fistula has been laid open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. This option leaves behind a scar, and depending on the position of the fistula in relation to the sphincter muscle, can cause problems with incontinence. This option is not suitable for fistulas that cross the entire anal sphincter.
If the fistula is in a high position and it passes through a significant portion of the sphincter muscle, a cutting seton may be used. The seton is tightened over time, gradually cutting through the sphincter muscle and healing as it goes. This option minimizes scarring but can cause incontinence in a small number of cases, mainly of flatus (wind). Once the fistula tract is in a low enough position it may be laid open to speed up the process, or the seton can remain in place until the fistula is completely cured.
To allow healing in severe cases (usually where Crohn’s disease is present).
Fibrin glue injection is a method explored in recent years, with variable success. It involves injecting the fistula with a biodegradable glue which should, in theory, close the fistula from the inside out, and let it heal naturally. This method is perhaps best tried before all others since, if successful, it avoids the risk of incontinence, and creates minimal stress for the patient.
Fistula plug involves plugging the fistula with a device made from pig small intestinal submucosa. The fistula plug is positioned from the inside of the anus with suture. According to some sources, the success rate with this method is as high as 80%. As opposed to the staged operations, which may require multiple hospitalizations, the fistula plug procedure requires hospitalization for only about 24 hours.
Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place. The external opening is cleaned and sutured. Success rates are variable and high recurrence rates are directly related to previous attempts to correct the fistula.
LIFT Technique is a novel modified approach through the intersphincteric plane for the treatment of fistula-in-ano, known as LIFT (Ligation of Intersphincteric Fistula Tract) procedure. LIFT procedure is based on secure closure of the internal opening and removal of infected glandular tissue through the intersphincteric approach. Essential steps of the procedure include, incision at the intersphincteric groove, identification of the intersphincteric tract, ligation of intersphincteric tract close to the internal opening and removal of intersphincteric tract, scraping out all granulation tissue in the rest of the fistulous tract, and suturing of the defect at the external sphincter muscle.
A perianal abscess originates from the glands that line the anal canal. It can enlarge fairly rapidly to affect adjacent tissue as well. Patients with a perianal abscess typically complain of dull perianal discomfort and occasionally, pruritus. The pain often is exacerbated by movement and increased pressure from sitting or defecation. Physical examination demonstrates a small, inflamed, well-defined, fluctuant, subcutaneous mass near the anal orifice. When the infection spreads to deeper tissue like the ischiorectal fossa the patient may become quite ill with high fevers, chills and low blood pressure. In some cases the abscess might be difficult to detect clinically and a CT or MRI scan might be necessary to locate the abscess accurately.The presence of an abscess mandates incision and drainage. Intravenous antibiotics may be necessary to treat surrounding infection.
The spleen is a fist-sized organ situated high up in left side of the abdomen. Despite being well protected by the ribcage, the most common indication for splenectomy these days is blunt abdominal trauma. In this setting it is mostly done with open surgery (laparotomy).
Other indications for splenectomy include:
Idiopathic thrombocytopaenic purpura (ITP) unresponsive to medical therapy, hereditary spherocytosis, thalassemia major and certain stages of Hodgkin's disease.
Splenectomy is ideally suited to a laparoscopic (minimally invasive) approach as it can be a very inaccessible organ to extract and the incision used for open surgery (subcostal) tends to be quite painful.
After splenectomy the patient can be more prone to contract certain infections. It is therefore standard practice to vaccinate against pneumococcus, H. influenza and meningococcus.
Pancreatic surgery offers some of the most challenging procedures in general surgery. The pancreas gland is located deep in the abdomen (the retro-peritoneum) and is surrounded by many vital and delicate anatomical structures. Surgery of the pancreas is mostly done for one of the following three indications:
Trauma: Blunt abdominal trauma can lead to a fracture of the pancreas. In order to avoid a leak of pancreatic secretions the distal pancreas is resected and the ruptured pancreatic duct tied off. This procedure can be done in a manner that preserves the closely associated spleen
Pancreatitis:In acute pancreatitis necrotic (dead) parts of the pancreas can become infected. In order to remove the infection a 'debridement' (removal of all dead pancreatic tissue) is performed. This can be done from the front in an open surgical procedure or from the back in a minimally invasive manner.In chronic pancreatitis surgery is mostly used to treat the symptom of chronic pain. Surgical procedures employed here aim to resect the head of the pancreas, relieve pressure in the pancreatic duct or both.
Tumours of the pancreas:Tumours of the pancreas are fortunately quite rare. They can be cystic or solid, benign or malignant and situated in the head, body or tail of the pancreas. They can also be hormonally active, i.e. secrete insulin, glucagon, etc. Tumours in the tail of the pancreas are usually treated with a distal pancreatectomy with splenectomy. Tumours in the head of the needs a 'Whipple' procedure. This involves resection of the head of the pancreas, gallbladder, bile duct, duodenum, 1st 10cm of small bowel and potentially the distal 1/3 of the stomach. Continuity is then restored by joining the small bowel to the pancreas, remaining bile duct and stomach.
Groin hernias are protrusions of the abdominal contents through abnormal openings in the abdominal wall and can be divided in inguinal and femoral hernias.
Inguinal hernias usually present with an abnormal swelling in the lower abdomen just above the leg crease. They form in relation to the inguinal canal where a man's testicle must descend before birth. They are much more common in males and can be bilateral.
Femoral hernias usually present with an abnormal swelling in the lower abdomen just below the leg crease. They are more common in females than males and are more prone to develop complications than inguinal hernias.
The most feared complications of groin hernias (and most other hernias) are incarceration (inability to reduce the hernia) and strangulation (the blood supply to the hernia contents is cut off possibly leading to necrosis and perforation of the contents). Most hernias will need to be repaired in order to avoid the potential complications. However, if hernias are very small with no symptoms surgery might not be necessary.
Procedures to repair groin hernias can be divided in tension repairs or tension- free repairs; tissue based repairs or mesh based repairs and open or minimally invasive repairs.
Minimally invasive ('keyhole') procedures involve the stripping off of the inner membrane (the peritoneum) lining the abdominal wall from inside the abdomen. The hernia openings are then viewed from inside the abdomen. A tension free mesh is placed over each hernia opening and the peritoneum is again allowed to cover the mesh thus preventing adhesions to the bowel. Three ports are used resulting in only 1x10mm and 2x5mm incisions. These procedures can be done in a totally extra-peritoneal (TEP) manner or in a trans-abdominal pre-peritoneal (TAPP) manner. The advantages of minimally invasive or 'keyhole' surgery has been discussed extensively elsewhere on this site and are also applicable to groin hernia surgery.
Complications of groin hernia surgery are rare, but can include:
An umbilical hernia appears as a painless lump in or near the belly button that may get bigger when you laugh, cough or strain to pass a stool. It may shrink when you are relaxed or lying down.
Umbilical hernias are very common in infants and young children. In many of these cases, the umbilical hernia goes back in and the muscles reseal before the child's first birthday.
Umbilical hernias can develop in adults, in which case the hernia will probably get worse over time if not treated. Common factors contributing to the development of an umbilical hernia include:
Most umbilical hernias will need to be repaired. The repair is usually done via a small incision above the umbilicus and a small piece of mesh is placed to reinforce the repair and lessen the chance of a recurrence.
Whenever an incision is made and the abdominal wall is opened the possibility of a future incisional hernia exists. The risk is much smaller with minimally invasive surgery, but still exists.
The following factors will increase the risk of an incisional hernia developing:
Once an incisional hernia has developed it will need to be repaired to avoid the complications of incarceration and strangulation. The repair will generally involve the placement of a synthetic mesh to decrease the risk of hernia recurrence. This can be done in an open or minimally invasive manner. A minimally invasive approach lessens the risk of hernia recurrence and mesh infection.
Chemotherapy is the use of specific medications to treat or prevent the systemic spread of cancer. These drugs are mostly given by repeated intravenous injections and can be very toxic to peripheral veins. In order to avoid repeated painful peripheral venous access / drip lines it may be necessary to place an access catheter.
These catheters are placed directly in a large central vein, usually the subclavian vein (below the collar bone) and then connected to a subcutaneous 'port' which is easily palpable. This port can then be used to easily and painlessly administer the chemotherapy drugs.
The most serious complications of access catheters include:
An abscess is a collection of pus that has accumulated within a tissue because of an inflammatory process in response to either an infectious process (usually caused by bacteria or parasites) or other foreign materials (e.g., splinters, bullet wounds, or injecting needles). It is a defensive reaction of the tissue to prevent the spread of infection to other parts of the body. In most cases the abscess is surrounded by an area of cellulitis.
The cardinal symptoms and signs of any kind of inflammatory process are redness, heat, swelling, pain and loss of function.
Incision and drainage:
An ingrown toenail develops when the sides of the toenail grow into the surrounding skin. The nail curls and pierces the skin, which becomes red, swollen and tender. The toe can also feel painful when pressure is placed on it. The big toe is most likely to be affected, either on one or on both sides.
Partial nail avulsion, where part of your toenail is removed, is the most common surgical procedure for treating ingrown toenails. It is about 98% effective.
The edges of the toenail are cut away to make the toenail narrower and give the nail a straight edge. This makes it less likely to dig into the surrounding skin.
After the edges of the toenail have been cut, a chemical called phenol will be applied to the affected area. This prevents the nail growing back and stops an ingrown toenail developing in the future.
Total nail avulsion involves removing the whole of the toenail to reduce the risk of an ingrown toenail developing in the future.
The procedure may be recommended if the nail is thickened and pressing into the skin surrounding your toe.
During the procedure, the toenail will be removed and the patient will be left with the indentation (the concave area of skin) where the toenail used to be. It is perfectly safe not to have a toenail and the toe will continue to function normally.