Skip links and keyboard navigation

Surgery Referral Guidelines

Breast Surgery  |  Colorectal Surgery  |  Endocrine and General Surgery  |   Skin  |   Upper Gastrointestinal Surgery |  Vascular Surgery  |  Specialist Clinics Home

Breast Surgery

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Breast disease
*Queries by phone to breast surgeons are welcome
  • Asymptomatic
  • Strong family history
  • Mammogram 10 years before index case
  • Women who have a high risk, eg family or past history will require more active management
Contact genetic counsellor.
ring for appointment:
+61 7 4226 6247

Breast lump

NB: Surgeons prefer to see patient before core biopsy as it is difficult to assess a patient with bruising

Triple assessment (all three completed):

  • Clinical examination
  • Imaging (mammography and/or ultrasound)
  • Fine needle aspiration cytology (± core biopsy)

GP to manage

  • Young women with tender, lumpy breasts
  • older women with symmetrical nodality provided that they have no localised abnormality
  • Referral
  • Triple assessment results
  • Any lump that increases in size
  • Descriptors including size and location

 

Breast pain
  • Unilateral persistent mastalgia
  • Investigations
    • Mammography or breast USS
  • Localised areas of painful nodality / focal lesions
  • Fine needle aspiration cytology

 

GP to manage:

  • Mild / moderate pain
  • Consider referral to Cairns Breast Clinic

Refer:

  • Severe and intractable pain
  • Referral
  • Investigation results
Nipple discharge, Nipple retraction, Change in skin contour
  • Clinical examination
  • Nipple retraction or distortion, nipple eczema
  • Change in skin contour
  • Investigations:
    • Mammography
    • Ultrasound
    • Cytology of any fluid discharge
  • Supportive measures
  • Pain relief
  • Referral
  • Investigations results

 

Go to Toptop of page



Colorectal Surgery

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Diverticular Disease
  • History
  • Clinical examination
  • CT scan abdomen and pelvis
  • Pathology:
    • FBC / ELFT / CEA
  • Colonoscopy
    • all patients with diverticulitis 6 weeks after recovery

Acute mild diverticulitis:

  • Antibiotics
  • Fibre
  • Antispasmodics

Refer to Emergency:

  • Diverticulitis with systemic sepsis
  • Large bowel obstruction
  • Severe PR bleeding

Diagnosed recurrent diverticulitis:

 

Confirmed Colorectal Cancer
  • Clinical examination
  • Pathology
    • FBE / LFT / CEA
  • CT abdomen, chest and pelvis
  • Colonoscopy or Barium enema
  • MRI : to be arranged by hospital
  • Biopsy
  • Referral
  • Results
    • Blood tests
    • Histology
    • CT
    • MRI if available
    • Colonoscopy
Suspected Colorectal Cancer Colonoscopy arranged via referral to Endoscopy Service
  • Referral
  • Colonoscopy report
  • Pathology results
Haemorrhoids
Grades 2 - 4
  • Clinical examination
    • PR
    • Proctoscopy
  • Colonoscopy
    • Over 40
    • atypical bleeding: first
  • Lifestyle, including dietary,  advice and modification
  • Proprietary creams or  suppositories
  • Refer
  • Investigation result
Anal Fistula

Clinical examination

  • PR
  • Proctoscopy
 
  • Refer
  • Investigation result
Anal Fissure
  • Clinical examination
  • History
  • Proctoscopy and PR- only in absence of pain or spasm
  • NO donor creams Eg Rectogesic cream
  • Refer those that do not respond to 14 days of Rectogesic
  • Referral

Go to Toptop of page



Endocrine and General Surgery

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Appendicitis
  • Clinical examination
  • FBC / CRP
  • Ultrasound (children)
  • CT
  • Referral
  • Blood results
  • Diagnostic imaging results

Hernia

Incisional hernia
Femoral hernia
Inguinal hernia

  • History
  • Clinical examination
  • Ultrasound if hernia not obvious on examination
  • Analgesia prn
  • Supportive therapy
  • Divarication of rectus muscles should not be referred, as it is not surgically corrected

Refer to Emergency

  • Suspected bowel obstruction or incarcerated hernia
  • local tenderness or erythema
Painless neck mass
  • Complete head and neck exam for site of primary
  • Pathology
    • TFTs
  • CT or ultrasound
  • Refer
    • persists for two weeks without improvement
    • painless, progressive, enlargement
    • suspected metastatic carcinoma
  • Referral
  • Descriptors including size and location
  • Blood results
  • Radiology results

Thyroid mass

  • Pathology
    • FBE
    • TFTs / Antibodies
  • Ultrasound or CT thyroid
  • FNA solitary nodule after imaging
  • Nuclear Scan
    • Hyperthyroid
    • Multinodular goiter with suspected tumor
  • Hyper or Hypo thyroid patients should be treated to render euthyroid
  • Steroids for subacute thyroiditis
  • Referral
  • Descriptors
    • Estimated size
    • Symptoms
  • Blood results
  • Radiology results

Adrenal mass

  • Fine cut CT
  • Serum K+
  • Urinary catecholamines
 
  • Urgent
    • Functioning lesions
    • Adrenal masses >5cm
  • Non urgent
    • Non functioning Adenomas < 5 cm

Parathyroid disease

  • PTH/Ca2+
  • Sestamibi Scan (at CDI)  if proven primary Hyperparathyroididsm
 
  • Referral
  • Radiology results
  • Blood results

Go to Toptop of page



Skin

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Skin Cancer

  • Basal Cell Carcinoma (BCC)
  • Squamous Cell Carcinoma (SCC)
  • Premalignant Skin Lesions
  • Bowen's Disease
  • Solar Keratoses
  • Punch biopsy (where applicable)

NB Curettage and cautery is a specialized technique which requires specific training and therefore requires referral

Refer

  • Suspected melanoma
  • Diagnostic concern
  • Difficult excision eg rapid growth, lip or ear
  • Referral 
  • Descriptors
    • Position
    • Ulceration
    • Size
  • Punch biopsy result (when available)
  • Photo of the skin cancer (assists in triage)
 Suspected Melanoma
  • Do not do Punch biopsy 
  • Use ABCD Criteria and
    Dermatoscopy (if proficient)
  • Remember Nodular and Amelanotic Melanoma
  • Primary narrow excision with histology if small
  • Consideration of re-excision
  • Complete skin examination and planning of appropriate follow up
  • Referral
  • Histology
  • Description
    • Location
    • Size
  • Photo if able (assists in triage)

 

Skin Infections

  • Bacterial
  • Abscesses
  • Cellulitis
 
  • Oral antibiotics
  • Regular review
  • Long term oral antibiotics for recurrent or more extensive disease

Refer to on call surgeon

  • Unresponsive to therapy
  • patient systemically unwell
  • infections complicating inflammatory dermatoses
  • immunosuppressed patients

Refer to Emergency

  • necrotizing fasciitis suspected
  • Referral
  • Consider dermatology service where appropriate

 

Go to Toptop of page



Upper Gastrointestinal Surgery

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Gallstones
  • History
  • Clinical examination
  • Ultrasound- upper abdomen

Blood test- FBC / ELFT

  • Lifestyle modification

Symptomatic management for biliary colic

  • Referral
  • Blood results
  • Diagnostic imaging results
Obstructive Jaundice
  • Blood tests
    • FBC / ELFT
    • CA19-9
  • Ultrasound +/- CT abdo

Urgent referral:

  • Obstructive jaundice
  • CBD stones
  • Referral
  • Blood results
  • Diagnostic imaging results
Pancreatic Mass
  • Blood tests
    • FBC / ELFT
    • CA19-9
  • CT abdomen with pancreas protocol

Urgent referral:

  • Pancreatic or liver mass 
     
  • Referral
  • Blood results
  • Diagnostic imaging results

Go to Toptop of page



Vascular Surgery

 Diagnosis

 Evaluation

 Management

 Referral Guidelines

Carotid Artery Disease

  • History
  • Clinical examination
    • Neurological deficit
    • Cardiovascular assessment
    • Peripheral pulses
  • Investigations
    • USS
    • Duplex Scan
  • Commence aspirin
  • Manage hypertension

Refer to Emergency

  • Crescendo or multiple
  • TIA
  • RIND (Reversible ischemic neurologic deficit)
  • Amaurosis fugax

Where there is significant co-morbidity, discussion with the Vascular Service is appropriate prior to referral.

  • Referral
  • Results of investigations

Urgent

  • Isolated TIA/RIND/ Amaurosis fugax
  • Asymptomatic carotid stenosis of >80% on imaging

Refer for triage:

  • Asymptomatic carotid stenosis of <80% on imaging
  • Subclavian stenosis or vertebral steal
  • Carotid body tumour
Abdominal Aortic Aneurysm
  • History and risk factors
    • note genetic factors and collagen disorders
  • Clinical examination
  • Investigations
    • Abdominal ultrasound or
    • CT: Fine slice if > 5cm
    • Angiogram
  • Manage risk factors
  • Follow-up surveillance US scans- any increase of 1cm  or more within 12 months- refer

Refer to Emergency

  • > 6cm diameter- contact Vascular Consultant
  • Refer
  • Results of investigations
Renal Artery Stenosis
  • History
  • Evidence of:
    • Deteriorating renal function
    • Suspicion renovascular or resistant hypertension
  • Renal USS
  • Referral to Renal Service
  
Peripheral Vascular Disease
  • History and risk factors
    • Note genetic factors and collagen disorders
  • Clinical examination
    • Peripheral pulses
  • Duplex Doppler
  • CT angiogram
  • Lifestyle advice re: smoking / diabetes
  • Advice re graduated exercise programme

Refer to Emergency

  • Critical ischaemia
  • Referral
  • Investigation results

Urgent

  • Claudication <50m 
Popliteal Artery Aneurysm
  • History
  • Clinical examination
  • Investigations
    • Ultrasound
    • CT angiogram
Refer to emergency
  • >2.0cm diameter
  • Referral
  • Investigation results

Urgent

  • >2.0cm diameter

Varicose Veins including thrombophlebitis

  • History
  • Clinical examination
  • Investigations
    • Duplex scan
  • Mild cases to be manages by GP's
  • Consider graduated stockings if medically unfit for surgery

Refer to emergency

Ascending thrombophlebitis to the level of the saphenofemoral junction

  • Refer moderate to severe cases

Please note:

Sclerotherapy for cosmetic management of varicose veins is not provided at Cairns Hospital

Urgent

  • Venous ulcers
  • Haemorrhage from varicose

Go to Toptop of page




Last updated: 1 August 2013