Pinhole Surgery

There are an increasing number of conditions that can now be treated with image-guided interventional radiology procedures. Consultant radiologists with specialist training in interventional radiology can carry out these treatments, many of which will only require a pin-hole access and can be performed under local anaesthetic and sedation. In the past, these treatments would either not be possible, or would require surgery under general anaesthetic.
Ascites is the term given to the accumulation of fluid in the peritoneal cavity which contains the bowels and major organs like the liver, spleen, gall bladder, pancreas and kidneys. This fluid would normally be removed naturally before an excess builds up. There are many causes for ascites, including liver failure, inflammatory and infective processes but one of the commonest causes is cancer. The commonest tumours associated with ascites typically arise from the bowel, pancreas, liver, ovaries and breast. Many litres of fluid can accumulate and this causes abdominal distension, bowel habit disturbance, appetite loss and general nausea and malaise. The commonest treatments include the use of diuretics such as Spironolactone and drainage of the fluid called Paracentesis. The latter although reasonably effective has the disadvantage that it may need to be repeated (sometimes weekly) and each time fluid is removed, it is simply discarded with loss of valuable nutrients such as protein which are essential to maintain body muscle and provide defence against disease, especially infection. Although, protein can be given intravenously, this is usually inadequate and expensive. A minimally invasive technique offered by The Imaging Clinic in Guildford is to ‘shunt’ this valuable fluid from the peritoneal cavity back into the body’s blood circulation allowing excess fluid to be removed conventionally by the kidneys leaving the valuable proteins in the body. The procedure usually only needs to be performed once and the Denver Peritoneovenous shunt contains a filter to allow fluid and essential macromolecules like protein to recirculate whilst preventing the passage of cancer cells. The procedure is performed under local anaesthesia and mild sedation and usually takes 40 – 50 minutes. Recovery is rapid and patients are encouraged to return home in 24 – 48 hours. It must however be remembered that the procedure is not a cure for cancer but may be useful in managing the distressing side effects of ascites. The Imaging Clinic is also happy to drain the ascites fluid with ultrasound guided placement of the drain. This is usually performed initially until it is established how quickly the ascites is accumulating.

A facet joint injection is an injection into the small joints that connect the vertebrae within the spinal column. It is commonly carried out by a specialist under imaging guidance. The area of interest is localised and then under local anaesthesia a needle is placed intimate with the joint and adjacent nerves and an injection of local anaesthetic and steroid is made around this area. The local anaesthetic can have an immediate effect on symptoms and the steroid tends to have a delayed effect which may take up to two weeks. Often, due to the non-specific nature of back and neck pain, multiple joints are injected at one sitting as a trial of therapy.

This is now an established method for treating the symptoms of heavy bleeding and/or pelvic discomfort and pressure symptoms arising from enlarged fibroids, whilst avoiding major surgery. Guildford is the centre which has performed the largest number of these cases in the UK.


Prior to considering fibroid embolisation, you will have been seen by a gynaecologist to establish that your symptoms are due to fibroids, that there is no other gynaecological or hormonal problem that needs treating first and that the symptoms have not been controlled using medication alone. Part of your assessment will involve imaging in the form of an MRI scan and/or internal ultrasound scan. This will help determine the size and location of the fibroids and serve as a baseline prior to the procedure.


The procedure itself is performed under sedation and local anaesthetic through a pin-hole incision in the groin. The radiologist will guide the catheters using X-ray guidance along the arteries of the pelvis, selectively into the uterine arteries. Particles which block the blood supply to the fibroids will then be injected specifically into the uterine arteries. Most patients will need to stay in hospital for 1-2 nights.

Nerve root blocks are undertaken by a specialist in Spinal Imaging. Patients will attend for a variety of reasons. They can be referred by spinal surgeons or other doctors and also by paramedical practitioners. The purpose of a root block can be twofold:


1. To identify a root causing symptoms

2. To have a therapeutic effect which maybe longlasting but usually gets the patient through their acute problem
Nerve root blocks are x-ray guided and can be carried out in the neck or lower back. They are usually done with image guidance from a sophisticated x-ray scan called a CT Scanner as this the most accurate method. They can also be performed in the state of the art Interventional Suite at The Royal Surrey County Hospital. The injections involve a long acting local anaesthetic and steroids which act locally but have no other effects elsewhere.

Pelvic Vein Embolisation is a minimally invasive procedure which has been performed for over 20 years. It has been advocated for the treatment of “Pelvic Venous Congestion Syndrome” and more recently adopted for the management of pelvic vein reflux associated with leg varicose veins (particularly where previously ‘treated’ varicose veins have recurred) although there is a lack of robust level I evidence for either indication.

A ‘pinhole’ surgical technique, it is performed under local anaesthesia and usually mild sedation. A fine catheter is inserted into the vein behind the collar bone and directed to the incompetent veins. As with the leg vein surgery, only the abnormal veins are destroyed leaving normal healthy veins to carry blood away from the pelvis. Recovery from the procedure is rapid and return home is encouraged after a short bed rest. Normal activity can be commenced within 24 hours.

Minimum Standards for Pelvic Vein Embolization

Dr Lopez has established himself as one of the most experienced specialists performing this procedure in the UK and, from available published data, is one of the most experienced practitioners in the world including Europe & the US.  As such, he is well placed to help determine the minimum recommended standards for safely and successfully performing this specialist proecdure:

  • The procedure should be performed within a hospital environment using facilities certified by the Care Quality Commission (CQC) and employing specialist interventional radiology equipment certified by an accredited radiation protection supervisor.
  • The operating room ideally should have laminar air flow, since a prosthesis is being introduced and, rather like a joint replacement, infection should be avoided
  • The imaging equipment used must have its dose monitored regularly by a Radiation Protection Supervisor (RPA) who is typically a physicist.  At The Imaging Clinic, the radiation dose is consistently low.
  • It is highly recommended that the entire procedure is performed under conscious sedation using a mild intravenous hypnotic agent and narcotic analgesic, as the sclerotherapy component of the procedure uses an irritant ‘foam’ which is intensely uncomfortable, but felt by Dr Lopez to be essential
  • Sedation will ensure comfort throughout the entire procedure which should take less than 60 minutes (for up to four veins) yet enable the patient, who typically sleeps throughout, to be roused easily at the end followed by rapid ‘recovery’
  • A ‘hospital’ environment is important as there is easy access to aneasthetists and other colleagues if necessary.  It also alows a suitable area for recovery in a comfortable bedroom for this ‘day case’ procedure during a 5-6 hour admission

You are strongly advised to specifically ask any institution contemplating this procedure whether it us fulfilling the above criteria for the minimum standards suggested by one of the world-leading authorities on this specialist procedure.

Dr Lopez has published widely on this procedure and is invited regularly to present his work at leading UK, other European & US interventional radiology & surgery conferences.  He has spent considerable time teaching interventional radiology & surgical colleagues from many parts of Europe including France, Holland, Ireland, Italy and Portugal, including interactive ‘live case’ teaching.

He has also made a number of appearances in health documentaries on National & International television including:

Channel 4’s series Embarrassing Bodies (100th Edition)

The Learning Channel’s My Naked Secret (“Pam’s Story)

Dr Lopez & The Imaging Clinic are recognised by ALL private medical insurance companies.  There is no reason whatsoever that an insured patient needs to pay for this procedure assuming that the clinical indication is agreed by the insurance company, notwithstanding any co-payment or excess associated with some policies.  Furthermore, The Imaging Clinic can offer competitive self-funding rates for self-funding patients, and offers a number of locations to perform the procedure.

Dr Lopez receives referrals from surgeons, gynaecologists and other physicians Nationally and Internationally.  Patients requiring the procedure are encouraged to contact The Imaging Clinic directly so we can make the necessary arrangements and ensure that the surgeon performing any subsequent vein procedures receives all the operative notes and ‘xray’ images on CD ROM, immediately following the embolisation.


The Imaging Clinic and its radiologists are recognised by all medical insurers and unless otherwise requested, invoices are submitted directly to them using electronic software, and are usually settled directly.  As usual, you are advised to contact your insurance company prior to receiving treatment.

A competitive self-funding package (fully inclusive of hospital and consultant fees) is also available:

Treatment of one refluxing pelvic vein using foam sclerotherapy alone £1700

Treatment of 2-4 refluxing pelvic veins using foam sclerotherapy alone £1920

Your Consultant will advise you if your treatment will require placement of coils as part of an embolisation procedure.  These specialist prostheses are made of platinum and charged at £175 each, with a typical requirement of approximately four coils for the longer larger ovarain veins and three coils for the smaller internal iliac (hypogastric) veins.

A full written quotation will be provided and original printed receipts made available following treatment as required.

The Imaging Clinic currently performs the procedure in Guildford, with day care provided by Nuffield Health (Guildford).

Discography is a diagnostic technique favoured by spinal surgeons in their assessment of axial low back pain without dominant sciatica. After a consultation and full examination with a spinal specialist, patients are referred to a Consultant Neuroradiologist with special interest in the spine for the procedure. 


The procedure involves lying on the left side on an x-ray table and while under heavy sedation needles are placed in the troublesome discs which are pressurised by an injection of radiological dye. Normal discs are not painful and it is the neuroradiologist’s job to try and identify which discs are pain generators by assessing the symptomatic response to injection and by evaluating the images obtained during the procedure. Most patients will have a limited CT scan through the discs before returning to the ward. The results are fed back to the referring doctor who may decide on conservative management or surgery.

Many conditions require treatment needing reliable access to the bloodstream via veins eg cancer, blood disorders such as sickle cell disease & haemophilia and chronic disease eg cystic fibrosis, enzyme deficiences. This allows regular intravenous therapy to be administered such as chemotherapy, blood & related products and also facilitates frequent blood sampling without damaging valuable veins and causing distress.


Although ‘peripheral’ cannulas can be used for this purpose, they cannot be left in place for more than a few days. A number of devices however are now available. A peripherally inserted central venous catheter (PICC) is typically inserted at or just above the elbow and allows a ‘long line’ to be inserted into a peripheral vein and manipulated unto a central vein above the heart. These catheters are inserted under local anaesthesia and can stay in the vein for many months. In Guildford, The Imaging Clinic Radiologists have been inserting these devices for 25 years with a tremendous success rate and few complications.


Some patients find PICCs rather awkward as they can slightly limit bending of the elbow and as they are visible all the time, they may serve as a constant and distressing reminder of the underlying illness such as cancer. An alternative device is a more ‘centrally’ place device such as a Hickman/Broviac or Groshong catheter. The latter is valved and offers some advantages in most patients in preventing catheter blockage whilst the former is preferable when more channels are required or a higher flow rate is necessary to administer therapies. The Hickman line is typically larger and bulkier than the Groshong catheter and are preferred for patients undergoing bone marrow or other transplants.


These‘central’ catheters are very popular with patients and The Imaging Clinic has had a 100% success rate in inserting them for 25 years with barely any complication and none significant. In the operating room, typically under mild sedation and using local anaesthesia, the internal jugular or subclavain vein is entered under ultrasound guidance and the catheter manipulated into the superior vena cava or right atrium under x-ray control. These catheters contain a‘cuff’ which remains hidden under the skin and this helps prevent catheter dislodgement.


For many years, patients receiving treatment such as chemotherapy for 3 months or more have been referred for insertion of a Portacath. The method of insertion is similar to the procedure for other ‘central’catheters. However, instead of leaving the catheter end or ends protruding from the chest wall, the catheter is connected to a small just palpable chamber and implanted just below the skin of the chest wall so that the chamber can be accessed ‘by feel’ but is barely visible to the patient or others. Our clinic has been inserting these devices for over 20 years with a 100% success rate and no significant complication.


All of these devices allow home administration of products such as cancer drugs facilitating ambulatory outpatient therapy rather than hospital admission. They are all easily removed and can be repaired or replaced on the very rare occasions when function is impaired.


Other venous devices are also inserted by the clinic including haemodialysis catheters and Denver Peritoneovenous shunts. The Clinic also supports problems with any of these devices inserted outside Guildford.

Vertebroplasty is a relatively new, minimally-invasive procedure performed by The Imaging Clinic`s dedicated Neuroradiologist. A percutaneous procedure refers to one done through a small incision in the skin. Vertebroplasty is a technique to strengthen and repair the weakened bone of the vertebrae.

Vertebroplasty has been shown to:


  • Significantly reduce or eliminate pain in up to 90% of patients
  • Prevent old compression fractures from further collapse
  • Have a short recovery time
  • Reduce spinal deformity
  • Stop the “downward spiral” of untreated osteoporosis
  • Provide the patient with an early return to daily activities
  • Be cost effective

Vertebroplasty is for Patients with Vertebral Compression Fractures caused by:


  • Primary Osteoporosis
  • Secondary Osteoporosis
  • Vertebral fracture due to benign and malignant tumors
  • Fractures occurring in patients that take high doses of steroids

Are you a Good Candidate for Vertebroplasty?
  • Do you suffer from chronic back pain due to vertebral compression fractures and your fracture is less than one year old?
  • Do you suffer from a metabolic disorder?
  • Have you been treated with steroid therapy over a long period of time?
You are considered a good candidate for vertebroplasty if you can answer yes to any of these questions. Note: Vertebroplasty is not appropriate for treating pain associated with arthritis, herniated discs or degenerative disc disease.

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