By H. Mine-Boss. Stephen F. Austin State University. 2019.

The suture line now proceeds laterally to its side and meets in the midline anteriorly buy cialis professional pills in toronto. If a tube graft is used order discount cialis professional, it is of such a length that it will be under moderate tension when the distal suture is completed order cialis professional. The distal anastomosis is carried out in exactly the same manner as the proximal suture. When a bifurcation graft is used, the common iliac arteries are transected taking care not to damage their accompanying veins. Two points should be kept in mind at the time of distal anastomosis — (i) the intima of the common iliac artery should be carefully anchored by the suture so as to prevent formation of dissecting aneurysm and (ii) before completion of the distal anastomosis it is essential to release in turn the proximal and distal clamps to dislodge any thrombus which may be formed during operation. The aneurysmal sac is now approximated around the graft and the posterior parietal peritoneum is closed. Left colon should be inspected and as mentioned earlier reimplantation of the inferior mesenteric artery to the graft may be required. Haemorrhage is now not a very serious complication and occurs provided that anticoagulation is continued beyond the immediate postoperative period. Left colon ischaemia due to lack of collateral blood supply may occur in 10% of cases. Other early complications are haemorrhage, thrombosis of the graft, peripheral emboli, ileus, intestinal obstruction, ischaemia of the left colon and renal insufficiency. Late complications include graft thrombosis, false aneurysm, aortoduodenal fistula (it should be suspected whenever haematemesis or melaena occurs in months or years after operation. A successful outcome may be achieved by prompt operation in which aorta is separated from duodenum, the holes are closed and some omentum is interposed between two structures). Under radiological control a stent-graft delivery system is guided up into the aorta and is placed within the aortic sac. For the other iliac artery a separate single iliac-stent graft is introduced from the opposite common femoral artery. One must be careful to see that the upper most level of the graft and distally at both iliac levels the stent-graft should be bloodtight. Though this method is a success in the initial stage, but lately there is a possibility of stent- graft fragmentation and leakage at the interface of vessel and stent-graft. Two types of rupture may occur — In case of anterior rupture there is free bleeding into the peritoneal cavity. This condition is extremely fatal and only few patients can be brought to the hospital alive. Those who are brought alive, carries a high risk of surgery due to prolonged period of hypotension and shock. But frequent erroneous diagnosis as renal colic or massive myocardial infarct or pulmonary infarct may be made. If operation is performed as an emergency procedure 50% survival should be expected. It is important to know that elevation of blood pressure should be avoided until the abdomen has been opened and proximal control of the aorta is obtained. This must be achieved very quickly by cross-clamping the aorta below the renal arteries. If necessary the aorta may be compressed through the lesser omentum till infrarenal control can be obtained. The ruptured aneurysm is widely incised, intra-abdominal clots are evacuated and the renal arteries isolated. Recently there has been renewed interest in autotransfusion using blood sucked out from the peritoneal cavity. Low molecular weight dextran should not be used as when excreted by the kidneys it may block the renal tubules. Intravenous mannitol (200 ml of 20% solution) or frusemide (Lasix) may be of value particularly in the early post-operative phase, as renal failure is more common after this type of operation. If abdominal aorta is carefully examined, l/3rd of these cases may be seen to accompany aortic aneurysm. It usually occurs in men in 6th and 7th decades of life, half of whom are hypertensive. Two types are usually found— (a) the saccular form, may rapidly expand and rupture, (b) The fusiform type, which is often bilateral, rarely rupture and may be complicated by distal embolism. Symptoms and signs of progressive enlargement include local pain, tenderness and swelling of the leg due to compression of the popliteal vein. It should always be suspected and looked for in cases with embolism of the toes where there is no other obvious source. Only small asymptomatic aneurysms in the elderly patients and thrombosed aneurysms can be left alone. Otherwise this operation can be performed in supine position with the knee slightly flexed and the incision is made on the medial aspect of the lower thigh extended across the knee joint into the upper calf. Exposure can be improved by division of semimembranosus and semitendinosus tendons. Once the artery is exposed and isolated it is clamped to prevent distal embolization during operation. Perhaps the best is the use of saphenous vein as a by-pass graft in association with proximal and distal ligation and total obliteration of the sac. Another method is to lay a graft in the open sac and an end-to-end anastomosis is made above and below the aneurysm. The aneurysmal sac is not excised because both veins and nerves are intimately attached to its wall. The basic pathology is splitting of the intima, allowing the blood to track into the aortic wall creating a channel between the intima and the adventitia. This tracking of blood into the aortic wall causes distension of the aorta for which it is called an aneurysm. But this aneurysm develops months or years later, and such aneurysm is not present during acute dissection. The cause of weakening of the intima, which causes this condition is not definitely known. Hypertension is present in about 75% of patients and hypertrophy of the left ventricle characteristic of hypertension is present in about 90% of cases. But in this syndrome there is greater frequency of dissection in patients with coarctation or congenitally bicuspid aortic valve. It should be emphasized that this disease is not due to atherosclerosis, which is a disease of the intima which mostly affects the terminal part of the abdominal aorta. The aortic dissection is a disease of the media and almost always occurs in the thoracic aorta.

Larger protrusion causes less pain best purchase for cialis professional, as it fixes the nerve root firmly and there is less friction discount cialis professional 40 mg otc, but since the conduction is diminished buy cialis professional on line, so neurological signs are more marked. When the nerve root is medially displaced by the protrusion, the patient tends to stand with a tilt of the trunk away from the affected side to avoid more friction of the nerve root. On the contrary when the nerve root is displaced laterally by the protruding disc, the patient tends to stand with tilt towards the affected side. This is a protective mechanism to avoid stretch­ ing of the nerve root over the protrusion. Local tenderness over the interspinous ligament or just lateral to the spinous process over the affected intervertebral space can be detected in majority of cases. Often the pain is referred to the buttock or the lower limb when the affected area is pressed with a thumb. A diagnosis of disc protrusion can be made with confidence when this sign is detected. Shows that the disc protrusion is displacing the nerve root laterally, so that the Similarly backward patient stands with a tilt towards the affected side to avoid friction. Shows that the disc extension is also protrusion is displacing the nerve root medially, so that the patient stands with a tilt towards sound side to avoid frictions. Lateral flex­ ion of the spine is more limited on one side or the other depending on the displacement of the nerve root by the protruded disc. When it is laterally displaced lateral flexion of the spine on the affected side will not be limited, whereas on the opposite side will be extremely restricted. Similarly with medial displacement of the nerve root lateral flexion of the spine on the affected side will be very much restricted. In one word restriction of the lateral flexion of the spine will be seen on the opposite side of scoliosis. Paramedian pro­ lapse causes pain which is made worse when the patient bends laterally on the other side. Lateral prolapse (when the prolapse is lateral to the nerve root) causes pain which increases when he bends laterally towards the affected side. Lateral prolapse of the disc above the 5th lumbar vertebra may press on the 1st sacral (S1) or 5th lumbar (L5) or both nerve roots. In case of involvementof 4 th or 3rd lumbar root there will be wasting of the quadriceps muscle, whereas in case of involvement of the first sacral root, there will be wasting of the calf muscles. Whereas in case of involvement of the 5th lumbar root, there will be weakness of the extensor hallucis longus muscle and anterior tibialis muscle. So dorsiflexion of the ankle joint will be weak, similarly there will be weakness of extension of the toe. In case of involvement of 1st sacral root, there will be weakness of plantar flexors and flexor hallucis longus, so there will be weakness in plantar flexion of the ankle and flexion of the great toe. In case of involvementof the 1st sacral root there will be very much diminished or absent ankle jerk. In case of involvement of the 5th lumbar root, sensory impairment is detected in the back of the thigh, most of the lateral aspect of the leg and dorsum of the foot. In case of involvement of 1st sacral root (which suggests protrusion of L5/S1 disc) sensory impairment is noticed on the sole and outer margin of the foot with loss of ankle jerk. In short, in case of L51S1 disc protrusion, usually the 1st sacral nerve root is involved and there will be sensory im­ pairment of the sole and outer margin of the foot and in the dorsum of the web between the great and the second toe with absence of the ankle jerk. In case of L4/5 disc protrusion, usually the 5th lumbar root is involved, in which there will be sensory impairment of the dorsum of the foot, lateral aspect of the leg and back of the thigh, there will be weak dorsiflexion of the ankle and great toe but no alteration of the ankle jerk. In case of upper iumbar disc(L3/4 or L2/3) prolapse, there will be sensory impair­ ment of the front of the lower thigh and side of the thigh and anteromedial aspect of the leg. First exclude that there is no compensatory lordosis by insinuating a hand beneath the lumbar spine. He should continue to raise the leg till he experiences pain as evidenced by watching his face. To be sure the test is repeated and as the angle is approached additional care is exercised to note when the pain starts. If the pain is evoked under 40° it suggests impingement of the protruding intervertebral disc on a nerve root. If the pain is evoked at an angle above 40° it indicates tension on nerve root that is abnormally sensitive from a cause not necessarily an intervertebral disc protrusion. At the angle when the patient experiences first twinge of pain, the ankle is passively dorsiflexed. It suggests irritation of one or more nerve roots either by disc protrusion or from some other space occupying lesion. This second part of the test is important to differentiate sciatica from diseases of the sacro-iliac joint. In the latter condition straight leg-raising test will be positive but there will be no aggravation of pain during passive dorsiflexion of the ankle. Pathological narrowing of the intervertebral space is noticed in X-ray in l/3rd of cases of disc prolapse. Various other bone deformities may be detected by X- ray which are the causes of backache. Myelography is of tremendous impor­ tance in excluding a tumour of cauda equina to be differentiated from disc prolapse. It must be remembered that negative myelo­ graphy does not rule out presence of disc prolapse. Where facilities of this investigation are available, this has certainly surpassed the previous investigations so far as its diagnostic efficacy is concerned (See Fig. If the attack is less severe, the patient may get out of the bed earlier and a corset is worn. Immobilisation in plaster of Paris jacket may be recommended after a few days rest in bed when pain has subsided considerably. The traction may have opened up the disc spaces to cause reduc­ tion of the prolapse. Injection of 2 mg of chymopapaine into the disc space has also been claimed to reduce prolapse. Operation is only indicated if the symptoms persist or neurological signs develop. The muscles are stripped off from the outer surfaces of the laminae with a wide chisel. The nerve root and the duramater are gently retracted to expose the intervertebral disc. The disc above must be inspected even when the prolapse has already been detected and removed. An interlaminar approach with excision of the ligamentum flavum and little, if any, of parts of the adjacent lamillae. Many orthopaedic surgeons recommend immediate spinal fusion in every case operated for prolapse intervertebral disc.

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If at all this complication takes place buy cialis professional 40 mg without a prescription, continuous gastric lavage with I ml 1 : 1000 solution of adrenalin usually stops the bleeding buy cialis professional master card. If still the haemorrhage persists the abdomen is reopened buy discount cialis professional line, the suture is reinforced with through-and-through catgut. In these occasions, the stomach should be opened and actual bleeding points are under-run. It results in peritoneal soilage with gastroduodenal contents and is associated with peritonitis, ileus, sepsis with a moderately high (10 to 15%) mortality rate. As soon as this condition is suspected, a drain is immediately inserted upto the gastroduodenal anastomosis alongwith nasogastric aspiration and intravenous fluid administration. This is generally treated conservatively by nasogastric suction and intravenous therapy to correct the electrolyte balance. Potassium deficiency is more or less always associated with this condition and potassium supplementation is of utmost importance, (b) Retrograde jejuno-gastric intussus­ ception, in which efferent loop of jejunum enters stomach through gastrojejunostomy stoma, may occur as early as 3rd day or may delay upto 3rd week. If these fail, operation has to be performed and the jejunum is slowly dragged down to reduce the intussusception. Later on the afferent and efferent loops are sutured seromuscularly to prevent recurrence, (c) Technical error during operation may cause stomal obstruction e. This causes obstruction of the outflow from the stomach, (d) Stomal obstruction may be caused by oedematous and hypertrophied mucosa of the antrum following Billroth I operation. In this case the hypertrophied mucosa has to be excised, (e) Apparent stomal obstruction may be due to lack of muscle tone of the stomach without any organic lesion in the stoma. So in case of a stomal obstruction if no cause can be found out by barium meal X-ray, one must perform endoscopy to see if the stoma is widely patent or not. It is a serious complication, but fortunately enough this is very rare and mostly due to surgeon’s fault. But the present theory is that this ‘give way’ is due to avascular necrosis from over-distension of the afferent loop of the jejunum. Sudden intense thoraco-abdominal pain in the first postoperative week should be thought in the line of duodenal blow out rather than basal pneumonia with pleurisy. Jejunostomy may be performed and the duodenal discharge is pushed through the jejunostomy tube to maintain proper electrolyte balance. If the afferent loop is kinked at the anastomosing site, the contents of this loop (pancreatic juice and biliary secretion) will not get access and will ultimately blow out the duodenal stump, (ii) A drain should be put down to the duodenal stump if such complication is anticipated, (iii) The stump should be closed very meticulously through normal duodenal wall and not through ischaemic duodenal wall caused by the use of crushing clamp, (iv) The surgeon must be careful not to close the stump through an inflamed duodenal wall or through an active duodenal ulcer. It is also referred to as “Dumping syndrome” because it has been supposed to result from rapid emptying of the stomach and consequent distension of the jejunum. Post-prandial discomfort, giddiness and sweating are common phenomena in early days after gastrectomy and are expected to disappear with the passage of time. Majority find them nuisance during first 6 months and may disappear within one year, that is why this group is included in the early complications. These syndromes can be better described under three heads — early dumping, late dumping and bilious vomiting. This consists of abdominal colic, nausea, vomiting, fainting, diarrhoea, epigastric discomfort, sweating, pallor and palpitation. This is due to sudden entry of hyperosmolar foods into the jejunum causing splanchnic hypovolaemia (fall in the blood volume). There is often pronounced fall in serum potassium associated with T and S-T segments alterations. The other theories postulated as cause of this syndrome are — (a) that there is some disorder of carbohydrate metabolism and following ingestion of carbohydrate diet there is initial transient hyperglycaemia. This causes suppression of absorption of glucose which is retained in the intestine, causes hyperosmolarity and leads to fluid shift from the blood to the lumen of the intestine leading to fall of blood volume and increased intestinal activity, (b) Many physicians find a correlation of the severity of dumping syndrome with symptoms of emotional instability. This is due to the fact that while almost all post-gastrectomy patients will have minor dumping symptoms, why is it that only 5% of patients have symptoms severe enough to bring them back to the surgeons. If still the symptoms persist for 8 months and are becoming more troublesome, operation is justified. A small segment of reversed jejunum (approximately 10 cm) may be placed between stomach and duodenum to impede gastric emptying (Henley loop). After initial rise of blood sugar, there is rapid fall of the blood sugar to about 50 mg/100 ml or so. This was considered to be due to mechanical obstruction from kinking of the afferent jejunal loop. The afferent jejunal loop is divided 2-3 cm from the point where it joins the stomach. The attached end is closed by invagination and the free end is anastomosed to the jejunum in an end-to-side fashion well below the gastrectomy stoma. When bilious vomiting occurs after Billroth I operation, a portion of jejunum is interposed between the duodenum and the stomach to prevent biliary regurgitation into the stomach remnant. As soon as this has been suspected, the abdomen is reopened, the hemia is reduced and if the hemia has become gangrenous, that portion of the bowel should be resected. It goes without saying that incidence of recurrent ulcer can be very much reduced by proper case selection and selection of the ideal operation which will be suited for the particular patient. The acid status of the individual should be brought down by selecting proper operation. Some surgeons are in the opinion that application of occlusion clamps predispose to ulcer formation and better be avoided. That is why the incidence of recurrent ulcer has gone down recently to less than 2%. One word of caution should be remembered by the students and young doctors that while performing partial gastrectomy the level of the excision of the stomach should not be as low as to leave a part of antrum, which will increase the incidence of recurrent ulcer to 40% or should not be as high as to produce nutritional deficiencies later on. The symptoms generally appear 2 years after operation and consist of persistent pain ‘burning’ in type, which becomes worse within half an hour of taking food. This pain generally radiates down to the left side of the abdomen towards the left iliac fossa. Very occasionally they may perforate, which is more fatal than the perforation of a duodenal ulcer. When clinically it seems that the patient is suffering from a recurrent ulcer, barium meal X-ray should be performed. When the ulcer follows vagotomy and a drainage operation, Hollander test should be performed to know completeness of the nerve section. If the test reveals incomplete nerve section, operation is re-performed and a search is made to identify undivided vagal nerve. If an intact vagus nerve cannot be identified or the Hollander’s test does not reveal incomplete nerve section, a Polya gastrectomy should be performed. When an anastomotic ulcer is found following Polya gastrectomy, vagotomy should be performed.

But in bone the peculiar feature is that the malignant growth osteosarcoma presents with pain first and swelling later on purchase 40 mg cialis professional with amex. Otherwise the tumours whether they are benign or malignant are painless to start with order generic cialis professional pills. In malignant bony tumours the duration is relatively short in comparison to the benign bony swellings buy 40 mg cialis professional otc. In diaphyseal aclasis there will be multiple swellings arising from the metaphyses of different bones affecting a young boy. In osteosarcoma the skin over the swelling remains tense, glossy with dilated veins. In tuberculous osteomyelitis cold abscess will lead to a swelling in the beginning and later on sinus formation. The tuberculous sinus will reveal its characteristic features like undermined edge and bluish margin, whereas in chronic pyogenic osteomyelitis there will be sprouting granulation tissue which indicates presence of sequestrum at the depth. There may be paresis neous veins in case of osteo- due to involvement of the nerves by the bony swellings. Sometimes acute osteomyelitis may destruct the epiphyseal cartilage thereby hampering the growth of that particular bone. Genu valgum or genu varum may be the result of asymmetrical destruction of the lower epiphyseal cartilage of the femur. Shortening or lengthening of the bone — may sometimes be seen following infection of the bone which either provokes the growth of the bone or destroys the epiphyseal cartilage and hence retards the growth of the bone. In osteosarcoma the consistency varies — somewhere bony hard, somewhere firm and may be even soft at places. Being a bony swelling its consistency should also be bony hard, but the condition is so painful and tender that the clinician hardly reaches the bone during palpation and can only palpate the soft tissues overlying the bone which pits on pressure. Telangiectatic osteosarcoma, aneurysmal bone cyst, occasionally highly vascular osteoclastoma, very rarely haemangioma of bone and highly vascular metastatic carcinomas from thyroid cancer and renal adenocarcinoma. Note the foot drop on the right side due to involvement of the lateral popliteal nerve by an osteoma at the head of the fibula. These are commonly seen in chronic pyogenic osteomyelitis and tuberculous osteomyelitis. In case of the former there will be sprouting granulation tissue at the orifice of the sinus indicating presence of sequestrum in the depth and in case of the latter the ulcer will be undermining with bluish newly growing epithelial edge. In fact sometimes this fracture becomes the first presenting symptom of the primary carcinoma which may be in the lung, kidney, breast, prostate, thyroid etc. Shortening will be found when the epiphyseal cartilage is destroyed and the bone may be lengthened when the metaphysis is included within the zone of hyperaemia. Osteosarcoma, which mainly starts from the metaphysis, does not invade the epiphyseal cartilage until late and hence the joint remains unaffected. Swellings of the distal limb and venous engorgement may be due to pressure on the neighbouring veins. In tuberculous osteomyelitis general examination must be made to exclude pulmonary tuberculosis and lymphadenitis. Enquiry must be made whether the patiert had cough, evening rise of temperature, pain in the chest, haemoptysis, etc. In syphilitic osteitis, one should look for other syphilitic stigmas in the body (See Fig. In osteomyelitis a search should be made for infective foci in the skin, tooth, tonsil, ear, air sinuses, etc. Diaphyseal (metaphyseal) aclasis, generalized osteitis fibrosa, multiple myeloma are the examples of this condition. So the patient must be asked if there is any other bony swelling in his body or not. In secondary carcinoma a thorough examination must be made to exclude primary carcinoma in the thyroid, kidneys, lungs, prostate, breasts, uterus, gastrointestinal tract, testis, etc. There will be hyperproteinaemia, the globulin (particularly gamma globulin) being raised, (c) A rise in serum calcium indicates generalized osteolysis (which is seen in cases of hyperparathyroidism, metastatic bone tumours, multiple myeloma, sarcoidosis etc. Bence Jones protein may also be found in cases of skeletal carcinomatosis, leukaemia and rarely in nephritis. In chronic osteomyelitis, a dense sequestrum and surrounding involu- crum may be noticed. Density of the seques­ trum is due to decreased mobilization of calcium from decreased blood supply, whereas in involucrum calcium deposition has just commenced. This is revealed in X-ray by an osteolytic lesion affecting the FiS11 16 - Osteosarcoma showing the typical radiating lateral condyle of the tibia (indicated by spicule type. Osteoid osteoma is seen as a radiolucent nidus with a surrounding zone of bony sclerosis. In chondroma, whether enchondroma or ecchondroma, X-ray shows an osteolytic lesion with demarcated outline. The metaphysio-epiphyseal areas are seen to be enlarged and occupied by a cystic tumour. The cortex is thin with a sharp line of demarcation between the tumour and the unaffected shaft in contradistinction to the sarcomas. The expanding osteolytic lesion can continue to destroy the cortex, although usually it leaves some external rim. The cavity is traversed by bony trabeculae giving mosaic or soap-bubble appearance. Mostly the tumour grows eccentrically, often destroys the epiphyseal cartilage and it may penetrate the articular cartilage. This tumour expands transversely whereas a bone cyst expands along the long axis of the bone. X-ray appearance of osteosarcoma shows a combination of bone destruction and bone formation. Three types are commonly seen — (i) Sclerotic type, usually found at puberty, shows dense new irregular bone with a few spicules projecting from its surface in the metaphysis. The periosteum may show sun-ray spicules due to calcification along the blood vessels supplying the raised periosteum. In bone sarcoma there is always the soft tissue shadows in the skiagram due to increased vascularity of the tumour. Chondrosarcoma in skiagram shows frank destruction of the trabecular bone and cortex with an expanding lesion which contains irregular flecking and the mottling of calcified tissue. At least 50% of medulla must be destroyed before a lesion will be seen radiologically. Osteolysis without formation of new bone is the feature except in carcinoma of the prostate where Fig, 11.

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Impending Rupture of Cecum Pitfalls and Danger Points For routine cases of left colon obstruction discount cialis professional 20mg, with the diagnosis confirmed by barium enema radiography order 40mg cialis professional free shipping, the colon may be Performing colostomy in error for diagnoses such as fecal approached through a small transverse incision in the right impaction or pseudo-obstruction (which might respond to rectus muscle purchase cialis professional us. Exceptions to this policy should be made for transverse colon, not in the redundant sigmoid colon, patients with a sigmoid volvulus, those suspected to have jejunum, or even the gastric antrum. When impending rupture is suspected, direct visual inspection of the cecum is mandatory. Make the transverse incision sufficiently long to accomplish accurate identification of the Contrary to widespread medical opinion, it is not necessary transverse colon. The incision will be partially closed, leav- to construct a double-barreled colostomy with complete ing a 5-cm gap to accommodate the colostomy. A long (5 cm) longitudinal incision on the antimes- laparotomy for removal of colon pathology, begin the trans- enteric wall of the transverse colon, followed by immediate verse incision 2 cm to the right of the midline and extend it maturation, allows fecal diversion due to prolapse of the pos- laterally. This results in functionally separate distal and surgeon from using a long midline incision for the second proximal stomas. Incise the rectus muscle transversely over the hemostat with coagulating electrocautery Documentation Basics for a distance of 6 cm. Then enter the abdomen in the usual manner by incising the posterior rectus sheath and peritoneum. Identification of Transverse Colon Operative Technique Even though the transverse colon is covered by omentum, in the average patient the omentum is thin enough that the colon can be Incision seen through it. If Make a transverse incision over the middle and lateral thirds colon is not clearly visible, extend the length of the incision. Ideally the length Exteriorize the omentum and draw it in a cephalad direc- of the skin incision equals the length of the longitudinal inci- tion; its undersurface leads to its junction with the transverse sion to be made in the colon (5–6 cm). At this point, make a window in the overlying is necessary to identify the level at which the transverse omentum so the transverse colon may protrude through the colon crosses the path of the right rectus muscle. To solve this problem, apply two Babcock clamps 2 cm apart to the anterior wall of the transverse colon. Insert a 16-gauge needle attached to a low-pressure suction line into the colon between the Babcock clamps (Fig. After gas has been allowed to escape through the needle, the colon can be exteriorized easily. Make a 5- to 6-cm longitudinal incision along the anterior wall of the colon, preferably in the taenia (Fig. Make a stab wound through the skin at a point about 4 cm caudal to the midpoint of the proposed colostomy. By blunt dissection pass a glass or plastic rod between the subcutaneous fat and the anterior rectus fascia, proceeding in a cephalad direction. This technique permits the subcutaneous fat to be protected from postoperative contamination by stool and greatly simplifies application of the colostomy bag. An alternative to the solid rod is a thick Silastic tube, 6 mm in diameter, such as a nonperforated segment of a closed-suction drain tube. However, because this tube is soft, it must be fixed to the skin of the two stab wounds with nylon sutures. Stapled Distal Segment In some cases where absolute certainty about fecal diversion Fig. This will require M o d i fi cation of Technique Using a Glass Rod resection and anastomosis for colostomy closure, but pro- vides the best assurance complete diversion. Be absolutely We prefer not to interrupt the suture line between the colon certain as to orientation of bowel loop, as stapling the proxi- and skin by use of a glass rod or ostomy bridge. In markedly mal segment would be disastrous, and document the staple obese patients who have a short mesentery, a modified glass line in the operative note to inform surgeon at time of rod technique may be used to prevent retraction while closure. A simple technique for constructing a loop enterostomy which allows immediate placement of an ostomy appliance. Temporary decompression after colorectal surgery: randomized Peristomal sepsis is surprisingly uncommon. Chassin† Indications Operative Strategy A temporary ostomy should be closed when it is no longer To avoid suture-line leakage, use only healthy, well- needed. Anastomotic healing and absence of a distal obstruc- vascularized tissue for ostomy closure. Loop osto- adhesions between the transverse colon and surrounding mies may be closed by the techniques described in this structures allows a sufficient segment of transverse colon to chapter. If neces- sary, the incision in the abdominal wall should be enlarged to provide exposure. If the tissue in the vicinity of the colos- Preoperative Preparation tomy has been devascularized by operative trauma, do not hesitate to resect a segment of bowel and perform an end-to- Barium colon enema radiography to demonstrate patency of end anastomosis instead of a local reconstruction. These same principles enemas to cleanse the inactivated left colon segment may apply for closure of a loop ileostomy. Infection of the operative incision is rather common fol- Perioperative systemic antibiotics. Another phenomenon that contributes to wound infection is retraction of subcutane- Pitfalls and Danger Points ous fat that occurs around the colostomy. This can produce a gap between the fascia and the epidermis when the skin is Suture-line leak sutured closed, creating dead space. Avoid this problem by Intra-abdominal abscess leaving the skin open at the conclusion of the operation. Wound abscess Operative Technique Incision Throughout this chapter, transverse colostomy closure is C. This can often be accomplished without appreciably enlarging the defect in the abdominal wall. However, if any incision parallel to the mucocutaneous junction until the difficulty whatever is encountered while freeing the adhe- entire colostomy has been encircled. Applying three Allis sions between the colon and peritoneum, extend the incision clamps to the lips of the defect in the colon expedites this laterally by dividing the remainder of the rectus muscle with dissection and helps prevent contamination. Deepen the electrocautery for a distance adequate to accomplish the dis- incision by scalpel dissection until the seromuscular coat section safely. Then separate the serosa and surrounding subcutaneous fat by Metzenbaum scissors dissection (Fig. Perform this dissection with metic- Closure of Colon Defect by Suture ulous care to avoid trauma to the colon wall. Continue down to the point where the colon meets the anterior rec- After the colostomy has been freed from all attachments for tus fascia. A few small superficial patches of serosal damage are of no Fascial Dissection significance so long as they are not accompanied by devascu- larization. In most cases, merely freshening the edge of the Identify the fascial ring and use a scalpel to dissect the sub- colostomy by excising a rim of 3–4 mm of scarred colon cutaneous fat off the anterior wall of the fascia for a width of reveals healthy tissue. In these cases the colostomy defect, which resulted until the peritoneal cavity is entered. Then initiate a second suture of the same material on the cephalad margin of the defect and continue it also to the midpoint; terminate the suture line here (Fig. Invert this layer with another layer of interrupted 4-0 silk atraumatic seromuscular Lembert Fig. Because of the transverse direction of the suture line, the lumen of the colon is quite commodious at the conclusion of the closure.

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The long arm of the T-tube is taken out through a separate small incision on the duct and not through the end-to-end suture cialis professional 20mg visa. If the stricture is a very small one affecting the supraduodenal portion of the duct an end-to-end choledochostomy is performed buy cheap cialis professional 20mg line. When the stricture is long purchase cialis professional 40mg, but the upper portion of the bile duct is quite patent, it is a good practice to do choledochoduodenostomy. Sometimes the duodenum cannot be taken up to the patent portion of the common bile duct. When the stricture affects the upper part of the duct so that no portion of the common bile duct is available for anastomosis, a hepaticodocho-jejunostomy is advised. The Roux-en-Y limb of the jejunum is anastomosed to the common hepatic duct with interrupted sutures of fine chromic catgut passed through all the layers of thejejunum and the wall of the common hepatic duct. Such prosthesis is not required if the hepatoenteric stoma is of adequate calibre. Simple T-tube may be employed as prosthesis and can be inserted through the limb of thejejunum. Sometimes the stricture may affect the common hepatic duct and the right and left hepatic ducts so that no portion of even the hepatic ducts is available for anastomosis. In this case Longmire’s operation can be performed only when the surgeon is certain that there is good communication between the intrahepatic duct of the left lobe with that of the right. In this operation the left lobe of the liver is mobilised and its lateral 2/3rds are removed. The largest branch of the left hepatic duct is isolated and is anastomosed to a Roux-en-Y jejunal loop. Sometimes stent can be used for short term in case of bile duct leaks after laparoscopic cholecystectomy. It has been maintained that fibrosis takes place only when inflammatory reaction has been associated with an impacted calculus in the ampulla or papilla, or when the end of the common bile duct has been injured during dilatation with probes, sounds, scoops etc. Stenosis of the sphincter of Oddi is commoner in females than in male* in the ratio of 3 : 1. The condition may reveal itself at any age but is most frequently observed between the ages of 50 and 70 year?. Symptoms are usually pain, which may be continuous or intermittent or even in the form of colic. Other symptoms include nausea, anorexia, indigestion, epigastric fullness after fatty food, vomiting and pruritus. The common bile duct is dissected out and is opened anteriorly after introducing two stay sutures on either side of the incision. If 3 mm dilator cannot be passed through the papilla, it is obviously stenosed or fibrosed. In this case the anterior wall of the duodenum is incised, duodenal contents are aspirated, small retractors are inserted and the papilla is visualised. Babcock’s forceps are applied on either side of the papilla to elevate the posterior side of the duodenum. The dilator through the choledochotomy is lifted up to make the papilla prominent. Papillotomy — simple longitudinal division of the papilla of Vater, followed by sphincterotomy should be performed for such lesions. Following sphincterotomy a short-guttered T-tube is used for drainage of the ductal system through choledochotomy incision. Duodenum is closed and the choledochotomy incision is closed by the side of the emerging T-tube. Whether single stones or multiple stones are more prone to cause gallbladder cancer is not known, but the size of the stone has a direct relationship with development of carcinoma. The risk for developing carcinoma in a patient with 3 cm gallstone is 10 times that for someone with a stone less than 1 cm in diameter. There are three other conditions which are presumably associated with the development of carcinoma of the gallbladder. But both these conditions are associated with gallstones, so whether these conditions de novo or gallstones are responsible for such association is to be questioned. Although the majority of neoplasms involve the bile duct about 15% originate in the gallbladder. It is still controversial which factor plays a major role in malignant transformation — whether (a) gallstones, (b) bacteria or (c) carcinogens associated with gallstones. These are lymphosarcoma, rhabdomyosarcoma, fibrosarcoma and reticulum cell sarcoma. Sometimes the patients complain of weight loss or anorexia or a mass in the right upper quadrant or sometimes simply pain in the right upper quadrant of the abdomen. Jaundice may be due to invasion of the common duct or compression of the common duct by involved pericholedochal lymph nodes. Jaundice may be due to involvement of liver or rarely due to concurrent stone in the biliary tract. In gallbladder carcinoma jaundice is often accompanied by pain and this is the distinguishing feature from periampullary carcinoma, which is usually painless Diagnosis is mainly confirmed by computed tomographic scan, sonography and angiography. So most often the surgeon has to be content with palliative procedure to relieve the obstructive jaundice. The choice lies between (i) extended cholecystectomy and (ii) extended right hepatic lobectomy depending on the age of the patient, spread of the disease and capability of the surgeon so far as hepatic resection is concerned. First operation is radical surgery and this involves excision of the gallbladder in continuity with the hepatic bed and regional lymph nodes. In the second operation besides excision of regional lymph nodes right hepatic lobectomy is performed through a right thoraco-abdominal approach. It is difficult to prove whether radical excision has been able to increase survival. These cases which after cholecystectomy have revealed carcinoma found histologically have not shown better prognosis after reoperation and radical surgeiy. In this operation the contrated empty common bile duct is opened and probes of various sizes are used to dilate the obstructed common hepatic duct into the dilated intra-hepatic duct system. When the bile drains out, a portion should be sent for culture and sensitivity tests. These conditions are mostly associated with pyogenic cholangitis due to stasis of bile within the liver. After dilating the malignant stricture properly a Cattell T-tube of the largest possible size is introduced through the opening in the common bile duct, so that its upper limb reaches well beyond the stricture into the dilated ductules. Some palliation may also be achieved by removing the gallbladder, when visible, in the hope of delaying obstruction of surrounding structures. Prognosis — In one sentence the prognosis is poor in malignancy of the gallbladder. If operation is performed when the tumour is confined to the mucosa and muscularis patients may survive for 5 years, but with serosal (or adventitial) involvement only 7% will live upto 5 years.

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When this layer is complete order cialis professional 40mg on line, make an incision along the antimesenteric border of the jeju- num slightly shorter than the diameter of the pancreas discount 20mg cialis professional fast delivery, as seen in Fig buy cialis professional 20 mg without prescription. Then insert sutures between the posterior edge of the pancreas, taking the full thickness of the jejunum in interrupted fashion to constitute the second posterior layer. If the pancreatic duct is large enough, include the posterior wall of the pancreatic duct in the sutures (Fig. Again, use interrupted 4-0 sutures to approximate the anterior edge of the pancreas to the full thickness of the jejunum, as in Fig. The final anterior layer of sutures complete the invagination of the pancreas by approximating the anterior wall of the pancreas to the seromuscular coat of the jejunum, as in Fig. The purpose of this T-tube is to drain bile to the outside until the pancreaticojejunostomy has completely healed. The jejunal incision should be approximately equal to the diameter of the hepatic duct. The anterior knots are placed on the serosal sur- face of the hepaticojejunal anastomosis. On the jejunal side of the anterior layer, use a seromucosal-type stitch (see Fig. If the diameter of the hepatic duct is small, enlarge the ductal orifice by making a small Cheatle incision in the anterior wall of the duct. Gastrojejunostomy Identify the proximal jejunum and bring it to the gastric pouch in an antecolic fashion. Approximate the cut edge of the pancreas to the antimesenteric wall of the jejunum to the greater curvature of 812 C. Then, with electrocautery make small stab Lembert stitch to approximate the stomach and jejunum at wounds in the posterior wall of the stomach and the jejunum. Carefully Insert the linear cutting stapling device, one fork in the gas- inspect the staple line for bleeding, which should be cor- tric lumen and one in the jejunum (see Fig. Use additional Allis clamps to 89 Partial Pancreatoduodenectomy 813 close the remaining aperture in the gastrojejunal anastomosis. Apply a 55 mm linear stapler deep to the line of Allis clamps and fire the staples. Try to iso- late the hepaticojejunal anastomosis from the pancreatic anastomosis by suturing the free edge of the omentum to the remaining hepatoduodenal ligament overlying the hepatic duct. Intermittently during the entire operation, a dilute antibiotic solution is used to irrigate the operative field. Insertion of Drains Insert a closed-suction drain through a stab wound in the Fig. Allow the T-tube to exit through a separate stab wound in the right upper quadrant. Bring the pancreatic catheter through a tiny stab wound in the antimesenteric wall of the jejunum about 10 cm distal to the pancreatic anastomosis. Place a 4-0 silk purse-string suture around this tiny stab wound; then make a stab wound in the appropriate portion of the abdominal wall, generally in the right upper quadrant, and bring the catheter through this stab wound. Alternatively, bring the catheter through a stab wound in the proximal jejunum as depicted in Fig. Through stab wounds in the left upper quadrant, insert Jackson-Pratt closed-suction drains and Fig. In the hope of reducing the risk of marginal ulceration, we place the duodenojejunal anastomosis closer to the biliary and pancreaticojejunal Fig. Included in this operative description is a method for place them in the vicinity of the pancreaticojejunostomy and bringing the pancreatic catheter to the abdominal wall subhepatic spaces. This has the important Needle-Catheter Jejunostomy advantage that the length of the catheter between the pancre- Consider performing a needle-catheter jejunostomy during atic duct and the abdominal wall is much less than that all pancreatoduodenectomies. Follow the procedure described in the first part of this chap- ter with the following exceptions: Closure 1. Additional blood supply comes from the left gastric artery along the ligating the gastroduodenal and right gastric arteries as lesser curve of the stomach. Apply the cutting linear stapling device to the duodenum teric side of the jejunum at a point about 20 cm distal to at a point about 2. This transects the duodenum and staples directly from the hepaticojejunostomy to the duodenum closed the proximal and distal ends of the divided for an end-to-side duodenojejunal anastomosis in the duodenum. The first step when preparing for the anastomosis is to the greater omentum along the greater curvature of the apply several Allis clamps to the line of staples closing stomach, as much of the blood supply to the proximal the duodenum. Then excise the staple line with scissors, duodenum now comes from the intact left gastroepiploic leaving the duodenum wide open. Do not place the anastomosis close to the pylorus because the close proximity of the suture line to the pylorus inter- feres with pyloric function and results in gastric retention. Insert a layer of 4-0 interrupted silk Lembert sutures to approximate the posterior seromuscular coat of the duode- num to the antimesenteric border of the jejunum. After this has been done, make an incision in the antimesenteric bor- der of the jejunum. Use 5-0 atraumatic Vicryl suture material and place the first stitch in the middle of the posterior layer of the anastomosis. If the bites are small, the continuous suture does not act as a purse string to narrow the anastomosis. This complication occurs if the duodenojejunal suture line abuts the pyloric sphincter muscle and thus interferes with this sphincter’s proper sutures (Fig. Most cases of delayed gastric emptying sub- method of draining the pancreatic duct. Insert the pedi- sequent to a pancreatoduodenectomy are due to leakage atric feeding tube into the pancreatic duct after com- from the pancreaticojejunal or hepaticojejunal anastomo- pleting the posterior layers of the pancreaticojejunostomy. Evacuation of intraperitoneal then bring it through a puncture wound in the proximal collections or abscesses accelerates the return to normal jejunum. Most of these abscesses can be evacu- catheter with a 4-0 silk purse-string suture. Peptic suture the jejunum to the parietal peritoneum around ulcer of the duodenum or jejunum may occur if the gastric the puncture wound through which the catheter exits. With bile diverted into the T-tube and all the pan- Postoperative Care creatic juice draining to the outside via the pancreatic duct catheter, one of our patients developed gastric pH 1 Perioperative antibiotics, which were initiated prior to the postoperatively while receiving cimetidine 100 mg/h operation, are repeated by the intravenous route every 4 h intravenously. The patient bled from a superficial pyloro- during the procedure and then every 6 h for four doses post- duodenal ulcer that healed when the pancreatic secretions operatively. If the bile was infected prior to surgery, admin- were injected into the nasogastric tube together with ant- ister antibiotics until the infection is suppressed. During the early postoperative period, it is impor- Maintain the gastric pH at or above 5. Because it is an 89 Partial Pancreatoduodenectomy 821 Complications Leakage from pancreatic anastomosis. In our experience sepsis and hemorrhage are most often the result of leakage from the pancreaticojejunal anastomosis. In some cases this is due to the development of acute pancreatitis in the pancreatic tail. As discussed above, the only solution to this vicious cycle is sometimes surgical removal of the residual pancreas.