Complications of splenectomy

◼️Bleeding, may occur due to slipped ligature on the splenic artery, this can cause rapid exsanguination.

◼️Injury to surrounding organs, tail of the pancreas can be injured resulting in (1)Acute pancreatitis, (2)Pancreatic abscess, (3) Pancreatic fistula, injury to the stomach can cause hematemesis, also injury to the greater curve during ligation of short gastric vessels can cause gastric fistula, acute gastric dilatation may also occur.

◼️Infection, such as wound infection or a left subphrenic abscess.

◼️Pulmonary complications, including left basal atelectasis and pleural effusion.

◼️Overwhelming post-splenectomy infections by encapsulated organisms including pneumococci, meningococci, and H.influenzae, viral influenza infections can predispose to these bacterial infections so annual influenza vaccine should be considered.

◼️Thrombocytosis, this can cause thromboembolic manifestations, if the count reach more than 1 million per microlitre, aspirin should be given.

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Testicular torsion

◼️Predisposing factors include (1) Undescended testis, (2) Spiral arrangement of cremasteric muscle, (3) Inversion of the testis, this is the most common factor in which the testis lies transversely and thus easily torted, (4) High investment of tunica vaginalis, also called Bell clapper anomaly, (5) wide seperation between the epididymis and the testis, it allows the testis to rotate without rotation of the cord.

◼️Clinically it present with sudden agonising pain in groin and lower abdomen, vomitting and mild pyrexia with or without scrotal swelling is common, the event usually occur after heavy lifting, straining or coitus, as these stimulate contraction of cremasteric muscle which is spirally arranged causing torsion.

◼️In epididymo-orchitis, pain is relieved by scrotal elevation, and associated urethritis is common.

◼️Duplex scan reveal reduced or no blood flow, when doubt exist exploration with bilateral fixation is required as the predisposing anomaly is bilateral.

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Signs of vascular trauma

◼️This is an essential part to recognize, a trauma to an artery may lead to acute spasm, or formation of a subintimal hematoma or acute thrombosis, all may occlude the vessel, alternatively a trauma may cause laceration of the vessel either completely or partially, remember: Partial laceration causes more bleeding than complete laceration.

◼️The HARD SIGNS of vascular trauma include (1) Pulsatile bleeding, (2) Pulsatile hematoma, (3) Signs of acute limb ischaemia, (4) Thrill or bruit due to traumatic AV fistula or a false aneurysm, (5) Rapidly Expanding hematoma.

◼️Soft signs include (1) Non pulsatile stable hematoma, (2) Unexplained shock or falling hemoglobin, (3) Injury at an anatomical site of an artery, (4) Evidence of nerve injury in proximity to an artery, (5) History of significant hemorrhage at time of trauma and before presentation.

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Fontaine classification and the ankle brachial pressure index

◼️Fontaine classification is used to stratify the severity of an underlying lower limb arterial disease as follows:

Fontaine I = Asymptomatic.
Fontaine IIa = Intermittent claudication at a distance greater than 200 meters.
Fontaine IIb = Intermittent claudications at distance less than 200 meters.
Fontaine III = Rest pain.
Fontaine IV = Ulceration and gangrene.

◼️Ankle brachial pressure index (ABPI) is used to detect and quantify degree of arterial insufficiency, it is the ratio of systolic pressure at the ankle (posterior tibial or dorsalis pedis which ever is higher) and at brachial artery, the normal ratio is 0.9 to 1.3, ratio less than 0.9 indicate diseased arteries, less than 0.3 indicate imminent necrosis.

◼️Exercising the patient leads to dilatation of vascular spaces distal to an obstruction, if the feeding vessel is diseased it cannot keep pace with increased vascular space and thus ABPI will drop furthur.

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Indications of mastectomy in early breast cancer rather than wide local excision followed by radiotherapy are:

1) Large tumour in relation to the size of the breast.
2) Central tumour below or involving the nipple.
3) Multifocality/ Multicentricity.
4) Patient's preference.
5) Local recurrence.

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Serum thyroglobulin can be used as a serum marker for thyroid malignancy, and also to help diagnose factitious thyrotoxicosis whereby patient is taking exogenous thyroid hormones, in such case the serum thyroglobulin will be greatly depressed, another note to make, that antithyroglobulin antibodies may interfer with the interpretation of serum thyroglobulin in those with thyroid malignancy.

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Differential diagnosis of right iliac fossa mass

◼️We can remember them as 4 iliocecal, 4 appendiceal, and 4 surrounding masses, these include the commonest causes and not all of them.

1) Four iliocaecal :
- Crohn's disease.
- Iliocaecal tuberculosis.
- Iliocaecal actinomycosis.
- Tumours of caecum and distal ileum.

2) Four appendiceal :
- Appendicular inflammatory mass.
- Appendicular abscess.
- Mucocele of vermiform appendix "see above figure".
- Appendicular tumours "most common is carcinoid tumour".

3) Four surrounding masses :
- Psoas abscess.
- Desmoid tumour.
- Hernia.
- Aneurysm of iliac artery.

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Summary of Fractures Treatment.

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MEN syndromes.

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To differentiate between testicular torsion and acute epididymo-orchitis:

-If pain is relieved by scrotal elevation, it acute epididymo-orchitis.

-If pain is increased by scrotal elevation, then it's torsion. "Perhin's sign".

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Any tumor in testis is malignant until proven otherwise.

Because 99٪ of testicular tumors are malignant!

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-The normal appendix may not be visualized on US.
-The diameter of the appendix is usually less than 6 mm. When visible, the normal appendix compresses when pressure is applied with the transducer.

-The inflamed appendix is noncompressible (using a technique called graded compression).

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Pericardial tamponade
-Becks triad
•Hypotension
•Engorged neck veins (elevated JVP)
•Muffled heart sounds.

-Acue tamponade 👉🏼100 cc of blood
-Chronic tamponade 👉🏼700-1000 cc of blood.
(Chronic tamponade occurs in pericarditis due to TB, renal failure, liver failure, heart failure, tumor).

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Esophageal echo is the best investigation to reveal cardiac injury.

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-Penetrating trauma has inlet only. -Perforating trauma has inlet and outlet.

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In TensionPneumothorax:

Needle puncture or needle decompression (wide bore needle): in the 2nd intercostal space at the level of mid-clavicular line, converting it into open pneumothorax allowing air to escape into atmosphere thus temporarily relief the tension pneumothorax.

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You must be able to identify the visceral pleural line(Fig.10-1) to make the definitive diagnosis of a pneumothorax!

-Visualization of the visceral pleural line—a must for the diagnosis.

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