Note

The appendix is an intraperitoneal structure, but occasionally the tip of the appendix becomes extraperitoneal lying behind the caecum or ascending colon.

#Appendix
#Surgery

Note
The appendix in infants has a wider mouth and also shorter when compared to older age groups, this makes it less liable to occlusion and Inflammation.

#Surgery

The vermiform appendix is a muscular tube and has all the layers common to the rest of the intestine namely mucosa, submucosa, muscularis propria and serosa, note the narrow lumen, combined with the blind end, indeed is liable to occlusion and becoming inflamed

#Surgery

What are the other benign tumors of the parotid gland?

•Warthin’s tumors (papillary cyst adenoma, lymphomatosum)
•Oxyphylic adenoma (Oncocytoma).



-What is the origin of Warthin’s tumor?
-The tumor probably arises from parotid tissue included in the lymph nodes which are usually present within the parotid sheath.
-Micro scopically it is lined by columnar epithelial cells supported by lymphoid stroma.

•What are the features of  Warthin’s tumor?
Clinical features of Warthin’s tumor:
•2nd most common benign tumor
•It is soft and sometimes fluctuant(cystic)
•Seen usually in males
•Seen after 40 years •May be bilateral (10%bilateral).
•This tumor has nomalignant potential.

#Salivary
#Surgery

Paraesophageal hernia (Rolling hiatus hernia)

◼️This includes protrusion of the greater curve of the stomach through the esophageal hiatus, sometimes the entire stomach is present in the chest, also small intestine and colon can be occasionally found in the hernial sac.

◼️Pure rolling hernia i.e the cardia of the stomach is located at its normal anatomical position, is very rare, the vast majority cases has a sliding component in which the gastroesophageal junction pass through the esophageal hiatus.

◼️It is potentially dangerous because it can twist (volvulus) and undergo perforation and even gangrene.

◼️Look at the above figure, this is a barium meal showing part of the stomach in the chest cavity with compression of the lower esophagus.

#Surgery

Sliding inguinal hernia

◼️It result from slippage of the posterior parietal peritoneum on the retroperitoneal structures bringing them to lie in the posterior wall of the hernial sac (figure c shows the caecum slipped down to form the posterior wall of the hernial sac).
◼️It is most common on the left side and almost always in those over 40 years.
◼️It is almost exclusive in men.
◼️This sliding may occur on the right side "Caecum" or on the left side "sigmoid colon" or the bladder on either sides (figure a show part of the bladder sliding in a left inguinal hernia).
◼️Occasionally large intestine is strangulated in an inguinal hernia but usually the non strangulated large bowel is present behind the sac containing strangulated small bowel.

#Surgery

What is incarcerated hernia?

Here the contents are fixed in the sac because of their size or adhesions. The hernia is irreducible, but the bowel is not strangulated.

#Surgery

What is strangulated hernia

-Strangulation is a condition where constriction of the venous return of the bowel occurs initially, which leads to congestion, arterial occlusion and gangrene of the bowel.
-When a loop of gut is strangulated there will also be intestinal obstruction.

#Hernia
#Surgery

•What is the current gold standard surgery for hernia repair [hernioplasty]?

-The gold standard current hernia surgery is the Lichtenstein Tension-free Hernioplasty.
-Here approximately 16 × 8 cm size mesh (polypropylene) is placed anterior to the posterior wall after herniotomy and overlapping it generously in all directions including medially over the pubic tubercle.

#Hernia
#Surgery

What are the preoperative preparations required in incisional hernia?

•Weight reduction by dieting and exercise.
•Patient is asked to stop smoking
•Treat the respiratory problems or BBH.

#Hernia
#Surgery

•What is ventral hernia?

-The term ventral hernia should be restricted to incisional hernia arising in abdominal midline operative wounds.

#Hernia
#Surgery

-What is the most important clinical sign for incisional hernia?

•The swelling will be come more prominent in head raising test. •Reducibility and cough impulse.

#Hernia
#Surgery

•If the lump does not reduce and does not have a cough impulse, what are the differential diagnoses in incisional hernia?

-Then it may not be a hernia.

-The following differential diagnoses are to be considered:
-Differential diagnoses if it is not reducible
•Deposit of tumor—Desmoid tumor •Hematoma
•Foreign-body granuloma
•Old abscess
•Lipoma.

#Hernia
#Surgery

Remember:

-Aspirin need not be stopped before surgery.

-Thyroid medications should be continued.

-Anti-hypertensives should be continued (even losartan).

-OCPs should be continued till day of surgery.

-Anti-depressants, anti-epileptics, anti-psychotics should be continued except TCA, which should be stopped 3 weeks before surgery due to risk of intra operative arrhythmia.

-Ticlopidine: 14 days before surgery.

-Clopidogrel: 7 days before surgery.

-Warfarin: 3 days before surgery.

-LMWH: 12 hours before surgery.

#Surgery

Indications for Open Reduction
NOCAST

-Nonunion
-Open fracture
-Neurovascular Compromise
-Displaced intraArticular fracture
-Salter-Harris3,4,5
-PolyTrauma.

Other indications include:
-Failed closed reduction
-Unable to cast or apply traction due to site.
-Pathologic fractures
-Potential for improved function and/ or out comes with ORIF.

#Surgery

Among the sources of bleeding, fractures are not to be taken lightly,

-For each rib fracture, blood loss can range from 100-200 mL,
-Tibial fractures can yield 300-500 mL,
-Femoral fractures can produce 800-1000 mL,
-Pelvic fractures may cause loss of more than 2000 mL.

#Surgery

Sure signs of fracture:

1-Deformity.
2-Length discrepancy.
3-Abnormal movement.
4-Crepitus.

#Surgery

Post-operative return of GI function:

-Small bowel: 12-24h.
-Stomach: 24-48h.
-Large bowel: 48-72h.

#Surgery

Stages of bone healing:

1- Hematoma 👉🏼0-3 wk
2-Callus+Osteoclast 👉🏼3-6wk
3-Bone formation in callus 👉🏼6-12wk
4-Cortical gap is bridged by bone 👉🏼6-12 m
5-Remodelling"Normal architecture"👉🏼1-2 yr.

-Tornoto notes
#Surgery

Stages of Appendicitis:

1-Catarrhal
2-Edematous
3-Phlegmonous
4-Gangrenous
5-Perforated.

#Surgery