Bile duct injury

◼️This can occur due to many errors in the surgical technique of cholecystectomy and less commonly other operations, one error is the blind clamping of a bleeding source which may come from cystic artery, accessory cystic artery or injured right hepatic artery, to avoid this, insert your finger in the foramen of winslow and pinch the free edge of lesser omentum to occlude the hepatic artery and stop the bleeding to allow identification of the bleeding source, this is called Hogarth Pringle's maneuver.

◼️Another error is during fundus first procedure, in which the gallbladder is freed by dissection started from the fundus, excessive traction on the gallbladder can tent the bile duct which may be clamped as it is mistaken for the cystic duct (see figure above).

◼️Lack of knowledge about congenital anomalies of the biliary system and failure to define the anatomy of Calot's triangle due to excessive inflammation are also risk factors for bile duct injury.

#Hepatobiliary
#Surgery

Limey bile

◼️Also known as milk of calcium bile, is an uncommon finding in which the bile inside the gallbladder is very rich in calcium carbonate and calcium phosphate.

◼️The bile has a consistency of a toothpaste, and tends to develop stones very easily, this condition is of unknown pathogenesis but is related to slow gradual obstruction to bile flow such as chronic pancreatitis or pancreatic cancer.

◼️As in the above figure, a plain radiograph of abdomen shows radio-opaque material within the gallbladder often with multiple stones.

#Hepatobiliary
#Surgery

Ascending cholangitis caused by Clostridium perfringens

◼️Ascending cholangitis is caused by infected static bile within the biliary passages.

◼️It is famously recognized by the Charcot's triad (Fever, Pain and Jaundice).

◼️C.perfringens (previously known as C.Welchii) are gram positive anaerobic spore forming bacilli (see fig above), Septicemia caused by this bacteria most commonly arise in the context of ascending cholangitis.

◼️The special feature about this, is that this bacteria produces an enzyme known as Lecithinase, which when produced in the blood can cause a severe degree of hemolysis secondary to disruption of red cell membrane.

◼️So in such event, the intravascular disruption of RBC, releases free hemoglobin that precipitate in the renal tubules causing acute renal failure.

N.B, mortality rate of this condition is very high, atleast 60%.

#Hepatobiliary
#Surgery

Acute appendicitis vs mesenteric adenitis.

#Appendix
#Surgery

Rule in  suture of wounds

Any wound covered  by dressing should be  covered  by suitable  antibiotics، and if the wound is not covered by dressing and no AB  is prescribed then  should be cleaned  by povidine- iodine  at least tow time per day

In acute appendicitis, there is no 
great increase  in body temperature.
-It relatively reaches 38 -38.5 C°.
-If greater think of complication or 
other diagnosis.

#Appendix
#Surgery

How to differentiate between acute appendicitis and renal colic?

-Acute appendicitis : the patient loathy to move, ask him to cough he  develops pain.

-Renal colic: rolling on the bed , coughing doesn’t elicit pain.

#Appendix
#Surgery

.

When would you find appendicitis and diarrhea?

-In retroilial appendix.

#Surgery

How to differentiate between sub-hepatic acute appendicitis and acute cholycycstis?

-By tow things
1-Type of the patient:
-In acute appendicitis : the patient is young , thin.
-In acute cholycystitis: female , fatty , fertile, fory, fair.

2-Hyperesthesia:
-In appendicitis: hyperesthesia in the tringle of sherrene.
-In cholycytisits : hyperesthesia in the on the back( boas's sign).

#Appendix
#Surgery

When would you find appendicitis and jaundice?

-In portal pyemia.

#Appendix
#Surgery

How to differentiate between acute appendicitis and mesenteric lymph  adenitis ?

-In mesenteric lymph adenitis the patient has shifting tenderness ( the patient hasPain localize tothe RIF, When he terns to the other side the pain  shift with the direction of the movement) also the patient may have tonsillitis.

#Appendix
#Surgery

How to differentiate between acute appendicitis and gastroenteritis?

-If abdominal  pain precedes  vomiting it indicates acute appendicitis, but if vomiting precedes abdominal  pain  it indicates gastroenteritis.

#Appendix
#Surgery

-Analgesics is contraindicated if acute appendicitis is suspected to avoid masking of diagnosis.

#Surgery

Differential Diagnosis for Epigastric Abdominal Pain:

1- Gastroenteritis:-

History and physical:-
Nausea, extensive vomiting, diarrhea, myalgia, fever, mild abdominal tenderness

2-Acute gastritis:-

History and physical:-
Burning/gnawing epigastric pain, NSAID use, mild abdominal tenderness

3-Acute cholecystitis:-

History and physical:-
Right upper quadrant/epigastric pain radiating to around the right back, nausea, vomiting, fever, Murphy’s sign

4-Peptic ulcer disease (PUD)

History and physical:-
Intermittent burning epigastric pain that is better (duodenal ulcer) or worse (gastric ulcer) with food intake, nausea, Helicobacter pylori infection, NSAID use, steroids

5-Perforated ulcer :-

History and physical:-
Initial epigastric pain, followed by diffuse tenderness, abdominal rigidity, rebound tenderness

6-Pancreatitis:-

History and physical:-
Epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, tachycardia, cholelithiasis, alcohol abuse

7-Appendicitis:-

History and physical:-
Periumbilical pain migrating toward the right lower quadrant (McBurney’s point), associated with nausea, vomiting, anorexia, fever, Rovsing’s sign, psoas sign

8-Small bowel obstruction :-

History and physical:-
Adhesions, hernia, neoplasms, dilated loops of bowel with air fluid levels, absence of distal colonic gas on plain radiograph

9-Mesenteric ischemia :-

History and physical:-
“Severe abdominal pain out of proportion to physical exam,” nausea, most often cardiac embolus to superior mesenteric artery from atrial fibrillation, bloody diarrhea in severe cases

10-Ruptured AAA :-

History and physical:-
Severe abdominal/back/left flank pain, pulsatile abdominal mass, hypotension, elderly male smoker

11-Referred pain from myocardial infarction:-

History and physical:-
Atypical presentation more common in women and diabetics, cardiovascular disease, obesity, hypercholesterolemia.

#Surgery

-In males, first decide whether the lump is a hernia or a true scrotal lump by seeing if you can ‘get above it’, namely feel its upper edge with a normal spermatic cord above.
-If you can, it is a scrotal swelling and not a hernia.
-If the lump has no upper edge because it passes into the inguinal canal, it is a hernia.

#Hernia
#Surgery

-Combination of indirect and direct inguinal hernias is called pantaloon hernia.

#Hernia
#Surgery

When the case is inguinal hernia and you asked why this not femoral hernia ?

-It is inguinal because:
1) The hernia is above inguinal ligament.
2) The neck of the hernia is above & medial to pubic tubercle.
3) Because the hernia descends into the scrotum (if so).

#Hernia
#Surgery

•Why is indirect inguinal hernia more common in right side ?

Due to delayed descend of right testis , slower closure of a patent processus vaginalis on the right side compared to the left.

It's almost about one month difference.

#Surgery

•What's the difference between osteoporosis and osteomalasia ?

-In osteoporosis, bone mass decreases, but the ratio of bone mineral to bone matrix is normal.

-In osteomalacia, the ratio of bone mineral to bone matrix is low.

#Surgery