Indications of drug therapy in liver hydatid cyst:
-10 days prior to intervention and to continue it for 1 month (albendazole) to 3 months (mebendazole) after the intervention
-Inoperable cysts
-Multiple or multiorgan cysts
-Recurrent hydatids
-Surgically unfit patients
-Cysts in lungs.
•Mebendazole—600 mg daily for 4 weeks.
•Praziquantel—60 mg/kg along with albendazole for 2 weeks.
•Albendazole-400 mg twice daily. 4-week cycles with 2 weeks drug free interval.
N.B.
-Surgery is still the choice and gold standard therapy for hydatid disease.
#Surgery
-10 days prior to intervention and to continue it for 1 month (albendazole) to 3 months (mebendazole) after the intervention
-Inoperable cysts
-Multiple or multiorgan cysts
-Recurrent hydatids
-Surgically unfit patients
-Cysts in lungs.
•Mebendazole—600 mg daily for 4 weeks.
•Praziquantel—60 mg/kg along with albendazole for 2 weeks.
•Albendazole-400 mg twice daily. 4-week cycles with 2 weeks drug free interval.
N.B.
-Surgery is still the choice and gold standard therapy for hydatid disease.
#Surgery
Inspection is done always first in standing straight up without bending later in lying down position, in case of hernia.
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#Surgery
•Why do we ask the patient to turn his face to opposite side during Expansile impulse on coughing?
-To prevent coughing towards examiner.
•Pubic tubercle may be reached by following the tendon of adductor longus.
•Taxis is gradual reduction of contents of the scrotum by gentle manipulation by flexion, adduction and rotation of hip joint.
#Surgery
-To prevent coughing towards examiner.
•Pubic tubercle may be reached by following the tendon of adductor longus.
•Taxis is gradual reduction of contents of the scrotum by gentle manipulation by flexion, adduction and rotation of hip joint.
#Surgery
Deep ring occlusion test:
-When deep"internal" ring is occluded after reducing the contents, if impulse on coughing is absent in standing position then it is indirect inguinal hernia; if impulse on coughing is still present then it is direct inguinal hernia.
-It is the most important test in inguinal hernia.
-Deep/internal ring is located 1.25 cm above the mid-inguinal point.
-Midinguinal point is mid-point between the anterior superior iliac spine and pubic symphysis.
#Surgery
-When deep"internal" ring is occluded after reducing the contents, if impulse on coughing is absent in standing position then it is indirect inguinal hernia; if impulse on coughing is still present then it is direct inguinal hernia.
-It is the most important test in inguinal hernia.
-Deep/internal ring is located 1.25 cm above the mid-inguinal point.
-Midinguinal point is mid-point between the anterior superior iliac spine and pubic symphysis.
#Surgery
Silk glove sign:
-Index finger is invaginated across scrotum towards the external ring. When patient coughs, inguinal hernia is felt as a slit-like sensation.
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-Index finger is invaginated across scrotum towards the external ring. When patient coughs, inguinal hernia is felt as a slit-like sensation.
#Surgery
Inguinal hernia is commonest type of hernia in females.
Inguinal canal in female is called as canal of Nuck.
#Surgery
Inguinal canal in female is called as canal of Nuck.
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Classification of Hernia According to Contents:
•Omentocele—omemtum.
•Enterocele—intestine.
•Cystocele—urinary bladder.
•Litter’s hernia—Meckel’s diverticulum.
•Maydl’s hernia.
•Sliding hernia.
•Richter’s hernia—part of the bowel wall.
•Omentocele—omemtum.
•Enterocele—intestine.
•Cystocele—urinary bladder.
•Litter’s hernia—Meckel’s diverticulum.
•Maydl’s hernia.
•Sliding hernia.
•Richter’s hernia—part of the bowel wall.
•Signs of inflamed appendix during surgery:
1-Peritoneal reaction (serous fluid or pus).
2-Presence of omentum at the wound.
•How to Identify the appendix:
-Follow the taenia coli convergence
towards the appendix.
-The base is at 2.5 cm from iliocaecal junction.
•Crushing with Kocher's forceps:
-To promote haemostasis.
-Speed fibrosis.
-Cause more fixation of the ligature.
#Surgery
1-Peritoneal reaction (serous fluid or pus).
2-Presence of omentum at the wound.
•How to Identify the appendix:
-Follow the taenia coli convergence
towards the appendix.
-The base is at 2.5 cm from iliocaecal junction.
•Crushing with Kocher's forceps:
-To promote haemostasis.
-Speed fibrosis.
-Cause more fixation of the ligature.
#Surgery
•Multiple air-fluid levels appear in plain X-ray abdomen in case of intestinal obstruction, Why?
-Because during vigorous peristalsis, air enters the distal fluid, results in churning, is the reason to caus multiple air-fluid levels.
•80% of intestinal obstruction is in small bowel.
•80% of small bowel obstructions are due to benign cause.
•70-80% of large intestine obstruction is due to malignancy.
•Adhesions (40%) are the commonest cause especially in developed countries.
#Surgery
-Because during vigorous peristalsis, air enters the distal fluid, results in churning, is the reason to caus multiple air-fluid levels.
•80% of intestinal obstruction is in small bowel.
•80% of small bowel obstructions are due to benign cause.
•70-80% of large intestine obstruction is due to malignancy.
•Adhesions (40%) are the commonest cause especially in developed countries.
#Surgery
Distension of bowel in case of IO:
-By gas due to:
1- Swallowed air (70%),
2-From blood in the lumen (20%),
3-From bacterial action and digestion (10%); mainly N2 and H2S.
-Due to fluid mainly of digestive juices which normally get absorbed, but in obstruction absorption ceases and accumulated fluid causes bowel distension (1500 ml saliva, 2000 ml gastric juice, 1000 ml bile, 1500 ml pancreatic juice and 3000 ml from small intestine [succus entericus]); often oedematous bowel wall further secretes more fluid into the lumen aggravating the distension.
#Surgery
-By gas due to:
1- Swallowed air (70%),
2-From blood in the lumen (20%),
3-From bacterial action and digestion (10%); mainly N2 and H2S.
-Due to fluid mainly of digestive juices which normally get absorbed, but in obstruction absorption ceases and accumulated fluid causes bowel distension (1500 ml saliva, 2000 ml gastric juice, 1000 ml bile, 1500 ml pancreatic juice and 3000 ml from small intestine [succus entericus]); often oedematous bowel wall further secretes more fluid into the lumen aggravating the distension.
#Surgery
PARALYTIC ILEUS:
-Do not stimulate the peristalsis (“Don’t flog a tired horse”).
-Most often, patient recovers in 3–6 days by conservative treatment.
-Measurement of abdominal girth is necessary to see whether patient is recovering or not.
-Neostigmine is used rarely only in resistant cases as medical therapy.
-Considered if it exceeds 3 days or 72 hrs post-opeartive.
#Surgery
-Do not stimulate the peristalsis (“Don’t flog a tired horse”).
-Most often, patient recovers in 3–6 days by conservative treatment.
-Measurement of abdominal girth is necessary to see whether patient is recovering or not.
-Neostigmine is used rarely only in resistant cases as medical therapy.
-Considered if it exceeds 3 days or 72 hrs post-opeartive.
#Surgery
•Ultrasound criterias for appendicitis (85% Specificity):
-Noncompressible appendix of size > 6 mm AP diameter, hyperechoic thickened appendix wall > 2 mm target sign.
-Appendicolith.
-Interruption of submucosal continuity.
-Periappendicular fluid.
•Contrast CT scan is very much useful when diagnosis is difficult especially in old people.
•It has 95% sensitivity and specificity with 95% accuracy.
#Surgery
-Noncompressible appendix of size > 6 mm AP diameter, hyperechoic thickened appendix wall > 2 mm target sign.
-Appendicolith.
-Interruption of submucosal continuity.
-Periappendicular fluid.
•Contrast CT scan is very much useful when diagnosis is difficult especially in old people.
•It has 95% sensitivity and specificity with 95% accuracy.
#Surgery
Types of Wound Healing
•PrimaryHealing (First Intention)
-It occurs in a clean incised wound or surgical wound. Wound edges are approximated with sutures. There is more epithelial regeneration than fibrosis. Wound heals rapidly with complete closure. Scar will be linear, smooth, and supple.
•Secondary Healing(Second Intention)
-It t occurs in a wound with extensive soft tissue loss like in major trauma, burns and wound with sepsis. It heals slowly with fibrosis. It leads into a wide scar, often hypertrophied and contracted. It may lead into disability.
-Re-epithelialisation occurs from remaining dermal elements or wound margins.
•Healing by Third Intention (Tertiary Wound Healing or Delayed Primary Closure)
-After wound debridement and control of local infection, wound is closed with sutures or covered using skin graft. Primary contaminated or mixed tissue wounds heal by tertiary intention.
#Surgery
•PrimaryHealing (First Intention)
-It occurs in a clean incised wound or surgical wound. Wound edges are approximated with sutures. There is more epithelial regeneration than fibrosis. Wound heals rapidly with complete closure. Scar will be linear, smooth, and supple.
•Secondary Healing(Second Intention)
-It t occurs in a wound with extensive soft tissue loss like in major trauma, burns and wound with sepsis. It heals slowly with fibrosis. It leads into a wide scar, often hypertrophied and contracted. It may lead into disability.
-Re-epithelialisation occurs from remaining dermal elements or wound margins.
•Healing by Third Intention (Tertiary Wound Healing or Delayed Primary Closure)
-After wound debridement and control of local infection, wound is closed with sutures or covered using skin graft. Primary contaminated or mixed tissue wounds heal by tertiary intention.
#Surgery
Prostatitis is suggested by perineal or suprapubic pain, pain on ejaculation and prostatic tenderness on rectal examination.
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In health, bacterial colonisation is confined to the lower end of the urethra and the remainder of the urinary tract is sterile.
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#Surgery
Hypertrophic pyloric stenosis of infancy
•A condition of unknown aetiology, in which the pylorus is thickened and elongated leading to gastric outlet obstruction with resultant projectile vomitting and metabolic derangments.
•It occur 3 in every 1000 born child, it is 4 times more common in males, and more common in the first born child, some cases show familial tendency.
•The condition most commonly present 4 weeks after birth, but it can range from as early as 2 weeks, to as late as 7 weeks, but this is rare.
•Non bilious vomitting that soon becomes projectile after 2 or 3 days is the main feature, other features include striking weight loss, dehydration, hyponatremia with a hypokalemic hypochloremic metabolic alkalosis.
•Visible peristalsis after a meal is also found, the Hypertrophic pylorus can also be palpated (olive sign) in the epigastrium or right upper quadrant.
•Investigation of choice is ultrasound (White line is elongated pylorus, black line is thickened pylorus).
#Surgery
•A condition of unknown aetiology, in which the pylorus is thickened and elongated leading to gastric outlet obstruction with resultant projectile vomitting and metabolic derangments.
•It occur 3 in every 1000 born child, it is 4 times more common in males, and more common in the first born child, some cases show familial tendency.
•The condition most commonly present 4 weeks after birth, but it can range from as early as 2 weeks, to as late as 7 weeks, but this is rare.
•Non bilious vomitting that soon becomes projectile after 2 or 3 days is the main feature, other features include striking weight loss, dehydration, hyponatremia with a hypokalemic hypochloremic metabolic alkalosis.
•Visible peristalsis after a meal is also found, the Hypertrophic pylorus can also be palpated (olive sign) in the epigastrium or right upper quadrant.
•Investigation of choice is ultrasound (White line is elongated pylorus, black line is thickened pylorus).
#Surgery
Effects and complications of gallstones:
● Biliary colic
● Acute cholecystitis
● Chronic cholecystitis
● Empyema of the gallbladder
● Mucocoele
● Perforation
● Biliary obstruction
● Acute cholangitis
● Acute pancreatitis
● Intestinal obstruction (gallstone ileus)
Differential diagnosis of acute cholecystitis:
Common:
● Appendicitis
● Perforated peptic ulcer
● Acute pancreatitis
Rare:
● Acute pyelonephritis
● Myocardial infarction
● Pneumonia – right lower lob.
#Surgery
● Biliary colic
● Acute cholecystitis
● Chronic cholecystitis
● Empyema of the gallbladder
● Mucocoele
● Perforation
● Biliary obstruction
● Acute cholangitis
● Acute pancreatitis
● Intestinal obstruction (gallstone ileus)
Differential diagnosis of acute cholecystitis:
Common:
● Appendicitis
● Perforated peptic ulcer
● Acute pancreatitis
Rare:
● Acute pyelonephritis
● Myocardial infarction
● Pneumonia – right lower lob.
#Surgery
Symptoms of appendicitis
● Periumbilical colic
● Pain shifting to the right iliac fossa
● Anorexia
● Nausea
Signs to elicit in appendicitis:
● Pointing sign
● Rovsing’s sign
● Psoas sign
● Obturator sign
Clinical signs in appendicitis
● Pyrexia
● Localised tenderness in the right iliac fossa
● Muscle guarding
● Rebound tenderness
The patient is then asked to point to where the pain began and where it moved (the pointing sign).
#Surgery
● Periumbilical colic
● Pain shifting to the right iliac fossa
● Anorexia
● Nausea
Signs to elicit in appendicitis:
● Pointing sign
● Rovsing’s sign
● Psoas sign
● Obturator sign
Clinical signs in appendicitis
● Pyrexia
● Localised tenderness in the right iliac fossa
● Muscle guarding
● Rebound tenderness
The patient is then asked to point to where the pain began and where it moved (the pointing sign).
#Surgery
Sleeping pulse rate:
Pulse rate counted early morning around 4 am, before the patient wakes up, without disturbing the sleep.
#Surgery
Pulse rate counted early morning around 4 am, before the patient wakes up, without disturbing the sleep.
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