🔰Bladder Injury

🔷Mechanisms Of Bladder Injury
📍1. Iatrogenic Injury During :
▪︎TURBT (TransUrethral Resection Of Bladder Tumours Most Common Iatrogenic Cause)

▪︎Anti-Incontinence Surgery

▪︎Pelvic Surgery (Hysterectomy/CS/ColoRectal Surgery)

📍2. After Abdominal Trauma Or Pelvic Fractures (Most Common Non-Iatrogenic Causes)

📍3. Spontaneous Rupture After Bladder Augmentation Due To OverDistention (in Patients With Limited Bladder Sensation)


🔷Types Of Bladder Injury
📍1. ExtraPeriToneal (Most Common 65%) :
▪︎Urine Leakage into RetroPubic Space With Intact Peritoneal Membrane

📍2. IntraPeriToneal (25%) :
▪︎Urine Leakage into The Peritoneal Cavity Due To Injury To The Peritoneal Membrane Over The Bladder

▪︎High Risk Of Urine Peritonitis & Ileus & More Complications

📍3. Mixed (Extra & Intra Peritoneal)

📍4. Only Bladder Contusions (No Urine Leakage)


🔷Grades Of Bladder Injury
📍1. Only Contusions & IntraMural Hematoma Or Partial Thickness Lacerations

📍2. ExtraPeriToneal Bladder Wall Lacerations <2cm

📍3. ExtraPeriToneal ≥2cm Or IntraPeriToneal <2cm

📍4. IntraPeriToneal ≥2cm

📍5. Lacerations Extending into Bladder Neck Or Trigone (Urethral Orifice)


🔷Clinical Features & Dx Of Bladder Injury
📍1. SupraPubic Pain

📍2. Not Able To Pass Urine

📍3. Hematruia

📍4. Abdominal Distention

📍5. Urine Peritonitis

📍6. Confirm Dx (Retrograde CytoGram Or CT CystoGram) :
▪︎Leakage Of Contrast Limited To The Area Surrounding The Bladder (Flame Shape) ➡ ExtraPeriToneal Leakage

▪︎Contrast Surrounding The Bowel ➡ IntraPeriToneal Leakage


🔷Mx Of Bladder Injury
📍1. ExtraPeriToneal Injury :
🔻I. Urethral Catheterization For 10-14 Days (Allows Spontaneous Healing)

🔻II. Immediate Repair For :
▪︎Iatrogenic Bladder Injury If Identified During Operation

▪︎Bladder Repair During Operations For Pelvic Fracture Or Rectal Or Vaginal Perforation Repair


📍2. IntraPeriToneal Injury :
🔺I. Open Surgical Repair

🔺II. Bladder Catheterization With Close Monitoring ➡ For Small IntraPeriToneal Leakage & Stable Patient

#Surgery #Bladder Injury
https://t.me/Surgery_Practice

🔰 Bladder Anomalies
📍1. Bladder Exstrophy :
▪︎Failure Development Of The Lower Part Of The Anterior Abdominal Wall Results in Exposure Of The Bladder To The Outside

▪︎More in Males

▪︎Associated With :
🔺I. EpiSpadias (Anterior Opening Of The Urethra)

🔺II. Diastasis Of The Symphysis Pubis/Waddling Gate

🔺III. Wide Pubic Bones/External Rotation Of Anterior & Posterior Bony Pelvis (Results in Outward Rotation Of Lower Limbs)

🔺IV. Short Penis & Vagina & Bifid Clitoris

🔺V. Incontinence & VUR

🔺VI. Low Set Umbilicus With Triangular Shape Fascial Defect in The Lower Abdomen & High Risk Of indirect Inguinal Hernia

🔺VII. Rectal Prolapse/Imperforated Anus/Short Perineum/Anteriorly Displaced Anus

▪︎Need Surgical Correction Of The Anomalies



📍2. Bladder Diverticulae :
▪︎It's Protrusion (Out-Pouching) Of Some Bladder Wall Layers (Mucosa) Through Wall Weakness To The Outside

🔻I. Acquired Diverticulae (Secondary) Occurs in :
▪︎Adult Men With BPH (Most Common)

▪︎Children With Posterior Urethral Valve (Infra-Vesical Obstruction) Or NeuroGenic Bladder (Detrusor Sphincter Dyssynergia DSD)

▪︎Characterized By Elevated Bladder Pressure & Thick Bladder Walls (Trabeculations) & Multiple Diverticulae


🔻II. Congenital Diverticulae (Primary) :
▪︎It's Bladder Wall Mucosal Herniation Through Congenital Muscular Weakness (Defect) Between Intra-Vesical Ureter & Roof Of Ureteral Hiatus (Hutch Diverticulum)

▪︎Associated With VUR

▪︎Characterized By Normal Bladder Pressure & Thin Walls & Usually Single Diverticulum


🔻III. Clinical Features & Dx & Mx Of Bladder Diverticulae :
▪︎Asymptomatic (Usually in Small Congenital Diverticulae)

▪︎Hematruia (30%)

▪︎Recurrent UTI & Bladder Stones

▪︎Urine Retention & Hydronephrosis

▪︎Risk Of Malignancy (1%)

▪︎Dx ➡️ US/CT/MRI/CystoGram/Cystoscope

▪︎Mx ➡️ Surgical Correction Only If Symptomatic (Bladder Outlet Obstruction) Or Malignancy Developed

#Surgery #Bladder anomalies
https://t.me/Surgery_Practice

🔴Bladder Cancer

▪︎Usually Transitional Type Arise From The UroThellium Of The Bladder

▪︎More in Men

▪︎Usually Superficial Low Grade Tumour With Good Prognosis (70-90% 5-Year Survival Rate)

▪︎High Grade Tumours (Muscle Invasion) Has 10-60% 5-Year Survival Rate

▪︎UroThelial Tumours Can Affect Other Parts Of Urinary Tract (Renal Pelvis/Ureter/Urethra)


🔷Risk Factors For Bladder Cancer
📍1. Smoking (Most Common)

📍2. Occupational & Environmental Exposure To Tanner/Rubber/Paints & Dyes/Gas & Tar/Arsenic in Water/HairDressers/Plumbers/Painters

📍3. Chronic Bladder Inflammation Results in Squamous Metaplasia Then Squamous Carcinoma (Catheter/Stones/Recurrent UTI/Schistosomiasis)

📍4. Drugs (Phenacetin/Cyclophosphamide)

📍5. Pelvic Radiation


🔷Types Of Bladder Cancer
📍1. Transitional Cell Carcinoma (Most Common >90%)

📍2. Squamous Cell Carcinoma (1-7%) ➡️ Usually Occurs Due To Chronic Inflammation in The Bladder (Stones/Prolonged Catheterization/Schistosomiasis)

📍3. Adenocarcinoma (2%) ➡️ Arise in The Dome Of The Bladder (Urachus) Or From Bowel Tissue Present in The Bladder (During Augmentation Entero-CystoPlasty Or Bladder Extrophy Repair)


🔷Clinical Features & Dx Of Bladder Cancer
📍1. Painless Visible Hematruia (Most Common Presentation 85%)

📍2. Lower Urinary Tract Symptoms (Frequency/Urgency/DysUria)

📍3. Recurrent UTI

📍4. Features Of Advanced Malignancy :
▪︎Flank/Pelvic/Bone Pain
▪︎Weight Loss
▪︎Lower Limb Edema

📍5. Confirm Dx :
▪︎Urine Exam & Culture & Cytology (Looking For Malignant Cells)

▪︎CT UroGram (Gold Standard)

▪︎CystoUrethroScopy & Biopsy (Direct Visualization Of The Bladder For Patients With Suspicious Of Cancer)


🔷Mx Of Bladder Cancer
📍1. No Bladder Muscle Invasion (NMIBC) :
▪︎TransUrethral Resection Of The Bladder Tumours (TURBT)

▪︎Then IntraVesical Chemotherapy To Reduce Risk Of Recurrence (MitoMycin C Course For 6w)

▪︎Then Regular Follow Up Using Cystoscope

▪︎IntraVesical BCG For Patients With Bladder Carcinoma in Situ (CIS Have Risk Of Progression into Bladder Cancer But Response To BCG)


📍2. Bladder Muscle Invasion (MIBC) :
▪︎Chemotherapy (Neoadjuvant) Then Radical CysteCtomy With Urinary Diversion (Preferred For Patients <70 Years Of Age)

▪︎Chemo-RadioTherapy Only (For Older Patients)


🪀Methods Of Urinary Diversion :
🔺I. OrthoTopic Bladder :
▪︎Creates New Bladder Pouch From Colon Or Small Bowel Tissue Then Connect it To The Urethra

▪︎Used When The Urethra Intact (in Good Condition)

▪︎Studer Pouch Most Commonly Performed

▪︎Not Used If There's Widespread Bladder Carcinoma in Situ (CIS) Or Tumours in The Prostatic Urethra


🔺II. Cutaneous Diversion (HeteroTopic Bladder) :
▪︎Connecting The Ureters To The Appendix Or Ileum

▪︎Then Creates Opening in The Skin (Stoma Near Umbilicus Or RIF) For Self Catheterization

▪︎Used When Urethra Removed Or Not-Functioning

▪︎Ileal Conduit is The Best Method Due To Low Risk Of Complications


🔺III. UretroSigmoidoStomy :
▪︎Attach Ureters To Sigmoid Colon So Urine Pass With Faeces

▪︎Need Good Anal Sphincter Function (To Prevent Incontinence Of Urine)

▪︎High Risk Of Complications (Ascending UTI/Malignancy/Bowel Frequency/Urge Incontinence/Metabolic Disturbances)

#Surgery #Bladder cancer
https://t.me/Surgery_Practice

اقرأوا هذه المعلومة الحلوة كتبتها لكم وخلوها في بالكم … وبعدها ارقدوا 😁

- تخيل أن مريض قد أجرى عملية استئصال الزائدة الدودية سابقا… ومع ذلك يعود بنفس ألم الزائدة الكلاسيكي (ألم يبدأ حول السرة ثم ينتقل للربع السفلي الأيمن، غثيان، قيء، وارتفاع كريات الدم البيضاء)!

🗣️ أثناء أخذ القصة المرضية يقول لك المريض:
"قد استأصلت الزائدة من قبل!"

والفحص السريري يبيّن وجود Scar في مكان العملية ⬅️ هنا مباشرةً تفكيرك بيروح لتشخيصات أخرى مثل النزلة المعوية وغيرها

❗️لكن المفاجأة: ما زالت ممكن تكون التهاب في الزائدة الدودية!

📌 في حالة نادرة قد تحدث مرة من بين كل 500 الف عملية تُسمى Stump Appendicitis وهي التهاب يحدث في الجزء المتبقي من الزائدة بعد استئصالها (appendiceal stump)، وتحدث بنسبة اكبر عند ترك جزء طويل أثناء العملية.

❇️ المعلومة المهمة:
قد يحدث التهاب الزائدة الدودية بعد أيام أو حتى سنوات من الاستئصال

العلاج: استئصال الجزء المتبقي جراحيًا (completion appendectomy)


#Surgery_note
https://t.me/Surgery_Practice

🔴Pneumothorax

▪︎Air Accumulation in Pleural Space (Between Visceral & Parietal Pleura)

🔹Causes Of Pneumothorax
📍1. Primary Sponetousnus :
▪︎Due To Apical Subpleural Blebs Rupture

▪︎No Hx Of Lung Disease

▪︎Mostly Occurs in Persons With :
🔻I. Cigarette & Cannabis Smokers
🔻II. Tall/Slim/Young Age Males (20-40 Years)
🔻III. Marfan Syndrome & Homocystinuria


📍2. Secondary Sponetousnus :
▪︎Hx Of Lung Disease Present

▪︎High Mortality Rate

▪︎Mostly Due To :
🔻I. COPD (Asthma Or Bullae Rupture in Emphysema)
🔻II. TB Infection & Lung Abscess
🔻III. Pulmonary Infarction
🔻IV. Lung Cancer
🔻V. Lung Fibrosis
🔻VI. Cystic Fibrosis


📍3. Traumatic ➡️ After Blunt Or Penetrating Or Iatrogenic Chest Trauma


📍4. Catamenial Pneumothorax ➡️ Pneumothorax Occurs At Time Of Menstruation In Women (Due To Endometriosis involving The Pleura)


🔹Types Of Sponetousnus Pneumothorax
📍1. Closed :
▪︎Air Accumulates Inside The Pleura Then The Leakage Stops

▪︎Spontaneous Air Absorption & Lung Re-Expansion in Days To Weeks

📍2. Open :
▪︎Air Moves Freely in & Out The Pleura

▪︎Seen in Emphysematous Bullae Rupture/TB Cavity/Lung Abscess

▪︎Risk Of Infection

📍3. Tension Pneumothorax (Most Dangerous) :
▪︎The Leakage Point Acts As One Way Valve Allow Air To Enter But Not Escape

▪︎Causing Large Amount Of Air Accumulation & Mediastinal Shift & Cardiovascular Compromise


🔹Clinical Features
📍1. Sudden Onset Unilateral Pleuritic Chest Pain & Dyspnea

📍2. Unilateral Decrease Or Absent Breath Sounds

📍3. Unilateral HyperResonant To Percussion

📍4. Unilateral Reduce Chest Expansion

📍5. Marked Tachycardia/Hypotension/Cyanosis/Tracheal Deviation Away (In Tension Pneumothorax)


🔹Dx Of Pneumothorax (By Chest Xray)
📍1. Visible Pleural Line
📍2. Absent Lung Markings At Periphery
📍3. Deep Sulcus Sign (Depression Of CostoPhrenic Angle)

*For Tiny Pneumothorax ➡️ Use Lateral Chest Xray


🔹Mx Of Pneumothorax
📍1. Give High flow Oxygen To All Patients

📍2. Mild Primary Sponetousnus (Lung Edge <2cm) ➡️ Resolve Spontaneously

📍3. Moderate To Large Primary Sponetousnus ➡️ Percutaneous Needle Aspiration Of Air

📍4. Secondary Sponetousnus (Chronic Lung Disease & Respiratory Distress Present) ➡️ InterCostal Tube Drainage & inpatient Observation

📍5. Tension Pneumothorax :
▪︎Immediate Insertion Of Blunt Cannula into The 2nd InterCostal Space Mid Clavicular Line

▪︎Then Chest Drain inserted into The 4th-5th-6th InterCostal Space Mid Axillary Line

#Surgery #cardiothoraxic
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Intestinal obstruction notes
❇️ The earliest symptom of IO
Pain

❇️ The most common cause of IO
Adhesive intestinal obstruction

❇️ The most common cause of IO in newborn
Jejuno-ileal atresia or stenosis

❇️ The most common cause of IO in old age
Malignancy

❇️ The most common cause of IO in infants
Intussusception

❇️ The main predisposing factor of intussusceptum
Partial obstruction

❇️ The most common type of Infantile intussusception
Idiopathic type

❇️ The most common intussusception
Ileo-cecal intussusception

❇️ The most vulnerable type to gangrene
Ileo-colic type

❇️The most common source of gas in Intestinal obstruction
Swallowed (68%)

❇️ The most common source of fluid in Intestinal obstruction
Secreted (8L)

❇️ Vomiting is early & most copious in
Jejunal obstruction

❇️ Absolute constipation mean
NO feces, NO flatus

❇️ IO is associated with
hypokalaemia & hyponatraemia

.............................................
🔥Difference between Simple & strangulated Intestinal obstruction
🔻Simple
Intermittent colicky pain
+long free interval

🔻Strangulated
Attacks of colicky pain
+short interval of
constant dull aching pain

🔥Direction of volvolus
🔻Volvolus of cecum
Clockwise direction

🔻Sigmoid Volvolus
Anti-clockwise direction


❇️ Signs in Intestinal obstruction ⬇️

☄ Red currant jelly stool
Intussusception

☄ Blood on gloves
Volvolus sigmoid (Sup rectal vein)
Mesentric vascular occlusion

☄Dead silent abdomen
Paralytic ileus

☄Valvulae conniventes
Intestinal obstruction at level of jejunum

☄ Gas in GB or biliary tree in Intestinal obstruction
Gallstone ileus

☄ Dance's sign
Emptiness on Rt iliac fossa
Intussusception

☄Multiple fluid levels Diagnostic for
Intestinal obstruction

☄Claw sign on Barium enema
Intussusception

☄Bird's peak deformity
Volvolus sigmoid

☄Ace of spades
Volvolus sigmoid

☄Inverted U shape on X-ray
Volvolus Sigmoid

☄Sudden onset of Abd-Pain
+infant draws his legs & screams
Intussusception

#Intestinal obstruction
#surgery
https://t.me/Surgery_Practice

وضع الدفعة:
#جراحة

❇️ Any young woman come with Single duct bloody discharge is =
👉 Duct papilloma until proven otherwise


❇️ Any young Girl come with Mobile breast lump = 👉 fibroadenoma until proven otherwise

#breast_Note
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