Surgical Emphysema

Surgical Emphysema or Subcutaneous Emphysema-

 means presence of air in the subcutaneous plane.

Right Sided Multiple Rib Fractures with Subcutaneous Emphysema

Characteristic clinical finding is crackling feel or creps.

 

The blown out appearance is sometimes described as 

Michelin Man (Tyre Man) appearance.

Causes

1. Multiple Rib Fractures- Pleural Tear

2. Penetrating Chest Injury  (Stab /Gunshot)

3. Rupture of  Emphysamatic Bullae on to the mediastinum.

4. Rupture Esophagus

5. Tracheal Injury

6. Facial Bone Fractures ( as sinuses contain air )

7. Infection with Gas forming organisms

Other Conditions producing Creps on palpation

1. Face, Neck, Chest - Surgical Emphysema

2. Bone – Definitive Sign of  fracture

3. Joint- Osteo Arthritis

4. Tendon – Teno Synovitis,inflammation of tendon sheath.

Carcinoma Colon- Synchronous Lesions

Carcinoma Colon- Synchronous Lesions

Definition : Occurrence of two or  more primary tumors identified in the same patient and at the same time.

   The most voluminous synchronous cancer is called "index" cancer.

   Synchronous Lesions are caused by 
                                  common genetic and environmental factors.

   Overall incidence of synchronous colorectal cancers 
                                   varies between 2% to 10%.

   Hence a complete colonoscopic work up is indicated in every case.

Buschke-Lowenstein Tumor

Buschke-Lowenstein Tumor of Penis

 is Giant condyloma Acuminata affecting anogenital region

Considered as a variant of verrucous carcinoma

Slow growing , locally invasive,  low grade malignancy

Gross appearance -cauliflower-like morphology

Aetiology- human papillomavirus  (HPV)  types 6 and 11

Diagnostic procedure- Biopsy

Treatment - Surgical excision / CO2 laser/ Chemotherapy

Differential Diagnosis

             1.Squamous Cell Carcinoma

             2. Genital warts,

Pantaloon Hernia

What is a Pantaloon Hernia?

Pantaloon Hernia- Indirect Sac (Black Arrow) & Direct Sac ( White Arrow) 

Pantaloon Hernia-  Inferior Epigastric Vessels  ( White Arrow)  & Spermatic Cord  (Black Arrow)

   If an inguinal hernia contains both direct and indirect sac, it is called a Pantaloon Hernia.

   An indirect sac is dealt by opening  the sac ( Herniotomy) , reducing the contents and transfixing it. 

   A direct sac is reduced into the peritoneal cavity and the plication of the upper part of the Transversalis Fascia over the sac and Ilio pubic Tract-Thickened lower most part of the Transversalis Fascia is done with the non absorbable suture material like poly propelene.

    Then the posterior wall of the Inguinal Canal is reinforced with a poly propelene mesh in the plane of the inguinal ligament and conjoint tendon.

Retrograde Jejuno Gastric Intussusception

Retrograde Jejuno Gastric Intussusception

Retrograde Intussusception means the telescoping in of a distal segment of gastro intestinal tract in to proximal part. After gastro jejunostomy patient can develop what is called Retrograde Jejuno Gastric Intussusception.

          The clinical features include -

                                                      Lump in the epigastrium, 

                                                      Haemetemesis 

                                                      Abdominal pain with vomiting

         Note the 'coil spring appearance' of the jejunum, which can be made out even in a plain radiograph of the abdomen. 

                                                                                      Courtesy- An Unknown Friend! 

Meckel’s Diverticulum presenting as Intussusception.

Meckel’s Diverticulum presenting as Intussusception.

Telescoping in of a proximal segment of intestine to a distal segment is called Intussusception. The proximal segment is called intussusceptum and the distal segment is called intussuscepiens.

The initiating lesion leading to  Intussusception is called a pathological lead point. A lead point can be a polyp,  submucous lipoma,  stromal tumour or Meckel’s Diverticulum.

The commonest site of Intussusception is Ileo caecal region. The clinical features include abdominal pain, vomiting, distension and passage of Red currant jelly stools.

The basis of Red currant jelly stools is due to the excess mucus production from the intussuscepted intestine which gets mixed with blood from the congested intestine.

On examination of abdomen, emptiness of the right iliac fossa is called signe-de-dance (The Sign of Dance). It is due to the pulled up caecum leading to a palpable sausage shaped mass in the umbilical area.

Ultra sonological sign of Intussusception is called Target sign on end on view and a Pseudo kidney appearance in the longitudinal view. Barium enema appearance of Intussusception is called Claw sign.

Non operative management of Intussusception can be tried with Hydrostatic reduction. Per operatively Intussusception is reduced by milking from the distal or advancing point (apex) and not by pulling from the proximal part.

Omental Patch Repair for Duodenal Ulcer Perforation

Omental Patch Repair for Duodenal Ulcer Perforation

One common complication of duodenal ulcer is perforation. Typically an ulcer which is located in the anterior wall of the duodenum perforates and one is located in the posterior wall bleeds.

Perforation can lead on to peritonitis. Hence it is a surgical emergency. The type of facies ( facial appearance) we get in a patient with terminal stage of peritonitis is called Hippocratic facies.

The diagnosis of perforation peritonitis can  be made from the clinical examination. There will be abdominal rigidity on palpation. Abdominal rigidity is due to the involuntary contraction of abdominal wall muscles.

The investigation of choice to diagnose a case of perforation peritonitis is a plain radio-graph of the abdomen in erect posture. The characteristic finding in a plain radio-graph is free gas under the diaphragm.

The treatment of a perforated duodenal ulcer is closure of the perforation with a patch of the omentum. This is known as Omental patch repair. An abdominal lavage with warm Normal saline or Ringer Lactate is mandatory after the procedure. 

Smiley Incision for Repair of Para Umbilical Hernia

Smiley Incision for Open Repair of Para Umbilical Hernia

   A Para Umbilical Hernia is herniation of the intra abdominal contents like omentum or intestine through a defect in the linea alba in the region of the umbilicus.

  Aetiological factors include conditions with  increased intra abdominal pressure like chronic cough, constipation, benign prostatic hypertrophy or an intra abdominal tumour. A weak anterior abdominal wall due to repeated pregnancy is another cause. 

   The complications include irreducibility, intestinal obstruction and strangulation ( arrest of blood supply ) of the contents.  The patient can also experience dragging pain due to the pull on to the mesentery. Hence a surgical correction is indicated.

  One common surgical procedure is the open repair of the para umbilical hernia, done under epidural or spinal anesthesia. The incision is a curved infra umbilical one called  the 'smiley incision.' The sac is dissected out and content is visualized. Beware of the bowel loop especially the transverse colon which can be a content of the sac.

    If the size of the defect is less than 2 centimeters a primary repair using Number one polypropylene and reinforcing darning ( figure of eight sutures ) is done. If the size of the defect is larger a polypropylene mesh is placed for the repair.

   If the mesh is placed over the linea alba, it is called 'On Lay Mesh Repair.'  If the mesh is placed in the  pre peritoneal plane it is called 'In Lay Mesh Repair.'