Sigmoid Volvulus

Sigmoid Vovulus

Sigmoid Volvulus

Volvulus is the twisting up of a loop of intestine on its mesenteric axis.

It can lead to partial or complete intestinal obstruction.

The volvulus is most common in the Sigmoid colon due to the long mesentery and comparatively loaded colon.

Radiological Appearance of Volvulus is called Omega Sign/ Inverted U Appearance or Pneumatic Tyre Appearance

Treatment

Resuscitation

Non operative decompression using a Rectal Tube

Laparotomy, Detorsion , Resection and primary anastamosis.

What is Volvulus Belt Countries?

 Volvulus Belt Countries are  South America, Africa , The Middle East, India and Russia, where the incidence of colonic volvulus is high.

Amyand's Hernia

Amyand's Hernia

Amyand's Hernia

What is an Amyand's hernia?

Amyand's hernia is an inguinal hernia with Vermiform Appendix as the content.

First documented successful appendectomy was done by Claudius Amyand, Sergeant-surgeon to King George II of England, in 1735.

What is an Inflamed Hernia?

When the hernia sac contains an inflamed organ like Vermiform Appendix, Salpynx or Meckel’s Diverticulum it is called Inflamed Hernia.

What is an Ogilvie Hernia?

A direct hernia occurring through the defect in the conjoint tendon is called Ogilvie hernia.

What is a Sliding Hernia/ Hernia-en-Glissade?

A hernia in which the viscous (Caecum /Left colon or Urinary Bladder) forms the posterior wall of the hernia sac.

What is a Richter’s Hernia?

A hernia in which the content is the circumference of the intestine.

What is a Littre’s Hernia?

A hernia in which the content is Meckel’s diverticulam

What is a Maydl’s  Hernia?

A hernia in which the content is W shaped loop of the intestine. Hence it is also called Hernia-en-W

What is a Giant Hernia?

A hernia which hangs down below the mid thigh of the patient on standing position is called a Giant Hernia.

What is Nyhus Classification of Hernia?

Type 1 : Indirect inguinal hernia, internal ring normal

Type 2 : Indirect inguinal hernia, internal ring dilated,

                   posterior inguinal wall intact;

                    inferior deep epigastric vessels not displaced

Type3 : Posterior wall defect

                    3a* Direct inguinal hernia

                    3b* Indirect inguinal hernia, internal ring dilated,           

                          medially encroaching on transversalis fascia

                    3c* Femoral hernia

 Type4 : Recurrent hernia

Torsion Testis

Torsion Testis

Torsion Testis - Left

 

Testicular torsion is a Surgical Emergency

Common Age Group: 10-25 Years

Clinical Features:

Sudden onset of pain in the testis, groin or Lower Abdomen

Associated nausea or vomiting may be present

The affected testis lies in a horizontal position or pulled up position.

Differential Diagnosis

Acute Epididymo Orchitis

Strangulated Inguinal Hernia

Testicular Trauma

In Acute Epididymo Orchitis, elevation of the testis or scrotal support results in the relief of  pain.

In Torsion testis elevation of the testis results in aggravation of  pain.

Specific Investigation

Doppler Ultrasound

Treatment

Scrotal Exploration. Untwist the torsion of the spermatic cord. Look for the viability of the testis. If the testis is viable, fix the tunica albugenia to the scrotal wall. If the testis is gangrenous a low orchidectomy is performed. Opposite side testis is also fixed as a precaution during the same operation.

Penetrating wound Abdomen-Splenic Injury

Penetrating wound Abdomen- Splenic Injury



Penetrating Stab Injury Abdomen



Management of Splenic Injury

Primary Survey and Resuscitation

      A- Airway maintenance with control of Cervical Spine

      B- Breathing

      C-Circulation-Intravenous Fluids

      D- Dysfunction of CNS Assessment

      E- Exposure in the Controlled Environment

Secondary Survey :- Detailed Head to Foot Examination Head to find out other associated Injuries:-

q Face

q Chest

q Abdomen

q Pelvis and Perineum

q Extremities

q General examination of vital signs

q Local Inspect anterior abdomen, lower thorax, perineum

q Log roll to inspect posterior abdomen.

Definitive care - Investigations and Treatment

  

Signs of Abdominal Trauma

Ø Tachycardia

Ø Hypotension

Ø Pallor

Ø Restriction of Abdominal Movements

Ø Grey Turners Sign/ Cullen’s Sign

Ø Rigidity

Ø Ballance’s Sign

Ø Absence of Bowel Sounds

What is Ballance’s Sign?

Ø Shifting Dullness on the Right of Abdomen

Ø Dull note on Percussion on the Left of Abdomen

Ø Due to Early Coagulation of Blood in the Left of Abdomen in Splenic Trauma

What is the difference between Guarding and Rigidity ?

Ø Guarding is the voluntary contraction of the abdominal wall muscles

Ø Rigidity is the involuntary contraction of the abdominal wall muscles

What are the treatment options available for Splenic Injury?

Non Operative Management ( Preferred)

Splenorraphy

Partial Splenectomy

Splenic Auto Transplantation

Splenectomy

What is the rationale of opting for Non Operative Management?

1.     To avoid complications with splenectomy like iatrogenic injury to the pancreas.

2.     To avoid immunosuppressive effects of Splenectomy-like OPSI ( Overwhelming Post Splenectomy Infection)

     

What are the indications of Angio Embolization in Splenic Injury?

1.     Extravasation of the contrast during CECT Abdomen

2.     Delayed splenic rupture/ Secondary splenic injury due the Pseudo Aneurysm Bleed.

Mesenteric Cyst

Mesenteric Cyst



Mesenteric Cyst



                 

 Mesenteric Cysts are cysts arising from the mesentery.

Types of Mesenteric cysts:-

1.     Chylo lymphatic cyst ( Commonest )

2.     Enterogenous cyst

3.     Urogenital Remnant

4.     Teratomatous Dermoid Cyst (Least common)

Commonest age group- Second decades of Life

What is the characteristic clinical feature of a Mesenteric Cyst?

Painless cystic intra abdominal swelling in the umbilical region which moves freely in a plane perpendicular to the line of attachment of root of mesentery.

Differential Diagnosis

Omental cyst/ Ovarian cyst

Complications

• Torsion
• Rupture
• Infection
• Hemorrhage into the cyst

What is the difference in Blood supply of a Chylo lymphatic cyst and an Enterogenous cyst?

Blood supply of a Chylo lymphatic cyst is independent of the adjacent intestine.Hence simple excision is possible.

But Enterogenous cyst derives its blood supply in common with the adjacent potion of the intestine.

Hence surgical removal of an enterogenous cyst entails the resection of the related segment of the intestine.

                        

Basic Principles of Laparoscopic Surgery-Part 2

Basic Principles of Laparoscopic Surgery-Part 2

 

Laparoscopic surgery is an instrument based surgery. The success of a laparoscopic procedure depends on the skill of the surgeon and the combined efforts of his surgical team.

Co axial / straight line principle of Laparoscopy:

The surgeon, the target organ of pathology and the monitor must be in a straight line.

Base Ball Diamond Court Concept of Laparoscopy:



                                        Pathology

 Right Port                                                            Left Port

                                      

                                      Centre Port

                                             

Baseball Diamond Court Concept is important in the triangulation of the instruments. If this principle is followed the clashing between the instruments can be prevented.

Manipulation Angle is the angle between two working ports. Ideal manipulation angle is 60º.

Azimuth Angle is the angle between one instrument and the optical axis of the endoscope. Ideal azimuth angle is equal for the active and assisting instruments.

Elevation Angle is the angle between the instrument and the horizontal plane. Ideal elevation angle is 60º.

These three angles determine the optimal port placement.

 

 

Bilateral Carcinoma Breast

Bilateral Carcinoma Breast

When the patient presents with features of Bilateral Breast Cancer, there are two possibilities.

The contralateral cancer can be a Second primary cancer or a Metastatic lesion.

The differentiation is very important in the management.

Synchronous Primary Cancer-when the two primary cancers develop with in 6 months

Metachronous Primary Cancer- when the second cancer develop after 6 months.

Histological grade, Immunohistochemistry, ERPR Status of both lesions must be studied. These are similar for a metastatic lesion and are different for a second primary lesion.

A complete metastatic work up for the patient is also necessary to rule out hepatic, lung, bone or brain metastasis.

If there is no evidence of metastasis, the diagnosis goes in favor of the second primary lesion.

Chaudary’s criteria is widely followed for the diagnosis of a second primary breast cancer.

Chaudary’s criteria

1.There must be insitu changes in the contralateral tumour.

2.The second tumour is histologically different from the first.

3.The histological differentiation grade of the second tumour greater than the first.

4.There must be no evidence of  metastasis.