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Pitfalls and Danger Points The hernia defect or defects are mapped out on the ante- rior abdominal wall 60mg levitra extra dosage fast delivery erectile dysfunction drug approved to treat bph symptoms, and a patch is cut sufﬁciently large to Injury to bowel overall defects by at least 4–5 cm in all directions levitra extra dosage 60mg with amex erectile dysfunction my age is 24. The mesh Inadequate mesh ﬁxation leading to recurrent hernia is prepared by marking one side for orientation and placing formation four corner sutures generic levitra extra dosage 60mg without a prescription impotence over 60, tied and with tails left on. The mesh is Chronic pain associated with mesh ﬁxation then rolled up and passed into the abdomen. The four corner ties are pulled out with a suture passer and tied deep to the subcutaneous tissues but superﬁcial to the fascia, and these anchor the mesh. Scott-Conner Operative Technique Exposure and Preparation of the Defect Position the patient supine with arms tucked. Often, an entry into the left upper quadrant (left subcostal) either with a Veress needle and optical trocar or with a Hasson cannula is the safest approach. Place three more tro- cars in such a manner as to span the perimeter of the defect, sufﬁciently far apart and far from the hernia defect to allow a comfortable working distance. If the hernia is in the upper abdomen, position instruments and laparoscope along an arc in the lower and lateral abdomen (Fig. Conversely, if the hernia is in the lower abdomen, position the trocars as shown in Fig. Sometimes the contents of the hernia sac will reduce as the abdominal wall expands with pneumoperitoneum, but often adhesions between omentum or bowel and the hernia defect persist, particularly around Fig. Use energy modalities sparingly; usually the adhesions are avascular, and simple blunt or sharp dissection sufﬁces. It is crucial to perform this dissection with care, as inadvertent enterotomy produces a contaminated ﬁeld not favorable to mesh placement. If such enterotomy occurs, carefully repair the bowel and consider a staged repair of the hernia. A missed defect is a common cause of recurrence, and it is only when the entire abdominal wall can be visualized laparoscopically that you can be certain no defects remain. Sizing the Mesh Map the extent of the area that must be covered with a 22 gauge spinal needle. Pass the needle directly into the abdo- men under laparoscopic visualization at the upper aspect of the most cephalad defect. Repeat this maneuver with the farthest lateral aspects of the defect or defects on each side. This distance (with an additional 10 cm for overlap) gives you the width of the Fig. Mark the side that is to face the vis- different point in the fascia and grasp and retrieve the other cera. The mesh will be anchored with four corner place all four sutures and test the mesh by pulling up on all sutures. Here, we show the method used the abdomen at this point to more nearly approximate normal when the sutures are placed before introducing the mesh. If the mesh Place these four corner sutures near the end of each marked spans the defect nicely, tie these deep to the subcutaneous axis such that the long tails are on the “out” or superﬁcial tissues (Fig. Take care not to catch any subcutaneous side of the mesh (mnemonic, “out-to-in, then in-to-out”) and tissue in the tie, as this may cause unsightly dimpling. It is now relatively simple to secure the perimeter of the Roll the mesh up into a tight cylinder and pass it into the mesh with a hernia tacker or with sutures (Fig. Unfurl it so that the marked side is made to face check by partially desufﬂating the abdomen to ensure that the viscera and separate the sutures into four bundles corre- the mesh does not gape anywhere. If omentum is available, bring it down Proper orientation of the mesh so that it is centered over to lie under the mesh. Remove the tro- mesh must also be placed with sufﬁcient tautness to span the cars and close sites as usual. We prefer to place all four sutures and pull them tight before tying all of them in order to ascertain that these cru- cial sutures place the mesh with sufﬁcient tautness and accu- Postoperative Care rately span the defect. These procedures are typically suture passer with a nonabsorbable suture (needle attached) done on an outpatient basis. Seroma formation is virtually into the abdomen, grasp one end of the preplaced corner universal, and the patient must understand that this is a nor- suture, and pull it out through the fascia. Many sur- the other end out of the mesh, anchoring it as needed with a geons advise wearing an abdominal binder to minimize grasper. Then replace the suture passer through a slightly seroma formation during the ﬁrst few weeks. Take extreme care during adhesiolysis, and care- carefully identifying all defects and by sizing the mesh fully inspect the bowel several times. Mesh placement in most recurrences occur at the interface between mesh and this situation is almost always destined to fail. Laparoscopic versus open hernia repair: outcomes and parietal peritoneum can also occur. Further Reading A comparative analysis between laparoscopic and open ven- tral hernia repair at a tertiary care center. Operations for Infected Abdominal 108 Wound Dehiscence, Necrotizing Fasciitis, and Intra-abdominal Abscesses Carol E. Chassin† Indications Preoperative Preparation Spreading infection of the anterior abdominal wall Administer therapeutic doses of systemic intravenous antibi- Infected dehiscence, with or without evisceration otics effective against gram-negative rods, enterococci, Prompt drainage of a subphrenic abscess is indicated when it and anaerobes, including clostridia, until deﬁnitive bacte- is diagnosed. This Only about two-thirds of patients with subphrenic abscesses requires an aminoglycoside, ampicillin or penicillin, and demonstrate the typical clinical picture of fever, localized clindamycin (or metronidazole or chloramphenicol). Consequently, Because intra-abdominal sepsis is a frequent companion, if recent advances in radiographic and other types of body not the cause, of the necrotizing infection, many of these imaging have been most welcome. Occasionally, a safe route cannot be planned, and opera- tive drainage is required. Operative drainage is also needed when there are multiple abscesses or associated Pitfalls and Danger Points intra-abdominal pathology that requires correction or when percutaneous drainage fails to eradicate the Inadequate débridement of devitalized tissue infection. Failure to identify and drain intra-abdominal abscesses, including loculations and multiple abscesses Failure to identify an associated gastrointestinal ﬁstula Injuring the spleen, liver, or a hollow viscus C. Chassin Operative Strategy: Infected Abdominal Marsupialization and Open Abdomen Wall and Dehiscence Management Wide Débridement When complex collections with multiple loculations and necrotic tissue are encountered, the probability of recurrence Unhesitatingly cut away all devitalized tissue and continue is high. In the critically ill patient, consider leaving the the scalpel dissection until bleeding is encountered from the abdomen open (and applying a vacuum dressing) so that cut edge of the tissue. If even a small remnant of devitalized daily explorations, débridements, irrigation, and packing can fat or other tissue is left, it is a haven in which bacteria can be done in the intensive care unit. Managing the Abdominal Wall Defect Intra-abdominal Abscesses: Classiﬁcation of Spaces of the Upper Abdomen Closure of even small abdominal wall defects in the setting of necrotizing infection is doomed to failure. The strategy that has For purposes of this discussion, we have adopted the classi- evolved accepts the trade-off of a possible incisional hernia for ﬁcation of Boyd (for spaces of the upper abdomen) with a a better chance of patient survival. On the right side, there is a single supra- diameter) may be managed by Adaptic gauze covered with hepatic subphrenic space and a right infrahepatic space. Larger defects may be managed by appli- the left, there is a subphrenic space and a left infrahepatic cation of a vacuum dressing or closure with absorbable mesh space that can be divided into two spaces: (1) the posterior (inserted by a rapid suture technique). Dressing changes and infrahepatic space, which constitutes the lesser sac, and (2) subsequent granulation tissue formation ultimately result in a the left anterior infrahepatic space, which is situated anterior surface that can be covered with a split-thickness skin graft. Generally, the large resulting incisional hernia is managed by delayed repair, possibly involving a musculocutaneous ﬂap, at a time remote from the life-threatening illness.
If suppuration is progressive buy 60 mg levitra extra dosage amex impotence in the bible, abscess cavities ftre formed with destruction of renal tissue order generic levitra extra dosage line impotence young adults. The outline of the calyces is destroyed and the resulting distortion is seen in X-ray film buy 40 mg levitra extra dosage amex zantac causes erectile dysfunction, which is an important feature of diagnosis. There is diffuse or spoty inflammation characterised by oedema and small haemorrhagic areas. There are also linear round cell infiltration with admixture of polymorphonuclears. There is destruction of the renal tubules with gradual replacement by scar tissue. The pathological process is characteristically patchy with intervening areas of the tubules which are either normal or dilated filled with pink staining colloid like material. In fact they are peculiarly immune to inflammatory change, though there may be some periglomerular fibrosis. The arteries show two types of changes — (a) endarteritis obliterans, a fibrous thickening of the intima with narrowing of the lumen and (b) thickening and hyalinization of all layers of the arterioles, which may cause renal hypertension. Peculiarly enough this condition affects right side more often than the left but it may be bilateral. The pain may radiate to the lower abdomen or to the groin mimicking ureteric colic. Sometimes anterior tenderness is not so easily palpable due to muscle spasm (iii) Percussion over the renal angle may be painful. Serial blood cultures should be done on any patient with high fever, chills and rigor as bacteraemia is not uncommon. When the condition is present for more than a day, the number of pus cells increases. Quantitative estimations of pus cells and bacteria are important in finding out the severity of the case. Culture of the specimen and sensitivity of the organism to antibiotics are highly important to find out proper chemotherapeutic agent 3. The pelvis and calyces on the affected side may be smaller, may be due to secretion of small volume of urine in the affected side. When infection is severe, it shows less concentration of dye on the affected side, which returns to normal after appropriate therapy. It should be borne in mind that excretory urography should not be used to diagnose this condition, neit her cystography should be performed for diagnosis. If diagnosis is delayed and treatment is inadequate, the condition may turn to be chronic. Such chronic form is not easy to diagnose as not only this condition is silent, but also there is few or no pus cell in the urine, however bacteria may be detected with difficulty. Such chronic form may gradually lead to (i) renal insufficiency, (ii) renal ischaemia and hypertension. Bacteraemic shock may be seen particularly when gram negative rods are the infecting organisms Differential Diagnosis. However change of bowel habit, normal urine and characteristic changes in barium enema will diagnose this condition. Skin hypersensit ivity and absence of pyuria are diagnostic points in its favour Treatment. Patient shoud be instructed to drink large quantities of bland fluid, at least 3 litres a day. In severe cases with vomiting and dehydration, intravenous dextrose saline may be required. If the urine is acid, which is common in coliform infections, alkalisation of the urine is beneficial to relieve symptoms. Potassium citrate with hyoscyamus in the form of mixture given 4 times a day is very useful treatment in this regard. Preferably the antibiotic chosen should reach a high concentration in urine and renal tissue. Such antibiotics are tetracycline, ampicillin, cotrimoxazole, polymyxin B, gentamicin. Once the culture and sensitivity reports are in hand, the proper antibiotic should be started in high dose for at least 10 days, till the urine is rendered sterile. It is better to administer another antibiotic of similar sensitivity for a further 10 days and again urine examination is performed. A few recently available antibiotics are quite effective and these are carbenicillin, cephalosporins (1st generation — cephalexin. If ureterovesical junction is grossly abnormal bacteria in the bladder reach the kidney and true chronic pyelonephritis continues. So treatment should be considered in this direction if permanent relief is to be obtained. The cut surface shows fair demarcation between the cortex and the medulla, but the kidney tissue is pale and fibrotic. Many of these become destroyed and disappear in the scar tissue The glomeruli however remain normal until late in the disease, when they may be hyalinized and fibrotic. Considerable thickening of the arteries and arterioles is evident and this is the cause of renal hypertension which is seen in half the cases. While majority of the females are below 40 years of age, majority of the males affected are above 40 years of age. Urinary sediment may or may not contain numerous white cells, but some bacteria are always present Renal function tests should always be performed. Voiding cystourethrography should be performed which demonstrates vesicoureteral reflux in at least half the cases. Suitable drugs include — Mandelic acid and its salts are quite effective against coliform organisms and Strept. Ammonium chloride of about 2 g may be given together with the previous drug 6 hourly. In about half the cases infection is by one organism, though after treatment with antibiotic it may be replaced by another organism. It needs only passing mention as it does not ordinarily lead itself to surgical treatment. It results in interstitial inflammation which leads to pressure necrosis of the papillae. Recurrent renal colic is complained of as sloughed papillae are passed through the ureter. Excretory urography may not reveal any definite clue to the diagnosis, except that satisfactory excretion of dye may not be present. Infusion of increased amount of radio-opaque material also may not show any abnormality.
Incise the external oblique aponeurosis along the line of its ﬁbers so the inci- sion joins the external inguinal ring at its cephalad margin (Fig discount 40mg levitra extra dosage with visa erectile dysfunction research. Occasionally purchase levitra extra dosage 40mg visa erectile dysfunction among young adults, the ilioinguinal nerve runs with the spermatic cord safe levitra extra dosage 60mg erectile dysfunction doctor montreal, in close approximation to the cremaster muscle. Retract the lateral leaﬂet of the external oblique in a caudal direction and expose its junction with the pubic tubercle. It is impor- tant now to elevate the medial leaﬂet of external oblique apo- neurosis from the underlying transversus muscle for a distance of at least 3–4 cm. Retract the medial leaﬂet cepha- lad by inserting one fork of the self-retaining Farr retractor Fig. Not only does this technique of local block eliminate pain, it produces surprisingly good Excising Cremaster Muscle muscle relaxation Incise the cremaster muscle sharply in the direction of its ﬁbers before encircling the cord (Fig. Then ligate and Incision divide excess cremaster muscle, taking care that no cord structures have inadvertently been included in the ligature. An attempt to encircle fashion to the point where the external ring adjoins the public the cord lateral to this point may result in traumatizing the tubercle. To reduce the diameter of the cord, excise the entire cremaster muscle from the portion of the spermatic cord that remains in the inguinal canal. This minimizes the diameter of the internal inguinal ring when it is reconstructed. Be sure to remove all the cremaster muscle ﬁbers from their attachments to the iliopubic tract, the femoral sheath, and the transversalis fascia (Fig. Only after removing all these ﬁbers is there clear visualization of these important structures. Clearly identify the vas deferens and the internal spermatic vessels before resecting the cremaster. Excising Indirect Sac At this point, place the left index ﬁnger behind the cord near the internal ring and dissect out the cord structures to rule out Fig. If the patient has a combined indirect and direct hernia, deal with each sac individually. It is important to free the neck of the hernial sac remains behind when the spermatic cord is ele- sac from surrounding structures so the stump of the ligated vated from the ﬂoor of the canal. Now remove the hemostat genitofemoral nerve and associated structures are included retracting the lateral leaﬂet of the external oblique aponeuro- and not injured (Fig. Place the cord and ilioinguinal nerve lateral to this leaﬂet drain for purposes of traction. Often a small branch of the genitofemoral nerve runs along the ﬂoor of the inguinal canal together with the external spermatic vessels. Make a scalpel incision through the bulging attenuated transversalis fascia from the pubic tubercle to a point just medial to the deep inferior epigastric vessels (Fig. When lobules of preperitoneal fat bulge through the scalpel incision, extend the incision with Metzenbaum scissors if preferred. If one is in the proper plane of dissection, the deep inferior epigastric vessels have been entirely cleared of areolar tissue; Cooper’s Fig. If any branches of the deep inferior epigastric vessels join the deep surface of the transversalis fascia, carefully divide and ligate them so a the epigastric vessels can be pushed down away from the repair. Otherwise, retroperitoneal bleeding may be caused by inadvertently piercing these vessels with a needle while suturing the transversalis layer. Excise the attenuated por- tions of transversalis fascia and apply straight hemostats to the free cut edge of the medial leaﬂet of the transversalis fascia for purposes of traction. Apply a moist gauze sponge in a sponge holder to the preperitoneal fat and bladder to push these structures posteriorly. Shouldice Repair Layer 1 Anchor the initial stitch (3-0 Tevdek on a C-5 atraumatic needle) by catching the lacunar ligament and pubic perios- teum in one bite and the undersurface of the medial ﬂap of transversalis with overlying rectus fascia in the other. Apply upward traction on the straight clamps b holding the medial leaﬂet of transversalis fascia; this maneu- ver reveals a “white line” of ﬁbrous tissue on the undersur- face of the transversalis fascia. The “white line” represents the aponeurosis of the transversus muscle as seen through the transversalis fascia. This aponeurosis of the transversus abdominis muscle is thought by McVay and Halverson and Fig. This arch of aponeurotic tion of the caudal margin of the transversalis fascia is also tissue becomes muscular as it approaches the internal ingui- termed the iliopubic tract. Include the “white line” in the continuous stitch that ter muscle ﬁbers that cover the iliopubic tract and femoral attaches the cut lateral edge of the transversalis fascia to the sheath. Otherwise it is not possible to identify these struc- undersurface of the medial leaf of the transversalis tures accurately for proper suturing. Insert the needle into the lateral leaﬂet of Each stitch should contain 4–6 mm of tissue. Continue the transversalis fascia near the point where this layer appears to suture in a lateral direction until the newly constructed 100 Shouldice Repair of Inguinal Hernia 901 Fig. A worthwhile modiﬁcation of the Shouldice technique is to excise the lower 2 cm of the internal oblique muscle to expose the underlying aponeurosis of the transversus muscle. This step is in fact an integral part of McVay’s method of hernia repair as shown in Fig. After accomplishing this step, one can invert the sutures for Shouldice’s layer 3 into the transversus aponeurosis instead of into the ﬂeshy, internal oblique muscle. If the internal oblique muscle is internal ring has been closed snugly around the spermatic ﬂimsy, resect the muscle and sew to the underlying aponeu- cord so only the tip of a Kelly hemostat ﬁts loosely between rosis of the transversus muscle. Do not leave any gap in the suture line Layer 2 near the pubic tubercle as this oversight is a common cause Excise the attenuated portion of the transversalis fascia and of recurrent hernia adjacent to the pubis. Then use the same continuous strand of suture material as L a y e r 4 in layer 1 and sew the free cut edge of the medial leaﬂet of Use the same continuous suture to create a fourth layer by transversalis fascia with adjacent internal oblique muscle to taking ﬁrst a bite of internal oblique muscle just cephalad to the anterior aspect of the iliopubic tract. Include 2–3 mm of the previous layer and then a 4 mm bite of the undersurface the shelving edge of the inguinal ligament in the continuous of external oblique aponeurosis just anterior to the previ- suture going medially (Figs. Anchor the last stitch by suture until it approaches its point of origin at the internal inserting it into the pubic periosteum. At this point, terminate ring, where the suture is terminated by being tied to its tail. This move prevents the testis from descending to an abnormally low point in the scrotum as a consequence of resecting the cremaster muscle. Laxatives may be given on the night of the ﬁrst post- Although the classic Shouldice repair calls for the four layers operative day to avoid patient discomfort at defecation. Berliner found no differences in the incidence of recurrence between the two-layer, three-layer, Complications and four-layer Shouldice repairs. Systemic complications of a pulmonary, cardiac, or urologic Closure of External Oblique Aponeurosis nature are rare. Meticulously inspect the cord and obtain complete hemosta- Wound infections are rare. Treat them promptly by open- sis with a combination of ﬁne ligatures and electrocoagula- ing the skin and subcutaneous tissues for adequate drainage tion. Replace the cord in the canal, which is now displaced and by prescribing appropriate antibiotics.
In case of a large ductus cheap levitra extra dosage 40mg on line impotence vacuum pump demonstration, the shunt may constitute 50 to 70% of the output of the left ventricle buy levitra extra dosage 60 mg without prescription impotence young male. With this pulmonary blood flow increases to as high as 10 to 15 litres per minute order levitra extra dosage us erectile dysfunction causes cancer. With this increase of blood in the lungs the pulmonary vessels become dilated (pulmonary plethora) and their pulsation becomes increased (hilar dance). This additional blood flow to the lungs will cause more blood to the left side of the heart resulting in left ventricular hypertrophy. Many cases may remain asymptomatic, whereas a few with large patent ductus may cause serious heart failure during the first year. More definite symptoms of congestive heart failure are usually seen only in adult patients. With smaller patent ductus, this murmur becomes audible earlier much before the patient develops cardiac failure. Electrocardiogram is usually normal with a small ductus, but will show left ventricular hypertrophy with large ductus. With appropriate manipulation the cardiac catheter can be passed through the patent ductus confirming the diagnosis. A temporary aortic shunt, usually a left atriofemoral by-pass may be used to permit temporary occlusion of the aorta above or below the ductus. The most popular theory is that coarctation is an extension of the fibrotic process which converts the patent ductus into ligamentum arteriosum. Dilated intercostal arteries entering the distal aorta provide collateral circulation to by-pass the constricted coarctation of aorta. There are two main types of coarctation of aorta — (i) Past-ductal type or adult coarctation. As the ductus usually remains patent, deoxygenated blood pass from the pulmonary artery into the aorta distal to the coarctation. So the lower trunk and lower extremities become cyanosed, whereas the head, neck and upper extremities remain pink. Hypertension will be characterised by headache, dizziness, epistaxis, throbbing and pulsation of arteries of head and neck and a systolic murmur at the apex. The features of hypotension are weak femoral pulsations, cold lower extremities and intermittent claudica tion of the legs. Complications include left ventricular failure, intracranial haemorrhage, intrathoracic haemorrhage and very rarely rupture of aorta. Cardiac catheterisation and aortography should be performed routinely to locate the site of coarctation and its extent. If performed earlier without any definite reason, coarctation may recur as the child grows older. A left posterolateral thoracotomy through the 4th intercostal space is usually preferred. The mediastinal pleura is incised, after which the vagus nerve is retracted medially. Now the aorta is mobilised both above and below the constriction taking care not to damage the intercostal vessels. In children as much as 5 cm of aorta may be excised, whereas in older children upto 3 cm of aorta can be removed. After anastomosis, the blood pressure should be measured proximal and distal to the anastomosis. The results of operation are usually good and the patients are discharged in 7 to 10 days. This defects allows blood to flow from left to right atrium, so that the right side of the heart and lungs become overfilled, whereas the left side of the heart receives less blood. Embryologically this results from failure of complete development of septum secundum. Treatment is direct suturing and closure of the defect by continuous suture with prolene. If direct suturing is not possible, a prosthetic patch of knitted dacron or pericardium may be inserted. This defect is usually associated with incomplete formation of mitral and tricuspid valves. Initially the cleft in the mitral valve is closed with interrupted sutures placed from the ventricular septum out to the free margin of the mitral orifice. After repair of the cleft mitral valve, the septal defect is repaired with a patch of pericardium inserted with interrupted sutures. A defect in the tricuspid valve is frequent but usually not amenable to repair by direct suturing. The right pulmonary veins usually enter the superior vena cava inferior to the point of entry of azygos vein, or enter into the right atrium or into the inferior vena cava. When treatment is required, the anomalous veins can be corrected by insertion of prosthetic patch so that the defect is closed and the pulmonary veins are made to enter the left atrium. Ventricular defect is mostly situated in the membranous part or fibrous part of the septum. The membranous septal defects are either located posteriorly or anteriorly in relation to the crista supraventricularis. The posterior defects are close to the tricuspid valve on the right and the mitral valve on the left. The anterior defect is safely away from the conduction bundle and its closure is easier than that of the posterior defect. The defects smaller than 1 cm is called ‘small’ defect and larger than 1 cm is called ‘large’ defect. The defect allows passage of blood from the left to the right ventricle resulting in over-filling of the right heart and pulmonary hypertension. But those with larger defects are usually symptomatic and the first and most common symptom is dyspnoea on exertion. On Physical examination a loud pansystolic murmur is typically present in the 3rd and 4th intercostal space along the left sternal border. Enlargement of pulmonary artery and its tributaries and pulmonary congestion may be visible in X-ray. Cardiac catheterisation confirms the diagnosis and it also assesses the extent of left to right shunt. If symptoms are not disabling, the time for operation may be deferred to 4 to 6 years. A longitudinal ventriculotomy is performed usually in the infundibular part of the right ventricle and near the anterior descending coronary artery. The alternate approach is through the right atrium, particularly when pulmonary vascular resistance is significantly increased. The defect is usually closed with an oval patch of knitted Dacron by mattress sutures (prolene) posteriorly and continuous suture (prolene) anteriorly. Postoperatively, Digitalis is usually given, as some degree of right ventricular failure is common. The risk of operation increases somewhat if pulmonary vascular resistance is increased.