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Two other types are also seen — (iv) Submucous and (v) Fissure abscess (associated with chronic fissure) cheap 160 mg super p-force oral jelly overnight delivery. This can be conveniently palpated with an index finger inside the anal canal and a thumb superficial to the swelling buy 160mg super p-force oral jelly fast delivery. This abscess is less painful than the ischiorectal abscess as the skin can expand easily in this region. Submucous and fissure abscesses can be diagnosed by history and rectal examination. Mostly these fistulae develop from ano-rectal abscess which burst spontaneously or was incised inadequately. A history of intermittent swelling with pain, discomfort and discharge in the perianal region can often be obtained. After discovery of an external opening it is possible to palpate the fibrous cord subcutaneously leading toward the anal canal. This is better palpated bidigitally — index finger inside the lumen of the anal canal and the thumb superficially around the anus. The most important part in rectal examination is to feel the ano­ rectal sling and to find out whether the internal opening is above or below that sling. While a low fistula can be laid open without fear of incontinence, treatment of a high fistula is very difficult and calls for expert hands in this speciality. These sinuses are commonly found in the skin covering the sacrum and coccyx, between the fingers (in hair dressers) and at the umbilicus. Hairs break off by friction and then find entry either through the open mouth of the sudoriferous gland or through the soften skin either by sweat or some form of dermatitis. Pain may be from dull ache to throbbing (particularly when the opening is closed and the discharge becomes purulent and stagnant inside). Pilonidal sinuses are always in the mid-line of the natal cleft over the lowest part of the sacrum and coccyx. Palpation of the skin and subcutaneous tissues around the sinus reveals areas of subcutaneous induration. Inguinal lymph nodes do not enlarge because the infection is mostly mild and chronic. In children direct downward course of the rectum due to undeveloped sacral curve and reduced anal tone predispose. If the prolapse is not immediately visible, it is often possible to make it appear by asking the patient to perform a Valsalva manoeuvre. Main difficulty in diagnosis is between mucosal (partial) and complete rectal prolapse. However this should not present a problem if it is remembered that a mucosal prolapse consists of only two layers of mucosa, whilst a complete prolapse consists of full thickness of rectal wall. Furthermore there may be a sulcus between the prolapse and the inside of the anal canal. A finger in the anal canal can estimate the tone of the anal sphincter and levator ani. Double contrast barium enema and colonoscopy will be required if no obvious cause of prolapse can be found out. This incidence of course depends on the site of gastrointestinal pathology — the more distal is the disease, higher is the rate of perianal complications. The perianal complications can be classified into primary conditions and secondary conditions. Primary conditions are fissures, cavitating ulcers like intestinal disease and ulcerated piles. These are often transmitted by sexual contact, hence these may be present or associated with sexually transmitted disease e. These are also noticed in patients whose immune response has been depressed with steroids or other forms of chemotherapy. On inspection perianal warts are multiple, pedunculated, papilliferous lesions seen around the anus. Sometimes the whole perineum is affected, even including the labia majora or the back of the scrotum. Main symptoms are irritation, discomfort and pain from rubbing against the clothings. The pain appears suddenly and cramp-like in nature, deep inside the anal canal and usually at night. It may be suggested that such pain is caused by spasm of the muscles of the pelvic floor. In case of proliferative growth in ampulla the patient feels the sense of incomplete defaecation even after full opening of the bowel. It is also due to the fact that hard faeces irritate the colon leading to diarrhoea. Pain is a late symptom, but pain of colicky character may be experienced by patients with annular growth of the rectosigmoid junction due to some degree of intestinal obstruction. In annular growth of the rectosigmoid junction the colon loaded with faeces may be felt.

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When the proximal half of the transverse colon is removed cheap 160mg super p-force oral jelly visa, the left colic connec- tion of this marginal artery supplies the remaining transverse colon discount 160 mg super p-force oral jelly fast delivery. Documentation Basics This is all done before there is any manipulation of the tumor—hence the “no-touch” technique. The specimen may • Findings now be removed by the traditional method of incising the peritoneum in the right paracolic gutter and elevating the right colon. Operative Technique (Right and Transverse When right colon resection is performed for benign Colectomy) disease, extensive mesenteric resection is not required and a lateral to medial approach may be utilized. In this Incision approach, the peritoneal attachments of the colon are incised and the colon mobilized. Resection is then per- Make a midline incision from the mid-epigastrium to a point formed, with care to visualize and protect the ureter. Insert a blunt Mixter right-angle clamp through an avascular Explore the abdomen for hepatic, pelvic, peritoneal, and portion of the mesentery close to the colon, distal to the nodal metastases. A solitary hepatic metastasis may well be tumor, and draw a 3 mm umbilical tape through this puncture resected at the same time the colectomy is performed. Tie the umbilical tape firmly to occlude the erate degree of hepatic metastasis is not a contraindication to lumen of the colon completely. Inspect the ver at a point on the terminal ileum, thereby completely primary tumor but avoid manipulating it at this stage. After this has been accomplished, with the transverse colon drawn in a caudal direction, the middle colic vessels For a carcinoma located in the hepatic flexure, divide the can be seen as they emerge from the lower border of the adjacent omentum between serially applied Kelly hemostats pancreas to cross over the retroperitoneal duodenum. If the neoplasm is located in the cecum, there appears to be no merit in resecting the omentum. The omen- Division of Middle Colic Vessels tum may be dissected (with scalpel and Metzenbaum scis- sors) off the right half of the transverse colon through the During operations for carcinoma of the cecum and the proxi- avascular plane, resecting only portions adhering to the cecal mal 5–7 cm of the ascending colon, it is not necessary to 49 Right Colectomy for Cancer 447 Fig. The left branch of the middle colic vessel may be preserved and the right branch divided and ligated just beyond the distal to the first. Divide the mesocolon toward the point on the During operations for tumors near the hepatic flexure of transverse colon already selected for division. Divide and the transverse colon, dissect the middle colic vessels up to ligate the marginal artery and clear the transverse colon of fat the lower border of the pancreas (Figs. Now Be careful not to avulse a fairly large collateral branch that apply an Allen clamp to the transverse colon, but to mini- connects the inferior pancreaticoduodenal vein with the mid- mize bacterial contamination of the abdominal cavity, do not dle colic vein (Fig. Place a Mixter Division of Ileocolic Vessels clamp deep to the middle colic vessels at the appropriate point; then draw a 2-0 silk ligature around the vessels and Retract the transverse colon in a cephalad direction. Sweep any surrounding lymph nodes down the left index finger deep to the right mesocolon (Fig. Gentle finger dissection should dis- For tumors near the hepatic flexure, no more than 8–10 cm close, in front of the fingertip, a fairly large artery with vig- of ileum need be resected. In any case, divide the ileal mes- orous pulsation; it is the ileocolic arterial trunk (Fig. After ligating each of the left, it palpates the adjacent superior mesenteric artery. By gentle dissection, remove areolar specimen has been isolated from any vascular connection and lymphatic tissue from the circumference of the ileocolic with the host. After rechecking the location of the superior mesenteric vessels, pass a blunt Mixter right-angle clamp underneath the ileocolic artery and vein. Ligate the vessels Division of Right Paracolic Peritoneum individually with 2-0 silk ligatures and divide them at a point about 1. Chassin The left index finger may be inserted deep to this layer of Ileocolic Two-Layer Sutured End-to-End peritoneum, which should then be transected over the index Anastomosis finger with Metzenbaum scissors or electrocautery. Continue this dissection until the hepatic flexure is free of lateral Align the cut ends of the ileum and transverse colon to face attachments. Rough dissection around the retroperitoneal each other so their mesenteries are not twisted. Because the duodenum may lacerate it inadvertently, so be aware of its diameter of ileum is narrower than that of the colon, make a location. Next, identify the right renocolic ligament and Cheatle slit with Metzenbaum scissors on the antimesenteric divide it by Metzenbaum dissection. When this is accom- border of the ileum for a distance of 1–2 cm to help equalize plished, the fascia of Gerota and the perirenal fat may be these two diameters (Fig. Do not round off the cor- gently swept from the posterior aspect of the right mesoco- ners of the slit. Continue this dissection caudally, eventually unroofing Insert the first seromuscular layer of interrupted sutures the ureter and gonadal vessel. Initiate this layer by inserting the first Lembert suture at the antimesenteric bor- der and the second at the mesenteric border to serve as guy Identification of Ureter sutures.

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Clusters of subpleural granu- lomas (large arrows) have been termed pseudoplaques generic 160 mg super p-force oral jelly mastercard. Atypical (nontuberculous) Small or large nodules with areas of bron- The presence of small nodules in areas of lung mycobacterial infections chiectasis super p-force oral jelly 160 mg otc, or patchy unilateral or bilateral air- distant to the dominant focus of infection probably (Fig C 50-9) space consolidation. Typical appearance of numer- ous, diffuse, poorly defined nodules, some of which are perivascular and centrilobular. Numerous well-defined 1–2-mm nodules diffusely distributed through the right lower lobe. Some nodules appear septal (arrows) or subpleural, whereas others appear to be associated with small feed- ing vessels, suggesting a hematogenous origin. Characteristic findings of bronchiectasis and small nodules and clusters of nodules in the peripheral lung. Septic embolism Bilateral peripheral nodules in varying stages of Cavitary pulmonary nodules presumably result (Fig C 50-11) cavitation. A characteristic appearance is the finding of feeding vessels in association with the peripheral nodules. Note that a number of these appear to be associated with “feeding” vessels (arrows), suggesting a hematogenous origin. With progression, whole distort the underlying parenchyma, sometimes into zones of the lung become lucent, and there is bizarre configurations. With increasing severity, the bronchi course in a predominantly horizontal bronchi may become beaded and resemble a or vertical plane. When vertical, dilated bronchi grouping of dilated bronchi to produce a “cluster appear as thick-walled circular lucencies, almost of grapes” pattern. These septa presumably Fig C 51-1 account for the finding of prominent linear opacifications within Emphysema. Many appear to be aligned ad- areas of markedly low tissue attenuation without clearly defin- jacent to peripheral vessels corresponding to lobular able walls also can be identified within the lung parenchyma. Note that residual lobular ves- Note that the intervening lung parenchyma is normal and that sels can still be identified within the center of some of these the intrapulmonary vessels are well defined and have smooth cysts (curved arrows). In the final stages of disease, lung fibrosis, a similar pattern can be seen in collagen (Fig C 51-4) volume markedly decreases, and a characteristic vascular diseases (especially scleroderma and pattern of honeycombing can be defined. Swyer-James syndrome Diffuse emphysema (severe decreases in density Presumably caused by an acute, possibly viral, (Fig C 51-5) of atelectatic involved lung segments), bron- bronchiolitis acquired in infancy or childhood that chiectasis, but patent central bronchi. Dilated, thick-walled bronchi lie adjacent to peripheral pulmonary artery branches, producing a signet ring appearance (arrows). Dilated Fig C 51-4 bronchi within the atelectatic middle lobe resemble a Idiopathic pulmonary fibrosis. Small, poorly defined variable-sized, thick-walled cysts producing a honeycombed centrilobular opacities seen peripherally represent appearance. Diffuse emphysematous changes throughout both lungs associated with dilated bronchi (arrow). Sections through the central airways (not shown) showed no evidence of a central endobronchial lesion. One study reported a predictable pattern of pro- histiocytosis With increasing severity, these cysts may gression from small nodules, which cavitated to (Fig C 51-6) develop bizarre, branching configurations mim- thick-walled cysts, and then to thin-walled cysts icking bronchiectasis. Lymphangioleiomyomatosis Multiple thin-walled cysts, varying in size from Rare disease of women of childbearing age that is (Fig C 51-7) a few millimeters to 5 cm, that progress to characterized by disordered proliferation within become almost uniformly distributed through- the pulmonary interstitium of benign-appearing out the lungs. Patients typically present with progressive dyspnea or hemoptysis (or both), with either recurrent pneumothoraces (caused by rupture of peripheral dilated air spaces secondary to air trapping from obstructed airways) or chylous effusion (secondary to dilated and obstructed lymphatics). The cysts seen long after all evidence of parenchymal con- may coalesce to more multiseptated, bizarre solidation has disappeared. In time, most of these thick-walled cysts that frequently abut the cysts will regress, although underlying paren- pleural space. Tuberculosis Mostly thick-walled cavities, although thin- Extensive pleural abnormalities are usually also (Fig C 51-9) walled lesions are frequently seen in patients present. Discrete thin- and thick- walled cysts occurring in association with consolidated lung. Coalescence of cysts results in the formation of a few bizarre- shaped cysts (arrows). Metastases Cavitary metastases are rare, occurring in less than (Fig C 51-11) Single or multiple cavitary lesions that often are 5% of cases. They most often result from primary associated with an adjacent feeding pulmonary squamous cell carcinomas (especially from the artery. Less frequent causes are primary adenocarcinomas, especially those arising in the gastrointestinal tract, and primary extrathoracic sarcomas.

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Chassin Preventing Splenic Injury rather than by the tightness of the wrap itself purchase super p-force oral jelly 160mg otc. Splenic trauma is a common but preventable complication of Therefore the fundoplication should be made loose discount 160mg super p-force oral jelly with visa, rather the Nissen operation. Many surgeons hand retractor, there is no reason for any retractor to come use an indwelling esophageal bougie to avoid creating a into contact with the spleen. Regardless of whether the indwelling injury is usually traction on the body of the stomach toward bougie is used, it is possible to judge the tightness of the the patient’s right, which avulses that portion of the splenic wrap by applying Babcock clamps to each side of the gastric capsule attached to the omentum or to the gastrosplenic liga- fundus and tentatively bringing them together in front of the ment. Note where the omentum geon should be able to pass one or two fingers between the may be adherent to the splenic capsule. If necessary, divide wrap and the esophagus without difficulty with an 18 F naso- these attachments under direct vision. Otherwise readjust the fundoplication apply a moist gauze pad over the spleen and avoid lateral so it is loose enough for this maneuver to be accomplished. Traction on the gastroesophageal junction in a caudal direction along the lesser curve of the stomach generally does not cause injury to the spleen. If a portion of the splenic capsule has been avulsed, it can almost always be managed by applying topical hemostatic Another cause of postoperative dysphagia is making the fun- agents followed by 10 min of pressure. For the usual Nissen operation, do can be repaired by suturing with 2-0 chromic catgut (see not wrap more than 2–3 cm of esophagus. Extensive disruption of the spleen at its hilus may may be appropriate when esophageal dysmotility and gastro- necessitate splenectomy. Avoiding Postoperative Dysphagia Avoiding Fundoplication Suture Probably secondary to local edema, transient mild dysphagia Line Disruption is common during the first 2–3 weeks following operation, although some patients have difficulty swallowing for many Polk and others have noted that an important cause of failure months after a hiatus hernia operation. There are several pos- after Nissen fundoplication has been disruption of the plica- sible causes for this dysphagia. For this reason, use 2-0 fundoplication wrap so tight or so wide that permanent dys- sutures. We have used 2-0 Tevdek because it retains its ten- may be sutured so tightly the hiatus impinges on the lumen of sile strength for many years, whereas silk gradually degener- the esophagus and prevents passage of food. It is also important not to pass the suture nasogastric tube in place, after the crural sutures have been into the lumen of the stomach or esophagus. If this error is tied to repair the defect in the hiatus, it should still be possible committed, tying the suture too tight causes strangulation and to insert an index finger without difficulty between the esopha- possibly leakage. There is no virtue in closing tion is to turn in the major fundoplication sutures with a layer the hiatus snugly around the esophagus. Patients who Failure to Bring the Esophagogastric present to the surgeon with reflux esophagitis and who also Junction into the Abdomen complain of dysphagia should undergo preoperative esopha- geal manometry to rule out motility disorders that may require If it is not possible to mobilize the esophagogastric junction surgery in addition to the antireflux procedure or instead of it. Such a situation can generally be suspected prior to opera- tion when the lower esophagus is strictured. In our opinion, The Nissen operation produces a high pressure zone in the these patients require a transthoracic Collis-Nissen opera- lower esophagus by transmitted gastric pressure in the wrap, tion (see Chap. Although it is possible to perform a 19 Transabdominal Nissen Fundoplication 195 Collis-Nissen procedure in the abdomen, it is difficult. In most cases it is not necessary to free the left lobe of the liver; simply elevate the left lobe with a Weinberg retractor to expose the Keeping the Fundoplication from Slipping diaphragmatic hiatus. Various methods have been advocated to keep the fundopli- cation from sliding in a caudal direction, where it constricts Mobilizing the Esophagus and Gastric Fundus the middle of the stomach instead of the esophagus and pro- duces an “hourglass” stomach with partial obstruction. The Make a transverse incision in the peritoneum overlying the most important means of preventing this caudal displace- abdominal esophagus (Fig. Also, catch the wall of the Then divide the peritoneum overlying the left margin of the stomach just below the gastroesophageal junction within the diaphragmatic hiatus. This suture anchors the lower portion of the esophagus using a peanut dissector until most of the the wrap (see Fig. Then pass the index finger gently behind the esophagus and encircle it with a latex drain (Fig. Enclose both the Documentation Basic right and left vagus nerves in the latex drain and divide all the phrenoesophageal attachments behind the esophagus. If • Findings the right (posterior) vagus trunk courses at a distance from • Placement of wrap relative to vagus nerves the esophagus, it is easier to dissect the nerve away from • Closure of hiatus? Some exclude both vagus trunks from the wrap, but we prefer to include them inside the loose Operative Technique wrap. Before the complete circumference of the hiatus can be visualized, it is necessary to divide not only the phreno- Incision esophageal ligaments but also the cephalad portion of the gastrohepatic ligament, which often contains an accessory Elevate the head of the operating table 10–15°. The midline incision beginning at the xiphoid and continue exposure at the conclusion of this maneuver is seen in about 2–3 cm beyond the umbilicus (Fig. Insert a Thompson or Upper Hand retractor to behind the gastric fundus to identify the gastrophrenic liga- elevate the lower portion of the sternum. Reduce the hiatus ment and divide it carefully down to the proximal short gas- tric vessel (Fig. While the assistant is placing traction on the latex drain to draw the esophagus in a caudal direction, pass the right hand to deliver the gastric fundus behind the esophagus (Fig. Apply Babcock clamps to the two points on the stomach where the first fundoplication suture will be inserted and bring these two Babcock clamps together tentatively to assess whether the fundus has been mobilized sufficiently to accomplish the fundoplication without tension.

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