By E. Sulfock. Lee College. 2019.

Towards the mouth of the sinus there may be stratified squamous epithelium lining purchase astelin 10 ml on line. The hairs are usually dead and are found (a) lying loose in the sinus buy astelin 10 ml amex, (b) embedded in the granulation tissue or (c) burried deep in the mature scar tissue at the depth purchase astelin with a mastercard. It is more com­ hairs to enter the open mouths of sudoriferous glands to produce mon in males than females in the ratio of pilonidal sinus. Typically the patient presents with a chronic sinus about the level of the first piece of coccyx. There may be secondary openings on either side of the middle or a little away from the main sinus. Selection of inappropriate operation and inadequate postoperative care are the main causes of recurrence. Hairs growing into the healing wounds is probably the most common cause of recurrence of pilonidal disease. Local cleansing, local antiseptic dressing, administration of broad spectrum antibiotic alongwith rest should be given to control infection. This incision is deepened vertically upto the fascia covering the sacrum and coccyx. If any of the ramifications has been cut, wider incision should be advised to include the whole of the ramifications within the excised mass. If there is any lateral sinus opening, after excision of the mass, a sinus forceps is pushed down the lateral track and widened. If the pilonidal sinus was not infected, one can attempt primary suture of the wound. A big bite should be taken from both the margins and the needle should pass through the fascia covering the floor of the wound. It is for this reason, that the surgeons prefer to leave the wound wide open packed with gauze impregnated with petroleum jelly. Daily cleansing and irrigation of the wound should be done with sitz bath to be followed by dressing and after each dressing, a T-bandage is applied. After excision of the pilonidal sinus some surgeons prefer to close primarily by Z-plasty (Fig. The edges of the skin are now sutured to the margins of the remnant membrane which forms the deep part of the sinuses. Marsupialization, though not used commonly, has been claimed to give good resultboth as a first operation and as a procedure for management of recurrent disease after other operations. After the wound has become free from infection by repeated cleansing, administration of systemic antibiotics and dressing, one should attempt proper excision of the sinus and its ramifications. Abdomen must be carefully palpated to exclude rigidity or tenderness, which indicates intraperitoneal rupture of rectum. With an appropriate speculum the rectum is inspected to note the type and extent of injury. The wound is properly ’dcbridcd’, bleeding vessels arc ligated, rectal injury is closed with fine sutures and a protective colostomy is advisable. When intraperitoneal injury is suspcctcd, the abdomen is opened, the perforation is closed by sutures. A left iliac protective colostomy is performed through separate grid-iron incision on the left iliac fossa. It may be associated with similar disease of the colon when the condition is called proctocolitis. This is an intense desire to defaecate, but the amount of faeces passed is small; instead blood, mucus and even pus are passed. Sigmoidoscopy will reveal red oedematous inflamed mucosa with small ulcers of the rectum. Sometime amoebic granuloma may present as a short mass in the rectosigmoid junction which may simulate a carcinoma. But hypertrophic type of tuberculous proctitis may be seen in association with tuberculous peritonitis or tuberculous salpingitis. Spirochaeta vincenti and basillus fusiformis may cause infection from rectosigmoid junction to produce strawberry lesion. But here I shall discuss mainly the surgical conditions which can give rise to this symptom. The surgical causes are : (i) Prolapsing haemorrhoid; (ii) Anal fissure; (iii) Fistula-in-ano; (iv) Ectropion; (v) Condyloma acuminata; (vi) Colloid carcinoma of the rectum ; (vii) Carcinoma of the anal canal; (viii) Basal cell carcinoma of the anal canal; (ix) Malignant melanoma of the anal canal. Other causes are :— (i) Dermatitis; (ii) Diabetes mellitus; (iii) Jaundice; (iv) Diarrhoea; (v) Leukorrhea; (vi) Parasitic causes (thread worms particularly in children); (vii) Monilial infection; (viii) Allergy; (ix) Psychoneurosis; (x) Idiopathic which constitutes a large group. Idiopathic pruritus ani requires hygienic measures to keep anus and perianal region clean and dry. Straping the buttocks apart play a considerable role in idiopathic pruritus ani to keep the perianal region dry. The extent of the disease varies to a few small warts to an extensive mass occluding the anal canal. Multiple biopsies and histological examination (these are papillomata with central core of connective tissue covered with epithelium) should be done to exclude associated squamous cell carcinoma. Immunotherapy using autogenous wart-tissue vaccine may be used in conjunction with excision to reduce recurrent rate. Close follow-up is performed to exclude recurrence and to detect secondaries in the inguinal nodes which will require block dissection with removal of glands. If the inguinal nodes become involved radical dissection of the groin should be carried out alongwith the actual resection of the tumour. Irradiation therapy is also started from the same day at 1000 rads per week for three weeks. Almost all the tumours arise from the epidermoid lining of the anal canal adjacent to the dentate line. Majority of the tumours are however lightly pigmented or non-pigmented, in which cases these are often misdiagnosed as epidermoid carcinoma or condyloma acuminata. When pigmented this tumour appears as bluish-black soft mass which may be confused with thrombotic pile. Inguinal nodes may not be involved, instead lymphatic spread may occur to inferior mesenteric nodes through rectal lymphatics. Haematogenous spread to the liver and lungs are relatively early and usually accounts for most of the deaths. Malignant melanoma is radioresistant and does not respond well to chemotherapy and immunotherapy. About 10 ml blood loss per day is necessary to have stool occult blood test positive. The loss of blood requires 2 units or more of blood for transfusion to bring about haemodynamic stability. Relation of bleeding to defaecation must be enquired — whether during or independent of the act. When bleeding occurs at the time of passing hard stool and the amount is not much, acute fissure-in-ano is the most probable diagnosis. A streak of fresh blood may be frequently noticed on the side of the stool in both acute and chronic fissure-in-ano.

The outline of the calyces is destroyed and the resulting distortion is seen in X-ray film buy 10 ml astelin with visa, which is an important feature of diagnosis buy astelin 10 ml low cost. There is diffuse or spoty inflammation characterised by oedema and small haemorrhagic areas buy astelin 10 ml mastercard. 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. If there is ulceration of central portion of the papilla cavities may be detected. But this operation should be undertaken with caution as the other kidney is liable to be involved later on. The fibrofatty tissue around the kidney becomes more fibrosed and adherent due to inflammatory process.

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If the gallbladder is too large to pass through the umbilical incision purchase astelin 10 ml without prescription, the incision can be enlarged somewhat by inserting a large hemostat and stretching the width of the incision 10 ml astelin. Alternatively buy discount astelin 10 ml, the inci- sion may be lengthened by several millimeters in both direc- tions using the scalpel until the gallbladder can be removed. Sometimes an endoscopic retrieval bag is useful, particularly if the gallbladder is inflamed. Remember, even with disposable trocars that have plastic shields, forceful collision of the shielded trocar with the vena cava may result in perforation of this vessel. Bleeding from the great vessels constitutes the main cause of the rare fatality that follows laparoscopic cholecystectomy. Carefully observe the withdrawal of each cannula to ascertain the absence of bleeding in each case. Finally, permit the escape of carbon dioxide from the abdominal cavity and remove the final cannula. Insert sutures of heavy Vicryl in the two 10-mm incisions in the midline of the abdomen. Ambulate the If the laparoscope has been transferred to the epigastric patient as soon as he or she awakens. A regular diet may be port, return it to the umbilical cannula and make a ordered unless the patient is nauseated. If there are any signs of retroperitoneal may resume full activity by the end of 1 week. A cephalad direction as though it were the cystic duct with retroperitoneal hematoma noted during laparoscopy requires transection of the proximal hepatic ductal system with or open exploration for great vessel injury. Bowel injury can result from introducing the Veress nee- Significant leakage of bile into the operative field is a dan- dle or a trocar, especially if the trocar is passed through ger sign that should not be ignored. Careful inspection of the abdomen by lapa- of the surgical field often contributes to these errors and to roscopy after inserting the initial trocar and again before ter- significant bleeding. With proper surgical dissection, it should be obvious that the pres- ence of this duct indicates that the operative strategy is wrong Bile Duct Damage: Excision of Common and requires an immediate course correction. Scott-Conner converting to open cholecystectomy whenever there is any doubt concerning the safety of the laparoscopic cholecystec- tomy. A satisfactory intraoperative cholangiogram must show intact bile ducts from the right and left hepatic ducts down to the duodenum. When there is doubt concerning which duct to use for the cholangiogram, a cholecystochol- angiogram may be obtained by injecting 30–40 ml of con- trast material directly into the gallbladder. Bile Leak Leakage of bile into the right upper quadrant following lapa- roscopic cholecystectomy does not necessarily indicate an injury to the bile duct. It may simply mean that the occluding clips have slipped off the cystic duct or that a minor acces- sory bile duct is leaking. Symptoms generally develop a few days after laparoscopic cholecystectomy and consist of gen- eralized abdominal discomfort, anorexia, fatigue, and some- times jaundice. In this case Intraoperative Hemorrhage from Cystic Artery the patient will have a total biliary fistula into the peritoneal cavity. It is generally a minor complication during open proximal portion of the cystic duct also encompasses the cholecystectomy because grasping the hepatic artery between right hepatic duct. Fibrosis in Calot’s triangle may contribute two fingers in the foramen of Winslow (Pringle maneuver) to this injury by placing the right hepatic duct in close prox- ensures prompt if temporary control of bleeding. This injury may be avoided if the roscopic cholecystectomy, however, losing 30–40 ml of surgeon properly dissects the gallbladder infundibulum and blood may be serious because the blood obscures visibility cystic duct from above down prior to applying the clips. Finally, late strictures (presumably due to thermal dam- Frequently it is possible to control cystic artery bleeding age) have been reported. It is not from the common hepatic duct, directing the dissection from worth spending much time on occluding this bleeder laparo- the distal gallbladder downward toward the cystic duct rather scopically because making a subcostal incision affords an than the reverse, using electrocautery with caution, applying opportunity to localize and control the bleeder quickly with routine cholangiography early in the operation, and no risk. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a meta- analysis of randomized clinical trials. Chassin† Indications Operative Strategy Cholecystostomy may be performed in patients suffering When Is Cholecystostomy Inadequate? When performing cholecystos- tomy, one must be alert not to overlook this disease of the bile duct. Contraindication Gangrene of the gallbladder is another complication of acute cholecystitis, for which cholecystostomy is an Patients with acute cholangitis owing to common bile duct inadequate operation. It is easy to over- look a patch of necrosis when operating through a small Preoperative Preparation incision under local anesthesia. When a necrotic area is found in the gallbladder, it is preferable to perform a com- Appropriate antibiotics plete cholecystectomy; if this operation is impossible for technical reasons, a partial cholecystectomy around a catheter with removal of the gangrenous patch can be Pitfalls and Danger Points done (Fig. This com- plication can generally be avoided by using a large catheter and suturing the gallbladder around the catheter (Fig. It is important also to suture the fundus of the gallbladder to the peritoneum around the exit wound of the drainage cath- eter (Fig. Documentation Basics • Findings and reason for procedure (rather than cholecystectomy) • Type and size of catheter Operative Technique Incision Fig. Once Emptying the Gallbladder this plane is entered, the omentum can generally be freed from the gallbladder wall by gentle blunt dissection. After ascertaining that there is no perforation of the Continuing in this plane, inspect the gallbladder and its gallbladder or any patch of gangrene, empty the gallbladder ampulla. Measure the daily output of bile and replace with an appro- Enlarge the stab wound in the gallbladder. Obtain a cholangiogram before removing the der ampulla manually to milk stones up toward the fundus. After flushing the gallbladder with saline, insert a 20 F straight or Pezzar catheter 3–4 cm into the gallbladder. If the gallbladder wall is unusually thick, it may be necessary to Bile peritonitis close the gallbladder around the catheter with interrupted Subhepatic, subphrenic, or intrahepatic abscess Lembert sutures. Septicemia If the patient is in satisfactory condition, attempt cholan- Patients with acute cholecystitis generally respond giography through the gallbladder catheter. Make a stab wound and insert two closed suction catheters: one in the vicinity of the cholecystostomy and one Further Reading in the right renal fossa. Emergency cholecystos- tomy and subsequent cholecystectomy for acute gallstone cholecys- titis in the elderly. Effective use of percutaneous cholecystostomy in high-risk surgical patients: tech- Connect the cholecystostomy catheter to a sterile plastic col- niques, tube management, and results. Percutaneous cholecystostomy – a safe option in the management of acute biliary Continue antibiotic treatment for the next 7–10 days. Alternative methods for management of the on the gallbladder bile, use antibiotics that are effective complicated gallbladder. We use mance of advanced biliary tract surgery and must be either a third- or fourth-generation cephalosporin or a thoroughly understood. Sepsis The principles delineated here apply in those situations as Failing to remove all of the biliary calculi well.

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Particularly in the latter case the use of antibiotics active against Ureaplasma and/or Corynebacterium (e buy astelin from india. Another effective approach to complement existing treatment for infection stones involves the use of derivatives of hydroxamic acid which inhibit bacterial urease discount astelin 10 ml overnight delivery. These may be used in low quantities or with milk or cream generic astelin 10 ml overnight delivery, in which case the oxalates are precipitated as insoluble calcium salts in the intestine and are not absorbed. Administration of magnesium oxide 150 mg 3 times a day may control recurrence of oxalate stones as magnesium combines with oxalate to form a more soluble complex. Sodium or potassium acid phosphate 4 to 6 g daily is effective (potassium salts are preferable). The combined use of thiazides and allopurinol seems to be more rational but the toxicity of the agents are enhanced a little bit. Carbohydrates and fats may be increased in the diet alongwith low sulphur content proteins. This prepa­ ration should be given in the dose of 30 mg/kg daily in divided doses. Sometimes stone fragments occlude the ureteral cath­ eters and cause acute obstruction. Preoperative urine cultures are used to guide antibiotic choice but prophylaxis should be provided in any case with intravenous gentamycin given immediately prior to treatment and oral antibiotics (Norfloxacin, Co-amoxiclav) continued postoperatively. With the patient in the prone/oblique position, access to the pelvicalyceal system is secured by a nephrostomy tract directed through a suitably placed calyx. This tract is then dilated to allow the passage of instruments used for stone removal. A nephrostogram 48 hours postoperatively confirms the absence of extravasation and free passage of contrast to the bladder allowing the removal of the nephrostomy tube. If bleeding continues, the drainage tube is clamped allowing the pelvicalyceal system to tamponade the bleeding vessel. If bleeding still continues or the patient is haemodynamically unstable, open surgery and exploration may be required. It utilises the generation of a shock wave by high tension dis­ charge across the conducting elements of a co-axial electrode. The emitted light is absorbed by the stone and a gaseous plasma forms on its surface. Plasma absorbs more light and expands generating a shock wave which fragments the stone. These situations are : (i) Large stones — bigger than 3 cm; (ii) staghom calculus; (iii) Hard stones e. The stone in the kidney is fragmented by repeated shock waves which are focussed towards the kidney stone. The fragments are made so small that they are automatically passed through the urine. Occasionally these may cause ureteric colic and even obstruction in the ureter which may need a temporary nephrostomy. The urinary calculus is bombarded with shock waves of sufficient energy so that it disintegrates into frag­ ments. In the original Domier machine the shock waves were generated by an electrical discharge placed at one focus of an ellipsoid mirror. The patient is so positioned under radiographic control and by placing a second mirror in such a position that its focus corresponds to the position of the calculus and the full force of the shock waves are subjected to the calculus. In present days water bath is not used and the fluid is confined to the path of shock waves. The shocks may be generated by the discharge of an array of pietzoelectric cells and they may be aimed by ultrasonography. All patients are routinely covered with some antibiotic parenterally starting from the previous night and continuing till the time of discharge. The second generation lithotriptor — ‘The Lithostar’ has many advantages over the previous Domier instrument. These are (i) Stone localisation is done by biplaner fluoroscopy and not by ultrasound. Stones in the renal pelvis and calyces are in ideal location for this treatment as these are surrounded by fluid. However, clinically significant haematuria or subcapsular/perirenal haematoma is rare. Lung tissue is sensitive to shock waves and needs to be out of the blast path or shielded prior to treatment. A self retaining stent may be placed in the ureter so that the fragments of stone can pass without obstruction. The only excep­ tions are pregnant women, abdominal aortic aneurysms and uncorrectable coagulation disorders. There seems to be no long term effects on renal function or glomerular filtration rate. Third generation machines, with improvements in shock wave energy range and integration of the shock wave source and imaging are now available, but the main advantages seem to be economic and in ease of use. Following dilata­ tion the bladder is emptied and the ureteroscope is passed through the ureteric orifice guided by the presence of a previously placed guidewire. However flexible ureteroscopy allows better access to the proximal ureter and kidney where rigid instruments are unable to negotiate. Later stricture formation is also an uncommon complication (less than 5%) and can be managed by balloon dilatation. Obstruction may be required to be relieved with persistent symptoms and infections. The main complication is ureteric obstruction secondary to the passage of stone frag­ ments. If staghom calculi are asymptomatic and the general health of the patient is poor with a good second kidney, conservative treatment can be adopted unless there is sepsis, pain or loss of function. Removal of stone is indicated when it is presumed that it cannot be naturally eliminated and may cause obstruction and progressive renal damage. The different operations that may be performed in cases of renal calculus are — (a) Pyelolithotomy, i. This may be required when a stone in the calyx is so much impacted that it cannot be removed through the pyelotomy incision, so a second incision through the renal parenchyma may be necessary. Staghom calculus is often silent and better be left alone if the kidney function has already become zero. When the function of the kidney is still good, an attempt may be made to remove this calculus which is very difficult and may require Gigli saw to break the calculus and remove it through pyelo- and nephrolithotomy incisions. The kidney is well mobilised and drawn towards the wound margin, so that its posterior surface is well exposed. The kidney is grasped in the left hand, so that the tips of the index and middle fingers lie beneath the renal pelvis and the thumb above it which prevents the stone from slipping into one of the calyces. The area is surrounded widi gauze packs and an incision is made on the posterior wall of the pelvis directly over the stone in the long axis of the renal pelvis. The incision should not be extended to the pelvi-ureteric junction lest a stricture may cause subsequent obstruction.

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