General Surgery - Science topic

Hello Daiwik Gandra

I would agree with Dr Osvaldo Valdés Dupeyrón to start by looking fpor opportunities at yur own organisation/university/hospital. Maybe you've done that already (?) - helpful?

the important thing is to believe in it

Greetings Qamar,

Thank you for your question.

General Surgery is a broad specialty with a plethora of sub-specialties and sub-subspecialties underneath it.

To find a valid meta-analysis idea, I would personally advise you to narrow down your scope to a subspecialty of your interest. Try subscribing to journals & updates falling under this particular specialty and read - as frequently as possible - the most recent publications. Additionally, you may use websites such as "Medscape" to remain up-to-date with the latest advancements in your specialty of choice. This approach may help you identify possible gaps in literature which may be addressed appropriately by conducting a meta-analysis.

When validating your meta-analytic idea, try making sure it follows the FINER criteria [Although ethics might be overlooked when conducting secondary research as the primary studies you're trying to pool have already had their ethical approval].

Hopefully this answers your question!

Best Regards,

Mohamed Ibrahim

= I treated a 7 yr old boy whose injury resulted from a .30 Cal deformed solid point which ricocheted from a granite wall. It penetrated his khaki trouser, scrotal skin and dartos muscle and located itself in the right testicular sac.

= Another case of a .22 Cal. solid point bullet ricochet on lagoon water fired from 500 yards on a 9 yr old. It penetrated her dress, anterior midline abdominal wall and was found sitting on top of her omentum,

= Another case was a .22 Cal ricocheted solid point bullet through the right flank of a 17 year old to lodge in his liver, right lobe. He developed and died of gas gangrene.

= Dr. Ordog, do you have studies on injuries of spent, ricocheted bullets?

Did this get published? Am I to understand that the wound trajectory is almost vertical? If so, we may have another "Space Bullet" which is a low velocity bullet and can travel alone the path of least resistance, thus dissecting a path along tissue planes, and may miss major structures as it does not follow a straight line. This should be visualized well on a 3-D CT scan. You can read the full-text on "Spent Bullets" here on RG; which explains the research on a large series of the first published cases. Thank you for your support, Gary Ordog, MD

La proteína C reactiva (PCR) es una proteína producida por el hígado que aumenta en respuesta de la inflamación, es decir, cuando existe alguna inflamación en el cuerpo, y no es específica. Antes de la cirugía tener una PCR significa que existe un proceso inflamatorio y como no es específico, se debe investigar la razón, y ayuda mucho la clínica que presente el paciente, es decir, una adecuada Historia Clínica y las investigaciones en relación con la sintomatología deben confirmar la hipótesis planteada. Los niveles muy altos puede significar la existencia de una infección grave u otro trastorno.

Hello Issawi, PDT depends on how and where the cancer is too. If the patiente has a big tumor, probably the doctor will operate and PDT can be used as a complementary tecnique, but if cancer is on surface and not so deeper, PDT can be used as an alternative method.

I hope it has helped you.

In addition to the earlier answers, recent studies suggest very early appendectomy may be associated with autoimmune disease development, including inflammatory bowel disease (IBD), rheumatoid arthritis and lupus. This is probably due to an exaggerated immune response, one that has not been adequately primed for appropriate reaction due to the absent appendix - a seat of lymphoid tissue. The 'hygiene hypothesis' applied to IBD may also be applied to this phenomenon. Further, this indicates a possible role of the appendix in "post-natal" immune tolerance, akin to the role of the thymus in-utero.

The other theory put-forth recently is the protective benefit of appendectomy in preventing neurodegenerative disease. The immune response initiated by the lymphoid tissue in the appendix each time they are stimulated result in free radicals, reactive oxygen species and other metabolic byproducts that have been implicated in the pathogenesis of neurodegenerative diseases including Parkinson's. The model of hepatic encephalopathy is a good comparison.

According to my experience,there is no difference but the patient may be more comfortable when it is reduced

Yes it is still used in advanced HCC provided that preserved liver fiumctio and performance status of the patient.

it also can be used as a bridge for OLT

All my cases are done as Day case and No follow ups. If I started using drains, my managers will kill me. Welcome to NHS

Patients with cardiovascular disease and or cardiovascular risk factor submitted to dental implant surgery require monitoring by multidisciplinary team.

During osseointegration some factors that increase implant failure rate include health problems that affect the bone healing process such as uncontrolled diabetes (cardiovascular risk factor).

After osseointegration, clinical and radiographic follow up of these patients with implants should include evaluations of pain, mobility, bone crest loss, probing depth and peri-implantitis. Also, genetic factors such as polymorphisms in interleukin-1 genes can be used to monitor the status of the implant site and minimize the chances of failure.

I don't remember that I read or do vesicotomy in transverse direction, we usually open the bladder in the Medline vertically, because it is always away from ureters, easily and safely extended, so you can bifid the bladder without risk, though if the bladder is opened by trauma in a transverse direction, it can be sutured in the same direction with the same healing rate.

Study is underway! 120 oesophagectomy patients have been entered in to the online database in the 5 weeks of opening. We are accepting new centre registrations until July 2018 - so if your centre wants to be involved please get in touch. All the best, Ewen.

what about the terminals of the neurons, how we shall guarantee the right nerve reaches the right end.

actually we adopted the saying: no news, good news.

1. The CEOS found that infantile esotropia persists in 98% of infants who have large-magnitude (≥20° or 40 PD) constant esotropia with onset after 10 weeks of age and refractive error ≤3.00 diopters. Thus these patients will benefit from early surgery.

2. Go through doi:  10.3129/i08-115 , Wong et al. The protocol attached is from this study.

3. The ELISS study (early vs. late infantile strabismus surgery study) also reported that children operated early had better gross stereopsis at age six as compared to children operated late .

4. Rule out an unstable angle of deviation and a paralytic component, then do early surgery for chances of stereopsis. This study also confirms the same.

Hirabe H, Mori Y, Dogru M, et al

Early surgery for infantile esotropia

British Journal of Ophthalmology 2000;84:536-538.

It is important your teeth are moved into the correct position before surgery so that they will meet properly after surgery. Therefore, as the teeth are lined up before the surgery, your bite may actually look worse. This is done purposely to give the best result and provide maximum improvement in your bite and facial/dental appearance.You will need to wear a fi xed brace for approximately 24 months before surgery and for 6 to 9 months afterwards. However this varies from patient to patient and your orthodontist should be able to advise you on this. Fixed braces are used as they allow the most accurate positioning of your teeth prior to surgery. During your operation, they also help the surgeon position your jaws correctly. The brace will consist of metal brackets, it is not possible to use tooth coloured braces or invisible aligners.The operation will be done from inside your mouth. If there is a possibility of scars on your face, this will be discussed with you before starting treatment. Some operations involve surgery on both your top and bottom jaw. Others involve only one jaw. Operations to reposition the jaw bones are called “osteotomies”. Your surgeon will tell you exactly what type of osteotomy you need. • All operations carry risk related to the general anaesthetic. This risk is rare, but potentially very serious. • It is common for you to have numbness or tingling of the lower lip, chin and tongue after an operation on the lower jaw. This is usually temporary and may last for a number of weeks or months. It may feel a bit like a dental injection that has not worn off. The numbness will not affect the appearance or movement of your lower lip or tongue, only the feeling in it. • There is a risk that you may experience permanent nerve damage. This can range from mild tingling through to a feeling of complete numbness. Your surgeon will discuss this with you in more detail. • Numbness of your upper lip, cheek, nose, palate and gums can occur after an operation on the upper jaw. Again, this usually resolves over a number of weeks. • Some bleeding is unavoidable during surgery but it is rare that patients need to be given extra blood during the operation. • It is usual to feel tired and weak for two to six weeks after surgery as your body makes up for any blood loss that has occurred. Patients who are having upper jaw surgery can fi nd their nose and sinuses feel blocked and can often taste blood from the operation for several days afterwards. • A small amount of bleeding or oozing after your operation is normal and you will have blood-stained saliva initially. This usually stops after 24 to 48 hours. If the bleeding is excessive, you will have to go back to theatre for the bleeding point to be located and sealed, however this is extremely rare. • There is about a fi ve per cent chance that at the end you will feel that the fi nal result was not worth all the trouble of the treatment. The reasons that patients feel like this are often complex but include their experience of the treatment process and their expectations of what the treatment will change in their life. • There are also risks associated with the braces and your orthodontist should have already provided you with some of the following information leafl ets, however if you have not been given these leafl ets, please ask your orthodontist when you see them next: i) Fixed braces ii) Risks of treatment iii) Retainers. The body’s usual response to surgery is one of mild depression. This seems particularly true of facial surgery. Most patients feel a bit low for a couple of weeks after the surgery. You might feel like you want to stay in bed, or at least at home, for a little while. You will need someone to look after you, both physically and emotionally, during this time.Patients who have signifi cant changes to their facial appearance can lose that comforting feeling of seeing a familiar face when they look in the mirror. This can be worrying until you get used to your new appearance. It takes time and patience.While patients often do experience psychological benefi ts as a result of the treatment, we cannot guarantee that this will happen. As a result of this potential change, we have a liaison psychiatrist on our team. You can meet them to: • clarify your current concerns • work out what you are hoping to achieve through treatment • weigh up the possible risks and benefi ts of the proposed treatment They can also help you to make the most of the physical changes that result from treatment. Some patients are extremely sensitive about their appearance and fi nd it diffi cult to talk to professionals about what they want. The liaison psychiatrist can support you so that your views are heard and considered We know that patients who have the support of family and friends are more likely to feel satisfi ed with the fi nal outcome. We suggest that you discuss decisions about your treatment with those close to you. Our liaison psychiatrist is happy to see patients with their friends or family. For patients who hope that they will feel more confi dent etc. after treatment, they may fi nd that this happens quickly after surgery, or gradually over a period of months, and occasionally not at all. If you do not experience the psychological or social benefi ts that you hoped for, you can see our liaison psychiatrist again to explore other ways of improving the situation.

A well taken answer but may not prove effective in younger individuals always .Serum TSH levels are to be estimated before as well as during dose titration.

I doubt that you're going to find many, if any, controlled studies on this topic. Pregnancy is an exclusion criteria for most studies. You may find case reports but as I say this I have not been able to find case reports on dental implant treatment during pregnancy.

My recommendation to a patient would be that, since implants are an elective procedure, if they discovered that they were pregnant after an implant was placed I would still suggest that they wait until they had delivered. the reason for this is just precautionary. As I said I cannot find any evidence suggesting a high risk but I can't see any obvious reason for taking even a low risk.

I searched my database, which includes about 50,000 articles and the only hits that came up were describing pregnancy as an exclusion criteria for the research protocols that were presented. I can't imagine someone designing a study to specifically test implants in pregnant women, I don't see the logic in doing that. I don't know how they would get an IRB approval.

If you go to Medline you will find a few reports discussing pyogenic granulomas, just what you might expect.

The built environment should be appropriate to allow cleaning and disinfection e.g. Impervious and intact surfaces for floors , walls , coverings on the mattresses, that allow ease of cleaning and prevent ingress. The principles of environmental decontamention after any patient is based on cleaning then disinfection if needed Including after spillage of blood or body fluids or patient known to be infected e.g. MRSA! CPE etc . All medical devices which includes the theatre table and any device used for treatment and therapy must be provided with manufacturer instructions for decontamination which must include method, product for risk levels of contamination low, medium, high risk!. In the UK, decontamination is guided by medical devices directives and Health technical memorandum's on decon. There are also national standards for environmental cleanliness and infection control in the built environment guidance to refer to. Therefore plastic covering for floor and table is not needed as the environment should be appropriate to prevent infection and allow decontaminationalongside management and decontamination of equipment and medical devices.

I would suggest the work of Dr. Kukak Oktay who has published extensively on this issue “or add. Excuse the typo which I cannot delete.

Lid retraction following glaucoma filtering surgery: a case series and literature review.

Saldana M, Gupta D, Khandwala M, Beigi B. Orbit. 2009; 28(6):363-7.

The exact pathogenesis of lid retraction in patients with glaucoma filltering blebs remains unknown. Mechanical and chemical causes have been suggested.

thamkyou

What you call intermediate surgeries encompass a vast majority of procedures, some of them being with a higher risk of unexpected hemorrhages. So, In my practice, pre-op Hb for similar operations is mandatory in order to avoid troubles when unexpected bleeding occurs. Moreover, we have in the algorityms and protocols of our health care system such a requirement for lab minimum parameters for different grade of surgeries. It should be fulfilled.

For fasting blood glucose 8- 10 hrs are suitable. For Lipid Profile you need 12 - 14 hrs are recommended. Its important to clarify that Total cholesterol does not need fasting, In addition, you can calculate LDL-C by Friedewald Equation ( [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/2.2) where all concentrations are given in mmol/L (note that if calculated using all concentrations in mg/dL then the equation is [LDL-chol] = [Total chol] - [HDL-chol] - ([TG]/5))

The Friedewald equation should not be used under the following circumstances: . fasting, is mandatory for teiglycerides analysis.

• when chylomicrons are present
• when plasma triglyceride concentration. exceeds 400 mg/dL (4.52 mmol/L)
• in patients with dysbetalipoproteinemia

Thank you I will try that!

Procedures left for the cardiac surgeon in the next decade:

1-CABG for small CAD , cardiogenic shock

2-stuck mechanical valves ? thrombus or nidus

3- prosthetic valve endocarditis

4- ascending with or without arch dissection

5- cardiac trauma

6- cardiac tumors

Its okay Montassar

Things like that happens!

By the way, the research shows that Cavity shaving halved the rates rates of positive margins and re-excision. Hope one day cavity shaving will become a standard procedure.

I think surgery may be helpful if the tumor cells are localized at a distinct anatomical site.

Wait until she is no remission with psoriasi. There is no need to performe abdominoplasty under MTX. Better wait and push the surgery for a while. Otherwise pause mtx two weeks before and after.

Considering the histological studies, usually 3 to 4mm is enough

Please read the article that has the answer to your question

Hyperlactatemia can occur in the setting of adequate tissue perfusion, intact buffering systems, and adequate tissue oxygenation.

Lactic acidosis, on the other hand, is associated with major metabolic dysregulation, tissue hypoperfusion, the effects of certain drugs or toxins, and congenital abnormalities in carbohydrate metabolism. It also occurs as a result on markedly increased transient metabolic demand (eg, postseizure lactic acidosis). Congenital lactic acidosis is secondary to inborn errors of metabolism, such as defects in gluconeogenesis, pyruvate dehydrogenase, the tricarboxylic acid cycle, or the respiratory chain. These disorders generally reflect situations in which the disposal of pyruvate by biosynthetic or oxidative routes is impaired.

Lactic acidosis may not necessarily produce acidemia in a patient. The development of lactic acidosis depends on the magnitude of hyperlactatemia, the buffering capacity of the body, and the coexistence of other conditions that produce tachypnea and alkalosis (eg, liver disease, sepsis). Thus, hyperlactatemia or lactic acidosis may be associated with acidemia, a normal pH, or alkalemia.

What about the prophylactic use of tranexamic acid? You also should consider the use of topical hemosatats (e.g. Floseal).

See also:

Durga P et al. Evaluation of the Efficacy of Tranexamic Acid on the Surgical Field in Primary Cleft Palate Surgery on Children-A Prospective, Randomized Clinical Study. Cleft Palate Craniofac J. 2015 Sep;52(5):e183-7. 

If you are talking about lymphatic sac of the vestibulocochlear system then it is not possible because of the limitations imposed by the current size of operative endoscopes.

Yes indeed. You must do a complete upper endoscopy with several biopsies from the esophagus and the stomach and also to see the status of H. Pylori infection

It is of course true that cardiac catheterization carries a negligible risk of bacteremia but with PCI bacteremia occurs frequently (in approximately 30% of cases); however, clinical sequelae occur rarely in such cases. PCI has a greater bacteremic potential, probably because of the length of the procedure and the repeated insertion of interventional devices into the vascular system . Infective mycotic aneurysm presenting as transient acute coronary occlusion and infectious pericarditis [Badshah A, Younas F, Janjua MSouth Med J. 2009 Jun; 102(6):640-2.]

I completely agree!

Alan Coulson

dear dr cordos

may you explain in detail please

The patient's condition and the patient's physical capacity.

Superbugs, also known as drug-resistant bacterial infections, can cause infections that are hard to treat.  According to the CDC, health care workers (including surgeons) should keep their hands clean to prevent the spread of MDR bacteria. In fact, surgeons have a greater access to open tissues and therefore high infection rates.

In response to your title question, I would say "Clinically"!! Treat the patient, not the signs! 

Sir , follow the classical approach, wait for 4 weeks atleast before considering ERCP

In the last twenty years in our emergency  hospital  we have performed only less than five DLP, I think. This extremely low number is explained because we have routinely performing FAST in the emergency department to all patients admitted with blunt  or open abdominal trauma. In some cases, when the diagnosis was uncertain we performed abdominal puncture under US guidance. Hemodinamic stable patients, in the last years, were referred to the CT scan for a thoroughly abdominal exam.

The simplest and fastest method to assess "low resistance" to any stress is the CBC.

Specifically when anypatient is under severe stress the White Blood Cell PMN)

Sorry do you mean subcarinal? 

Could this patient have had embolism and the culprit being cerebral rather than cardiopulmonary? The fact of good blood gases and no tamponade suggests this.

it would be interesting what the autopsy would reveal.

We do not use local antibiotics for prevention of SSI and I agree with the colleagues above. Recently, I read a RCT on gentamycin-containing collagen sponges in THA. No benefit was found. Perhaps, you may extrapolate to have an answer to your question. S. below: 

Effectiveness of gentamicin-containing collagen sponges for prevention of surgical site infection after hip arthroplasty: a multicenter randomized trial

Clin Infect Dis. 2015 Jun 15;60(12):1752-9

Westberg M. et al.

739 patients with a displaced femoral neck fracture to be treated with hemiarthroplasty were randomized into two groups, which received either routine intravenous antibiotic prophylaxis alone or intravenous antibiotic prophylaxis and local application of 2 gentamicin-containing collagen sponges into the hip joint. The purpose of the study was to determine the efficacy of these sponges in reducing surgical site infections (SSIs) within 30 days of surgery, in addition to routine antibiotic prophylaxis. The results indicated that gentamicin-collagen sponges did not provide any added benefit in terms of SSI incidence.

Level of Evidence: 2  (RCT) , Study Type: Therapy

Whilst the arguments for removing a normal-looking appendix are understandable, this undermines the logic for a diagnostic laparotomy. It must be explained to the patient that the appendix will be removed, unless other significant pathology is found, regardless of its appearance. Many patients may not wish to accept this logic. 

Furthermore the reported high risk of recurrence still does not mandate surgery. The same argument used to be made for diverticulitis, but now indications for sigmoid colectomy are very much more stringent. The difference, of course, lies in the relative simplicity (and lack of complication) of appendicectomy. No studies have been made on the application, however, of Sod's Law! If appendicitis recurs (but inflammation remains clinically localized, and not complicated by bacteraemia, constitutional upset or other factors are at play, a second, or even third course of antibiotics may still be reasonable.

It is important to involve the patient in this discussion, because it is ultimately him or her that will carry the consequences. The drawback of this approach is that social reasons for or against intervention may then predominate. 

I remember well, as an SHO in UK, how a well-to-do patient persuaded the consultant to perform surgery, which was strictly not necessary, because he had an important up-coming business job interview in Cape Town. He had been on a boat holiday in the Mediterranean and no-one noted that in fact he had a tinge of jaundice. He died of the post-operative consequences of liver failure induced by halothane used for his GA.

For RIF pain without obvious clinical and laboratory signs of inflammation, of course, antibiotics are probably not indicated, and a wait-and-see policy entirely appropriate. There is rarely need for an instant confirmatory diagnosis, as has been proven by institutions which have abandoned appendicectomy operations at night.

All this said, it is dangerous to be fixed in a belief. Learned opinion in 1900 was that 5 days should elapse to allow inflammation to settle before intervening to perform an appendicectomy. Sir Frederick Treves had become the authority on the subject, having performed over 2000 appendicectomies by 1902. In that year, Kind Edward VII fell ill and developed an appendicular abscess; two days before his scheduled coronation, Treves insisted on drainage, despite  the fact that many guests had already arrived. The big event had to be postponed several weeks. Treves had learnt how conservative treatment of his daughter two years earlier, when she was suffering flagrant appendicitis, led to her death. He did not want the guests to be attending a royal funeral... 

In my opinion, the  resurgence of the conservative treatment of acute appendicitis  - which used to be the state of the art 200 yrs ago- is  a matter where evidence and experience clash.  Common sense dictates a surgical treatment for most  cases of acute appendicitis, whatever scientific evidence there is  to support a nonoperative treatment. 

Which healthy young wants to  take antibiotics and wait for a complication to happen  or happen not and moreover risk a relapse  just to avoid a laparoscopic appendectomy which will  make him leave the hospital, cured,  one day later ?   No patient with an ounce of common sense. Let  us not rewrite history.

 We operate on all cases of acute appendictits if there is no appendicular mass or another specific reason to choose for a non-operative treatment. 

This is very interesting topic as you are rightfully trying to expand the current discussion of a possible paradigm change for the disease of appendicitis to children. My main struggle with the results of recent, well conducted RCTs in adults is that it is not at all clear to me how we should be able to expand their findings to the general, population of patients presenting with appendicitis. As Dimitri pointed out, we would first have to establish if they have an appendicolith or not. This is not at all trivial, as CTs whilst displaying highest sensitivities for appendicitis, are not a standard diagnostic tool in most countries. Furthermore, there is a false-negative rate diagnostic rate even when integrating all modalities that requires consideration as well. Then there are other factors that require consideration, which in an RCT-setting are usually exclusion criteria: comorbidities, immunosuppression, previous surgeries, and and and. Then also, in a regular every day setting, you would want to provide the patient with a treatment and discharge them, but with appendicitis and conservative therapy, we tend to keep them in extremely close follow-up, which might even prove less cost-effective than uncomplicated surgery with discharge within 24 hours. Finally, one must never forget, that RCTs represent highly selected patient populations and therefore any 'effect-size' seen in an RCT will most often be 'watered down' when the same approach is applied to the more general population. In this case, I would assume failure rates of antibiotic treatment alone to increase if this were to become the new 'gold-standard'. Thus, with all of these issues in mind - how should we even conceive taking this debate to children already? Whilst I strongly support trying to answer this important question in a paediatric RCT, I still think there's quite a bit of work left to do with this disease in adults. 

I agree with Hamin. But if you take all these facts together it is better to have excellent training and expertize in laparosocopic appendectomy so the surgeon could have less preoperative strategic difficulties. When I started laparoscopic appendectomy it was easier for me to do open appendectomy. Now after more than 200 lap appendectomies I realise that it is more simple procedure technically (for me) and the easiest operations last 15 min and the patients recover ealier.

Therefore whatever the studies claim, my opinion is that laparoscopic appendectomy is better procedure in experienced hands.

The deep  ring is a hole in the transverse fascia, you can see it from abdominal cavity. And it is important only in that situation but you will see it with no doubt.

Best treatment - conservative management . There's already a metaanalysis by Andersson RE, Petzold MG. Ann Surg. 2007 Nov;246(5):741-8.

Intervention when failed conservative management. Even then, it is commonly due to appendicular abscess - options include percutaneous drainage or surgical drainage ( laparoscopic or open) if technically difficult for radiologists

There's no option of early appendectomy. Presentation is always late, as the omentum and small bowel attempt to seal off the inflammed appendix.

If you're asking about interval appendectomy - not recommended anymore as the risk of recurrence is low.

If the mass is palpable on presentation, then not much of issues - imaging to confirm findings and to assess for appendicular abscess feasible for drainage , then CT abdomen/pelvis and colonoscopy after 6 weeks , in order not to miss a tumor in those more than 40 years old

The problem occurs with findings of appendicular mass intraoperatively , in a patient initially diagnosed with perforated appendicitis. Options then include peritoneal lavage and drainage of pus or right hemicolectomy. Appendicectomy is almost never possible unless in very early formed mass where the structures can still be easily identified. Otherwise, dissection through inflammatory mass will only cause more damage.

Some people practise performing right hemicolectomy in this situation. I would not do it. The risk of appendicular neoplasm is <1% and can be identified as such during surgery as a mass anywhere along the appendix with distally distended part containing mucoid material, or perforation with pseudomyxoma peritonei. A caecal tumor causing appendicitis? Possible but still uncommon. Therefore, a CT scan and colonoscopy performed in those more than 40 years old.

My personal opinion- right hemicolectomy unnecessary in this situation, unless very high suspicion of a tumor in a patient more than 40 years old with high risk of second surgery due to multiple comorbidities. Otherwise, elective surgery can be planned later.

If the bleeding is already controlled, and there is no availability for a surgeon with experience in HBP or cardiovascular surgery I think is better to reffer. 

On the other hand I think that you should prevent this. If the anatomy is not clear you should convert to laparotomy. In this scenario, if the hepatoduodenal ligament is severly  inflamed, especially in a chronic fashion, I think is safer an incomplete cholecistectomy, abandoning the gallbladder infundibulum. 

If you have a portal vein injury, more frequent are right branch injuries. In this case the referral is better.

In case of complete transection early repair is necessary. I am very curios about other answers. 

We perfom perineal colostomy. However we don't perform the seromiotomies like you but a musclar graft, easy to do. I was interested by your technique that i saw in an article. However the seromiotomies seems to me more complicate than my own technique.

Yes ,it,s posible ta atacch with a cortical screw plus washer.

best approach is throcoscopic.Preferred on right side

Probably the same Idea as ruberband ligature for Hemoroids

As Dr.Henja and Dr. Asirdizer in most of the cases we routinely start opening the skull and then from head to heel, but in those cases where are involved injuries to the neck we always left it to the end. In this way the anatomic structure can drain not only to the head but also to the chest cavity, in our experience we have a better and "clean" neck dissection. So if head should be the first, why don´t let the neck to the end in asphyxia-related deaths?

Best Regards

Well need to find some sources for you

however there are several obvious reasons

1. longer operation times are usually associated with more complex operations or procedures where something is not fitting well and the surgeons has to take longer to complete the task at hand.

2. in long surgeries usually the staff and operating team changes again due to several reasons resulting in greater staff movement and greater risk of contamination.

3. bacterial flora flourishes back to normal in 2 hours time and double there on exponentially if the kits are not changed and surgeon does not re0scrib

4. These procedures are associated with infusion of larger amount of fluids including colloids, This change in homeostasis is a major risk factor in development of complications

5. Longer surgeries specially laparoscopy are assocaited with greater CO2 Level absorption and risk of hyper carbia and poor ventilatory effort is more common

6. recovery time from longer complex surgeries are extended and usually associated with elective or manadatory mechanical ventialtion postoperatively

I can think of these only . I think other can add a few points

regards

If it is a congenital ano-vestibular, it will have an epithelial lining. If it is, then does it cause enough symptoms to warrant excision? In infants I would normally excise with a covering colostomy, but I know that in places where there is a lot more experience (India & China) it is often done without.

Cholecystectomy have to be considered if the patient general condition is well and good but if not as in emergency situations do cholecystostomy. 

As a policy we do not use perioperative antibiotics for uncomplicated hernia repair, circumcision or orchidopexy. Underlying cardiac issues, VP shunts in hernia sac, recent balanitis may require coverage.

Depends on what you have and your aim. There are many published researches on mortality of elderly surgical patients. Going through some may help

Hi everyone! does anyone knows a website that I can use to do an on line survey other than survey monkey? Please help if you do. Thanks for reading.

The best way to prevent lymphorrea is to ligate all tissues. 

I use a posterior tibial nerve block with lidocaine 2%. It is quite simple. Find the artery and leave a depot near the artery. Take care not to puncture the artery. With this technique the whole foot sole is numb. A number 11 blade is ideal to remove the corn with an elliptical excision. Sharp spoons are also useful. I close the skin with an absorbable suture.

Hi Awad Ali,

first of all I would like to point out some essential ideas about procedures to reduce infectivity of hands before surgery. I therefore add some notes I found in the internet:

How To Perform Surgical Hand Scrubs

By Deborah Gardner, LPN, OPAC, and Ellen Anderson-Manz, RN, BSN

"Human hands are the most important tools for caring. Hands feel, diagnose, cure, prod, and provoke as they are placed upon each patient who is hoping for answers, understanding, and healing remedies. The hands can also be a portal and transmitter of infection. While handwashing may be the simplest way to control infection, it is often not practiced where warranted.

Surgical site infections greatly contribute to nosocomial infections. Some of the risk factors for nosocomial infections include the behavior of OR personnel regarding decontamination practices, hand hygiene/antisepsis, and compliance with universal precautions. Most surgical professionals agree on the importance of good surgical hand-washing practices in infection prevention. Hand transmission is a critical factor in the spread of bacteria, pathogens, viruses that cause disease, and nosocomial infections in general.

The purpose of surgical hand scrub is to:

Remove debris and transient microorganisms from the nails, hands, and forearms

Reduce the resident microbial count to a minimum, and

Inhibit rapid rebound growth of microorganisms.1

Surgical Scrub Techniques

All sterile team members should perform the hand and arm scrub before entering the surgical suite. The basic principle of the scrub is to wash the hands thoroughly, and then to wash from a clean area (the hand) to a less clean area (the arm). A systematic approach to the scrub is an efficient way to ensure proper technique.

There are two methods of scrub procedure. One is a numbered stroke method, in which a certain number of brush strokes are designated for each finger, palm, back of hand, and arm. The alternative method is the timed scrub, and each scrub should last from three to five minutes, depending on facility protocol.

The procedure for the timed five minute scrub consists of:

Remove all jewelry (rings, watches, bracelets).

Wash hands and arms with anitmicrobial soap. Excessively hot water is harder on the skin, dries the skin, and is too uncomfortable to wash with for the recommended amount of time. However, because cold water prevents soap from lathering properly, soil and germs may not be washed away.

Clean subungual areas with a nail file.

Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for two minutes.

Proceed to scrub the arms, keeping the hand higher than the arm at all times. This prevents bacteria-laden soap and water from contaminating the hand.

Wash each side of the arm to three inches above the elbow for one minute.

Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by one minute for the area that has been contaminated.

Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.

Proceed to the operating room suite holding hands above elbows.2

If the hands and arms are grossly soiled, the scrub time should be lengthened. However, vigorous scrubbing that causes the skin to become abraded should be avoided.

At all times during the scrub procedure care should be taken not to splash water onto surgical attire.2

Once in the operating room suite, hands and arms should be dried using a sterile towel and aseptic technique. You are now ready to don your gown and sterile gloves.

When gowning oneself, grasp the gown firmly and bring it away from the table. It has already been folded so that the outside faces away. Holding the gown at the shoulders, allow it to unfold gently. Do not shake the gown.

Place hands inside the armholes and guide each arm through the sleeves by raising and spreading the arms. Do not allow hands to slide outside the gown cuff. The circulator will assist by pulling the gown up over the shoulders and tying it.

To glove, lay the glove palm down over the cuff of the gown. The fingers of the glove face toward you. Working through the gown sleeve, grasp the cuff of the glove and bring it over the open cuff of the sleeve. Unroll the glove cuff so that it covers the sleeve cuff. Proceed with the opposite hand, using the same technique. Never allow the bare hand to contact the gown cuff edge or outside of glove.

The scrubbed technologist or nurse gowns the surgeon after he or she has performed the hand and arm scrub. After handing the surgeon a towel for drying, the technologist or nurse allows the gown to unfold gently, making sure that there is enough room to prevent contamination by nonsterile equipment. To glove another person, the rules of asepsis must be observed. One person's sterile hands should not touch the nonsterile surface of the person being gloved.

Pick up the right glove and place the palm away from you. Slide the fingers under the glove cuff and spread them so that a wide opening is created. Keep thumbs under the cuff.

The surgeon will thrust his or her hand into the glove. Do not release the glove yet.

Gently release the cuff (do not allow the cuff to snap sharply) while unrolling it over the wrist. Proceed with the left glove, using the same technique.

Formal guidelines and recommended practices for hand washing have been published by professional organizations (e.g., Association for Professionals in Infection Control (APIC), Association of periOperative Registered Nurses, Inc. (AORN). AORN recommends the use of a traditional standardized anatomical timed scrub or counted stroke method for surgical hand scrub and encourages institutions to follow the scrub agent manufacturer's written recommendations when establishing policies and procedures for scrub times. On this basis, for example, the typical scrub procedure for a PVPI-containing product based on manufacturer's labeling would require the use of a scrub brush and two applications of five minutes each, whereas the typical procedure for a CHG-based product would require a three-minute scrub followed by a three-minute wash. In actual practice, however, variations in surgical hand scrubbing times may be of shorter duration than manufacturer's recommendations for a number of reasons:

Staff time constraints.

Desire to reduce poor hand health.

Acceptance of data from other sources suggesting those scrub times shorter than those recommended by manufactures are adequate.3

Hand condition is emerging as an increasingly important factor in personnel compliance and infection control. Frequent surgical scrubbing can cause dermatitis of the hands and arms. Most antimicrobial agents are drying to the skin, especially when coupled with a scrub brush.

Characteristics of a Surgical Scrub

Performance characteristics for a surgical scrub agent generally fall into four categories:

1. Antimicrobial Action--an ideal agent would have a broad spectrum of antimicrobial activity against pathogenic organisms. This agent would have to work rapidly. An agent that does not work rapidly may not provide adequate bacterial reduction before being rinsed off.

2. Persistent Activity--an agent offering persistent activity keeps the bacterial count low under the gloves. It is not unusual for a surgery to last in excess of two hours. Studies have shown the rate of glove failures (non-visible holes) increases with the duration of surgery.4 In addition, studies show bacteria grow faster under gloved than ungloved hands.5,6,7

3. Safety--the ideal agent would be non-irritating and non-sensitizing. It must have no appreciable ocular or ototoxicity, be safe for use on the body, and not be damaging to the skin or environment.

4. Acceptance--probably most important to achieving compliance in using a new product is its acceptance by the healthcare worker. A product that has ideal antimicrobial action and an excellent safety profile is of little value to good infection control if the user population fails to support its use. Although each is important in its own right, all four characteristics should be present for a complete package.

Surgical scrub agents come in many forms. Not all forms meet all characteristics.

1. Liquid or foam soaps. These are the most common products for surgical scrubs and are used in conjunction with water and dry scrub brushes or sponges. The most common antimicrobial agents in these products are CHG (chlorhexidine gluconate), iodophor, or PCMX (parachlorometaxylenol). These agents are very drying and with repeated scrubbing with the scrub brush can cause skin damage.

2. Impregnated scrub brushes/sponges. Scrub brushes/sponges are preloaded with CHG, iodophor, or PCMX and are water-aided products.

3. Brush-free surgical scrub. These products use an antimicrobial agent and water but no scrub brush.

Conclusion

No matter what agent is used, or which scrub technique you practice, there is only one goal: infection prevention. Effective surgical scrubs are one of the most powerful strategies of infection prevention in the OR. Glove usage gives a false sense of security against bacteria. Gloves provide an ideal environment for bacterial growth, moisture and warmth, which makes good hand-scrub techniques and aseptic gowning and gloving an important part of the total infection prevention platform. It is important for healthcare management to help the personnel understand the cause/effect cycle of surgical scrubs as they relate to infection prevention."

Coming to your question I am sure that a hand brush to scrub prior to surgery is an essential even if you use socalled "modern desinfectants". I would never rely on what the products call "modern" unless there is evidence of a significant reduction of infective risk proved by the reduction of bacterial growth, describing the method of hand desinfection applied etc. in comparison to traditional techniques of hand brushing and cleaning with so called "old" desinfectants. All above mentioned methods (time of brushing, how to brush etc.) must be standardized for a comparison. To rely on the notes of the manufacturer alone may otherwise be desastrous for the patients.

Dear Raza and all,]

Thank you for starting a nice topic. I will give my answer and operative strategy and reasons:

Dr. Heemskerk is making sense, but almost certainly in cases of acute incarceration I would recommend a swift (with 4-6 hrs) operation and do an open modified McEvedy approach. This without a doubt gives the best access for every contingency. Anyone doing a low Lockwood and lower midline is missing out on a much more elegant and sensible approach. A low approach that requires cutting the inguinal ligament is not ideal also, as is a Lotheissen approach which inherently weakens the inguinal canal and thus necessitates mesh in a case where translocation of gut organisms and transient bacteraemia is likely. TAPP is an option but will double the operating time I suspect in most peoples hands.

The modified McEvedy as I do it (unlike the description from Peter McEvedy from Manchester in the 1950's) is through a transverse incision about 4cm above the ipsilateral inguinal (Poupart) ligament - somewhere midway between an appendix and an inguinal hernia incision. The original description was all vertical. Unlike the description once I get down to the fascia I open it transversely, i.e. EOA and anterior rectus sheath. If you now retract the rectus abdominis muscle medially, then inferiorly with a Langenbeck retractor and you will have a great view of the extraperitoneal space and femoral canal. Palpate the bony landmarks to orientate yourself if need be. Occasionally the epigastrics appear - ligate them.

Once you see the sac, apply external pressure to reduce it. If you struggle I divide the lacunar ligament (being cognisant of the possibility of an aberrant obturator artery!). The best way to do this is to place a Lahey forceps in the lacunar ligament very superficially (i.e. immediately under it) and diathermy its most lateral edge with the hand held finger-switch diathermy (Bovie) - often this is enough to release the sac. Then open it using clips, when you'll almost certainly find a Richter's hernia and wrap in warm wet swabs, and fix the defect.

The simplest and probably best way to do this is an emergency is to use braided suture i.e. Ethibond on a J needle. Inguinal to pectineal ligament - by the time this is complete you will notice that the bowel is viable. Naturally beware the femoral vein laterally.

Then a layered closure and post-op VTE prophylaxis, mobilisation and E+D as tolerated and your patient will be ready for home soon. Of note, I give 1 shot of ABx on induction and if the bowel is viable no further doses.

In the elective setting a low Lockwood approach is sufficient, and in those cases indeed a mesh can be used, either normal polypropylene cut as a long rectangle and rolled up as a cigarette and pushed in, or a Bard plug. To be honest, I think simple sutures work fine also. As I say, Dr. Heemskerk makes a point that a co-existing inguinal hernia can exists also, in which case TEP is an option. I suspect in the most NHS trusts, for a unilateral femoral hernia, would only fund open surgery.

Hope that helps!

BW,

John.

Our unit doesn't have a precise weight cut off for refusing surgery - but we do evaluate patients carefully from a nutritional point of view. We won't resect patients who are grossly malnourished with low albumins etc. We place feeding jejunostomies in patients with severe dysphagia and / or significant weight loss who are suitable for resection. Patients who don't respond to chemo and still have dysphagia get a NG /NJ feeding tube if they don't have a feeding jejunostomy. This allows nutrition during neoadjuvant chemotherapy. All patients see a dietician.

We avoid PEGs - as they can knacker the stomach or more importantly prang its blood supply. Also PEGs can pull tumour cells and implant they into the abdominal wall rendering the patient palliative.

I avoid covered stents pre oesophagectomy, as they

1. often migrate with chemotherapy causing shrinkage

2. make the resection more difficult if they stay insitu (fibrosis etc)

3. some evidence they may compromise survival - free tumour cells in blood after stenting colorectal cancer and progression to surgery in patients who require stenting pre-oesophagectomy is very poor (althought this may be due to their advanced stage

See the attached commentery on the safety of stents in the neoadjuvant setting for oesophageal cancer.

Perhaps a need for a RCT comparing,,,,,,,

NG/J

Feeding jejunostomy

Possibly covered stents

In resectable patients with dysphagia who need chemo or CRT prior to oesophagectomy?

we in a major corporate setup,do not see that many DU perforations.Incidence of peptic ulcer disease was very common in south India attributed once to High spicy food,but after the advent of H2receptor antagonists and ppis,it was almost disappeared except few perforations in public hospitals.Certainly now there seems to be a reappearance due to above mentioned reasons by Dr Ireradi and also due to modern life style changes adopted in this part of the world as well.

Quite interesting but rare in human.

Implantation was the consequence of appendectomy whereas appendix was primarily infiltrated by carcinoid tumor. The treatment is local R0 excision.

Thanks for your interest Jean. We did initially ask for international interest, but it was minimal and therefore we are concentrating now on UK and Irish centres. The study period opens in two weeks time.

There is a global study which you may be interested in. More details can be found at www.globalsurg.org. In brief, this study will help identify variation in outcome of emergency midline laparotomy across the globe to determine whether there are globally relevant quality markers for emergency surgery. It you are interested simply fill in the registration form at http://globalsurg.org/register/

All the best

Ewen