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Surgery - Colorectal Resection, Left Hemicolectomy
Indications
Elective: The most typical indications include tumors of the proximal sigmoid colon and descending colon. extreme diverticular illness.
Emergency: In rare cases, recommended for ischaemia, hemorrhage, perforation, or blockage.
Anatomy
The peritoneum covers the anterior surface and sides of the descending colon, which extends from the splenic flexure to the sigmoid colon at the pelvic brim. The phrenicocolic ligament, which runs parallel to the larger omentum and is closely linked to the spleen and tail of the pancreas, connects the splenic flexure to the diaphragm. Associated with the left kidney, lumbar region, and iliac fascia posteriorly.
vascular The sigmoid colon, the superior two thirds of the rectum, and the descending colon are all supplied by the inferior mesenteric artery (IMA). The IMA gives rise to the left colic artery, and the marginal artery (of Drummond) is partially formed by its ascending branch. The portal system receives venous drainage from the inferior mesenteric vein.
Investigations
Imaging: CT scan for staging and diagnosis; barium enema; erect CXR; abdominal radiograph.
Colonoscopy and sigmoidoscopy: For biopsy and diagnosis. Colonic lesion extraluminal localization can be facilitated by endoscopic tattooing.
Bloods: FBC, U&Es, clotting, and crossmatch prior to surgery. general evaluation of anesthesia. dosage of thromboprophylaxis, a preventive antibiotic. Preparing the bowels may be necessary.
After surgery: Better recuperation, prompt resumption of food and drink, mobilization, and effective analgesia. IV fluids are continued until oral intake is sufficient. Maintaining a precise record of fluid equilibrium is necessary. prevention of DVT. Revert to an NG tube and IV fluids until symptoms of post-operative ileus subside. In the postoperative phase, if there are any indications of a systemic disturbance, an anastomotic leak must be ruled out.
Procedure
Position: Lloyd Davis/modified lithotomy.
Access: Laparoscopic or midline incision methods. The contents of the abdomen are examined, looking for signs of liver metastases or swollen lymph nodes, and the small bowel is packed away from the left hemicolon.
The division of the peritoneal attachments at the white line of Toldt to the level of the splenic flexure mobilizes the descending colon. The spleen, left ureter, gonadal arteries, kidney, pancreas, and fourth portion of the duodenum must all be carefully avoided. Enough transverse colon mobilization occurs to allow for a tension-free anastomosis.
Ligation of vessels: The inferior mesentery artery and left colonic branches are located by dissecting the mesentery. The artery supply to the proximal and distal edges is then preserved by isolating, ligating, and dividing them.
Resection of bowel segment: The colonic segment and its accompanying mesentery are removed, and the bowel is clamped and separated, usually using linear staples.
Restoring intestinal continuity involves performing a handsewn or stapled anastomosis between the descending colon and the rectosigmoid colon. Closing the mesenteric defect prevents internal herniation.It is possible to create an aproximal defuncting stoma to shield the distal anastomosis.
Conclusion: Hemostasis is verified. Usually, a drain is installed. Sutures or clips are used to finish the skin closure once the abdominal wall is mass closed.
Complications
bleeding, infection, ileus, anastomotic leak, hernias, and thromboembolism are examples of visceral injuries.
Indications
Elective: The most typical indications include tumors of the proximal sigmoid colon and descending colon. extreme diverticular illness.
Emergency: In rare cases, recommended for ischaemia, hemorrhage, perforation, or blockage.
Anatomy
The peritoneum covers the anterior surface and sides of the descending colon, which extends from the splenic flexure to the sigmoid colon at the pelvic brim. The phrenicocolic ligament, which runs parallel to the larger omentum and is closely linked to the spleen and tail of the pancreas, connects the splenic flexure to the diaphragm. Associated with the left kidney, lumbar region, and iliac fascia posteriorly.
vascular The sigmoid colon, the superior two thirds of the rectum, and the descending colon are all supplied by the inferior mesenteric artery (IMA). The IMA gives rise to the left colic artery, and the marginal artery (of Drummond) is partially formed by its ascending branch. The portal system receives venous drainage from the inferior mesenteric vein.
Investigations
Imaging: CT scan for staging and diagnosis; barium enema; erect CXR; abdominal radiograph.
Colonoscopy and sigmoidoscopy: For biopsy and diagnosis. Colonic lesion extraluminal localization can be facilitated by endoscopic tattooing.
Bloods: FBC, U&Es, clotting, and crossmatch prior to surgery. general evaluation of anesthesia. dosage of thromboprophylaxis, a preventive antibiotic. Preparing the bowels may be necessary.
After surgery: Better recuperation, prompt resumption of food and drink, mobilization, and effective analgesia. IV fluids are continued until oral intake is sufficient. Maintaining a precise record of fluid equilibrium is necessary. prevention of DVT. Revert to an NG tube and IV fluids until symptoms of post-operative ileus subside. In the postoperative phase, if there are any indications of a systemic disturbance, an anastomotic leak must be ruled out.
Procedure
Position: Lloyd Davis/modified lithotomy.
Access: Laparoscopic or midline incision methods. The contents of the abdomen are examined, looking for signs of liver metastases or swollen lymph nodes, and the small bowel is packed away from the left hemicolon.
The division of the peritoneal attachments at the white line of Toldt to the level of the splenic flexure mobilizes the descending colon. The spleen, left ureter, gonadal arteries, kidney, pancreas, and fourth portion of the duodenum must all be carefully avoided. Enough transverse colon mobilization occurs to allow for a tension-free anastomosis.
Ligation of vessels: The inferior mesentery artery and left colonic branches are located by dissecting the mesentery. The artery supply to the proximal and distal edges is then preserved by isolating, ligating, and dividing them.
Resection of bowel segment: The colonic segment and its accompanying mesentery are removed, and the bowel is clamped and separated, usually using linear staples.
Restoring intestinal continuity involves performing a handsewn or stapled anastomosis between the descending colon and the rectosigmoid colon. Closing the mesenteric defect prevents internal herniation.It is possible to create an aproximal defuncting stoma to shield the distal anastomosis.
Conclusion: Hemostasis is verified. Usually, a drain is installed. Sutures or clips are used to finish the skin closure once the abdominal wall is mass closed.
Complications
bleeding, infection, ileus, anastomotic leak, hernias, and thromboembolism are examples of visceral injuries.
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Surgery - Colorectal Resection, Low Anterior
Indications
Elective: Sigmoid or Rectal tumours, if adequate margins above the anal sphincter complex.
Anatomy
Starting at the level of the third sacral vertebra, the rectum (12 cm) descends and lies in the sacrococcygeal curve until it reaches the tip of the coccyx. After that, it abruptly turns back into the anal canal. The autonomic plexus, hypogastric nerves, and presacral (Waldeyer) fascia divide the rectum from the mesorectum. There are lymphatics and fatty tissue in it, and complete mesorectal excision has been demonstrated to lower the risk of local recurrence.
Vascular: The superior rectal artery receives blood from the inferior mesenteric artery to supply the upper rectum. The internal iliac artery is the source of the middle and inferior rectal arteries, which supply the lower rectum. The superior, middle, and inferior rectal vessels—the sites of portacaval anastomosis—are the drains of the rectal venous plexus.
Lymphatics: Drainage reaches the para-aortic nodes via following the inferior mesenteric artery.
Investigational studies
Imaging: CT, MRI, endorectal ultrasound: For planning/assessing appropriateness for anterior resection, as well as staging.
Pre-op: Chemoradiotherapy prior to surgery may be necessary (reduces local recurrence).
Bowel preparation, bloods: FBC, U&Es, clotting and crossmatch, general anaesthetic assessment and relevant investigations.
Close observation follows surgery. prevention of DVT.
Actions
The patient is arranged in an elongated Lloyd-Davis posture.
Incision: Laparoscopic procedures or lower or longer midline incisions are both possible.
Examining the abdominal cavity and determining the size and location of the tumor constitute the process of mobilizing the colon. The ureter and gonadal veins are carefully identified as the left colon and sigmoid mesentery are mobilized. Mobilization of the splenic flexure can be necessary.
The inferior mesenteric artery and vein are split, dissected, and ligated in order to mobilize the rectum.Using a stapler, the sigmoid, mesocolon, and sigmoid are separated, generally at the apex. The plane between the mesorectum and the sacral fascia can then be seen by pulling the rectum forward. The rectum is further dissected laterally and posteriorly, giving rise to a distinctive bilobed look.The plane between the anterior mesorectum and the seminal vesicles in the male and vagina in the female is then developed by the division of the peritoneum right above the apex of the rectovesical or rectouterine pouch.
Resection: A minimum of 2 cm of adequate clearance is required both proximally and distally from the tumor.
At the proximal and distal resection sites, clamps are positioned. Using a proctoscope, the lower rectum and anus are cleaned with an antiseptic solution. The bowel is then split between the proximal and distal clamps using a stapler.
Anastomosis: A circular staple gun is typically used by surgeons. An helper inserts the gun PR and advances the rod through the staple line's center. The anvil, which is the receiving end of the stapler gun, is wrapped with sutures around the proximal bowel end. The stapler is closed and fired to ensure that there is no twisting, resulting in the excision of a ring of intestine and the stapleing of the two ends together. The tissue "donuts" that are removed are sent to histology in addition to being inspected to make sure the rings are complete. By using air sufflation PR to conduct a leak test, the anastomosis can be verified.
Closure: Typically, a pelvic drain is left in place. There are non-absorbable stitches used to seal the abdominal wall. Sutures or clips finish the skin closing process. It is common practice to create a malfunctioning ileostomy to redirect stool contents during anastomotic recovery.
Complications
bleeding, ileus, anastomotic leak, infection, and abscess. The frequency and severity of bowel movements
Indications
Elective: Sigmoid or Rectal tumours, if adequate margins above the anal sphincter complex.
Anatomy
Starting at the level of the third sacral vertebra, the rectum (12 cm) descends and lies in the sacrococcygeal curve until it reaches the tip of the coccyx. After that, it abruptly turns back into the anal canal. The autonomic plexus, hypogastric nerves, and presacral (Waldeyer) fascia divide the rectum from the mesorectum. There are lymphatics and fatty tissue in it, and complete mesorectal excision has been demonstrated to lower the risk of local recurrence.
Vascular: The superior rectal artery receives blood from the inferior mesenteric artery to supply the upper rectum. The internal iliac artery is the source of the middle and inferior rectal arteries, which supply the lower rectum. The superior, middle, and inferior rectal vessels—the sites of portacaval anastomosis—are the drains of the rectal venous plexus.
Lymphatics: Drainage reaches the para-aortic nodes via following the inferior mesenteric artery.
Investigational studies
Imaging: CT, MRI, endorectal ultrasound: For planning/assessing appropriateness for anterior resection, as well as staging.
Pre-op: Chemoradiotherapy prior to surgery may be necessary (reduces local recurrence).
Bowel preparation, bloods: FBC, U&Es, clotting and crossmatch, general anaesthetic assessment and relevant investigations.
Close observation follows surgery. prevention of DVT.
Actions
The patient is arranged in an elongated Lloyd-Davis posture.
Incision: Laparoscopic procedures or lower or longer midline incisions are both possible.
Examining the abdominal cavity and determining the size and location of the tumor constitute the process of mobilizing the colon. The ureter and gonadal veins are carefully identified as the left colon and sigmoid mesentery are mobilized. Mobilization of the splenic flexure can be necessary.
The inferior mesenteric artery and vein are split, dissected, and ligated in order to mobilize the rectum.Using a stapler, the sigmoid, mesocolon, and sigmoid are separated, generally at the apex. The plane between the mesorectum and the sacral fascia can then be seen by pulling the rectum forward. The rectum is further dissected laterally and posteriorly, giving rise to a distinctive bilobed look.The plane between the anterior mesorectum and the seminal vesicles in the male and vagina in the female is then developed by the division of the peritoneum right above the apex of the rectovesical or rectouterine pouch.
Resection: A minimum of 2 cm of adequate clearance is required both proximally and distally from the tumor.
At the proximal and distal resection sites, clamps are positioned. Using a proctoscope, the lower rectum and anus are cleaned with an antiseptic solution. The bowel is then split between the proximal and distal clamps using a stapler.
Anastomosis: A circular staple gun is typically used by surgeons. An helper inserts the gun PR and advances the rod through the staple line's center. The anvil, which is the receiving end of the stapler gun, is wrapped with sutures around the proximal bowel end. The stapler is closed and fired to ensure that there is no twisting, resulting in the excision of a ring of intestine and the stapleing of the two ends together. The tissue "donuts" that are removed are sent to histology in addition to being inspected to make sure the rings are complete. By using air sufflation PR to conduct a leak test, the anastomosis can be verified.
Closure: Typically, a pelvic drain is left in place. There are non-absorbable stitches used to seal the abdominal wall. Sutures or clips finish the skin closing process. It is common practice to create a malfunctioning ileostomy to redirect stool contents during anastomotic recovery.
Complications
bleeding, ileus, anastomotic leak, infection, and abscess. The frequency and severity of bowel movements
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Surgery - Colorectal Resection, Right Hemicolectomy
Indications
Elective: Most frequently, appendiceal neoplasms, such as carcinoids >2 cm, or colonic neoplasms (caecum, ascending colon, or hepatic flexure). When hepatic flexure or transverse colon tumors are involved, extended right hemicolectomies are done. Crohn's disease is another.
Emergency: Recommended in cases of caecal volvulus or diverticulitis, as well as right colonic obstructive lesions, perforations, hemorrhages, or ischemia. In cases of severe appendicitis where the caecum is affected, ileocaecal resection or limited right hemicolectomy may be required.
Anatomy
From the caecum to the hepatic flexure, the ascending colon ascends (15 cm long). After that, it suddenly bends forward and to the left to form the transverse colon. Its anterior surface and sides are covered by the peritoneum, making it retroperitoneal. The right kidney, duodenum, and gonadal arteries, as well as the right ureter, are crucial structures to recognize and protect during surgery.
vascular The right colic, middle colic, and ileocolic arteries are the branches of the superior mesenteric artery that supply the arterial supply. Variable venous drainage enters the portal circulation mostly by the ileocolic, right colic, and middle colic veins.
Investigations
Imaging: CT scan, erect CXR, and abdominal radiograph: diagnosis and staging.
Colonoscopy: Polyp, tumor, inflammatory bowel, etc. diagnosis and biopsies.
Bloods: FBC, U&Es, clotting, crossmatch, preoperative.
evaluation of general anesthesia and thromboprophylaxis.
Post-op: Following elective surgery, improved recovery involves an early return to food and drink, prompt mobilization, effective analgesia, and close monitoring of the FBC, electrolytes, and urine output. Should there be indications of postoperative ileus, return to the traditional oral NG tube feeding regimen and gradually introduce liquids and solids as tolerated. Keep up the thromboprophylaxis.
Procedure
Lie down or do a modified lithotomy.
Access: Laparoscopic technique, transverse incision, or midline incision. The small intestine is packed up and the intra-abdominal contents evaluated.
Mobilize: Approaches from medial to lateral or lateral to medial are applied.
Lateral to medial: The division of the hepatocolic ligament mobilizes the hepatic flexure and inclines the right colon's lateral peritoneal attachments (white line of Toldt). identifying and avoiding the ureter, gonadal, and duodenum with caution. cautious removal of the right plane in front of Gerota's fascia. larger omentum dissection from the transverse colonic region that needs to be split.
Ligation of vessels: The ileocolic and right colic vessels are ligated and separated after the mesentery from the terminal ileum to the transverse colon is thoroughly dissected. It might also be necessary to divide the middle colic artery's right branches.
Resection of bowel segment: Clamps are positioned at both ends of the length that needs to be resected after measuring the amount of adequate clearance from the lesion. Linear staplers are frequently used to separate the gut, and the right colon is submitted for histology.
Restoring intestinal continuity: Healthy, well-vascularized, and tension-free bowel ends are required for bowel anastomosis. Using sutures or staples, the terminal ileum is anastomosed to the transverse colon in one or two layers, either side-to-side, end-to-end, or end-to-side. To stop internal herniation, the mesenteric defect is sealed.
Closure: A drain could remain in place. Mass closure after haemostasis confirmation.
Sutures or clips finish the skin closing process.
Complications include incisional hernias, thrombosis, ileus, abscess, wound infection, and anastomotic leak.
Indications
Elective: Most frequently, appendiceal neoplasms, such as carcinoids >2 cm, or colonic neoplasms (caecum, ascending colon, or hepatic flexure). When hepatic flexure or transverse colon tumors are involved, extended right hemicolectomies are done. Crohn's disease is another.
Emergency: Recommended in cases of caecal volvulus or diverticulitis, as well as right colonic obstructive lesions, perforations, hemorrhages, or ischemia. In cases of severe appendicitis where the caecum is affected, ileocaecal resection or limited right hemicolectomy may be required.
Anatomy
From the caecum to the hepatic flexure, the ascending colon ascends (15 cm long). After that, it suddenly bends forward and to the left to form the transverse colon. Its anterior surface and sides are covered by the peritoneum, making it retroperitoneal. The right kidney, duodenum, and gonadal arteries, as well as the right ureter, are crucial structures to recognize and protect during surgery.
vascular The right colic, middle colic, and ileocolic arteries are the branches of the superior mesenteric artery that supply the arterial supply. Variable venous drainage enters the portal circulation mostly by the ileocolic, right colic, and middle colic veins.
Investigations
Imaging: CT scan, erect CXR, and abdominal radiograph: diagnosis and staging.
Colonoscopy: Polyp, tumor, inflammatory bowel, etc. diagnosis and biopsies.
Bloods: FBC, U&Es, clotting, crossmatch, preoperative.
evaluation of general anesthesia and thromboprophylaxis.
Post-op: Following elective surgery, improved recovery involves an early return to food and drink, prompt mobilization, effective analgesia, and close monitoring of the FBC, electrolytes, and urine output. Should there be indications of postoperative ileus, return to the traditional oral NG tube feeding regimen and gradually introduce liquids and solids as tolerated. Keep up the thromboprophylaxis.
Procedure
Lie down or do a modified lithotomy.
Access: Laparoscopic technique, transverse incision, or midline incision. The small intestine is packed up and the intra-abdominal contents evaluated.
Mobilize: Approaches from medial to lateral or lateral to medial are applied.
Lateral to medial: The division of the hepatocolic ligament mobilizes the hepatic flexure and inclines the right colon's lateral peritoneal attachments (white line of Toldt). identifying and avoiding the ureter, gonadal, and duodenum with caution. cautious removal of the right plane in front of Gerota's fascia. larger omentum dissection from the transverse colonic region that needs to be split.
Ligation of vessels: The ileocolic and right colic vessels are ligated and separated after the mesentery from the terminal ileum to the transverse colon is thoroughly dissected. It might also be necessary to divide the middle colic artery's right branches.
Resection of bowel segment: Clamps are positioned at both ends of the length that needs to be resected after measuring the amount of adequate clearance from the lesion. Linear staplers are frequently used to separate the gut, and the right colon is submitted for histology.
Restoring intestinal continuity: Healthy, well-vascularized, and tension-free bowel ends are required for bowel anastomosis. Using sutures or staples, the terminal ileum is anastomosed to the transverse colon in one or two layers, either side-to-side, end-to-end, or end-to-side. To stop internal herniation, the mesenteric defect is sealed.
Closure: A drain could remain in place. Mass closure after haemostasis confirmation.
Sutures or clips finish the skin closing process.
Complications include incisional hernias, thrombosis, ileus, abscess, wound infection, and anastomotic leak.
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Surgery - Coronary Artery Bypass Graft
Indications
Triple coronary vessel disease, left main stem coronary artery disease, and two coronary vessel disease with a proximal left anterior descending artery lesion are the three primary anatomical reasons for CABG.
In these patients, CABG reduces angina and increases long-term survival.
Anatomy
After emerging from the ascending aorta, the right coronary artery passes anteriorly between the right auricle and the pulmonary trunk before descending via the atrioventricular groove.
It passes posteriorly and anastomoses with the left coronary artery at the inferior heart boundary.
The ascending aorta gives rise to the left coronary artery, which splits into the left anterior descending and left circumflex arteries in the atrioventricular groove after passing posteriorly between the pulmonary trunk and the left auricle. The internal mammary artery originates from the subclavian artery and descends behind the costal cartilages along the pleura. It finishes at the sixth intercostal gap, when it splits into the musculophrenic and superior epigastric arteries.
Investigational studies
Prior to surgery: ECG, echocardiography, coronary angiography, and thallium perfusion scintigraphy. Bloods: crossmatch, clotting, U&Es, and FBC. general evaluation of anesthesia.
Close observation in an ITU setting following surgery. meticulous follow-up.
Actions
A median sternotomy was made. The heart, coronary vessels, and large vessels are exposed and examined during pericardial dissection. Nowadays, less invasive thoracotomy incisions are made in an effort to lessen the morbidity associated with sternotomy.
"On Pump" CABG: Cardiopulmonary bypass machines are utilized during cardiac surgery to oxygenate and circulate blood. Perfusionists operate these machines. Blood is taken out of the right atrium and redirected into the ascending aorta via a venous cannula, causing systemic hypothermia and the administration of IV heparin. The heart is given a cardioplegic solution to cause a hypothermic cardioplegic arrest so that surgery can be done.
"Off pump" CABG: The heart is allowed to continue beating by applying tissue stabilisers, which are devices, to the surgical site.
Bypass graft: The internal mammary, radial, and, in rare cases, gastroepiploic arteries are used in arterial grafts. Beyond the stenosis or occlusion, the internal mammary is mobilized and anastomosed to the coronary artery. Through open or minimally invasive incisions, vein grafts are taken from the leg's long saphenous vein and anastomosed from the aorta to the coronary artery beyond the stenosis or occlusion.
Closure: The bypass circuit is turned off for the patient, enabling the heart to fill and begin contracting again. Sinus rhythm either spontaneously resumes with systemic rewarming or is restored via cardioversion. All cannulas are removed once adequate cardiac output, and protamine is given to reverse heparin. Two sizable thoracostomy drains are placed into the chest cavity and pericardium, and temporary pacing wires are put into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Stroke and neurocognitive impairment, myocardial infarction during surgery, transient anomalies in conduction and arrhythmias (such as atrial fibrillation), pericardial effusion/tamponade, hemorrhage, mediastinitis, infection from a sternal wound, renal failure, and mortality.
Prognosis
A 2-3.5% operational mortality rate. Venous grafts show a 50–60% 10-year patency, compared to 90% for left internal mammary artery grafts. When CABG is contrasted with percutaneous coronary intervention, it has demonstrated a decreased requirement for revascularization and an improved prognosis for patients with diabetes who are older than 65.
Indications
Triple coronary vessel disease, left main stem coronary artery disease, and two coronary vessel disease with a proximal left anterior descending artery lesion are the three primary anatomical reasons for CABG.
In these patients, CABG reduces angina and increases long-term survival.
Anatomy
After emerging from the ascending aorta, the right coronary artery passes anteriorly between the right auricle and the pulmonary trunk before descending via the atrioventricular groove.
It passes posteriorly and anastomoses with the left coronary artery at the inferior heart boundary.
The ascending aorta gives rise to the left coronary artery, which splits into the left anterior descending and left circumflex arteries in the atrioventricular groove after passing posteriorly between the pulmonary trunk and the left auricle. The internal mammary artery originates from the subclavian artery and descends behind the costal cartilages along the pleura. It finishes at the sixth intercostal gap, when it splits into the musculophrenic and superior epigastric arteries.
Investigational studies
Prior to surgery: ECG, echocardiography, coronary angiography, and thallium perfusion scintigraphy. Bloods: crossmatch, clotting, U&Es, and FBC. general evaluation of anesthesia.
Close observation in an ITU setting following surgery. meticulous follow-up.
Actions
A median sternotomy was made. The heart, coronary vessels, and large vessels are exposed and examined during pericardial dissection. Nowadays, less invasive thoracotomy incisions are made in an effort to lessen the morbidity associated with sternotomy.
"On Pump" CABG: Cardiopulmonary bypass machines are utilized during cardiac surgery to oxygenate and circulate blood. Perfusionists operate these machines. Blood is taken out of the right atrium and redirected into the ascending aorta via a venous cannula, causing systemic hypothermia and the administration of IV heparin. The heart is given a cardioplegic solution to cause a hypothermic cardioplegic arrest so that surgery can be done.
"Off pump" CABG: The heart is allowed to continue beating by applying tissue stabilisers, which are devices, to the surgical site.
Bypass graft: The internal mammary, radial, and, in rare cases, gastroepiploic arteries are used in arterial grafts. Beyond the stenosis or occlusion, the internal mammary is mobilized and anastomosed to the coronary artery. Through open or minimally invasive incisions, vein grafts are taken from the leg's long saphenous vein and anastomosed from the aorta to the coronary artery beyond the stenosis or occlusion.
Closure: The bypass circuit is turned off for the patient, enabling the heart to fill and begin contracting again. Sinus rhythm either spontaneously resumes with systemic rewarming or is restored via cardioversion. All cannulas are removed once adequate cardiac output, and protamine is given to reverse heparin. Two sizable thoracostomy drains are placed into the chest cavity and pericardium, and temporary pacing wires are put into the atrium and/or ventricles. The skin is closed and the sternum is sealed with broken steel wires.
Complications
Stroke and neurocognitive impairment, myocardial infarction during surgery, transient anomalies in conduction and arrhythmias (such as atrial fibrillation), pericardial effusion/tamponade, hemorrhage, mediastinitis, infection from a sternal wound, renal failure, and mortality.
Prognosis
A 2-3.5% operational mortality rate. Venous grafts show a 50–60% 10-year patency, compared to 90% for left internal mammary artery grafts. When CABG is contrasted with percutaneous coronary intervention, it has demonstrated a decreased requirement for revascularization and an improved prognosis for patients with diabetes who are older than 65.
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Surgery - Endovascular Procedures
Indications
minimally invasive techniques, often known as "interventional radiology," are used to diagnose and treat venous or artery diseases endoscopically. carried out by a variety of specialists, such as gastroenterologists, cardiologists, neurosurgeons, radiologists, and vascular surgeons.
Endovascular procedures include :
Angioplasty and stents for arterial occlusive disease, such as those in the leg, renal, iliac, coronary, or carotid arteries.
Stenting of aneurysms, e.g. EVAR and popliteal aneurysms.coil embolization of aneurysms, such as those in the brain.
coil embolization of bleeding vessels, such as the duodenal artery when bleeding from a duodenal ulcer.
coil embolization of veins that have dilated, such as pelvic varicose veins and varicocoele.
catheter-directed thrombolysis or thrombectomy. tissue embolization, such as liver metastases through chemotherapy or embolization of uterine fibroids.
Shunts: in portal hypertension, transjugular intrahepatic portosystemic shunts (TIPS).
Filters: To avoid a venous embolism: vena cava inferior filters.
Vein ablation: Radiofrequency ablation of varicose veins or endovenous laser therapy (EVLT).
Benefits include: less pain; fewer incisions, frequently just a puncture wound; local anesthesia as opposed to general anesthesia; lower morbidity and mortality, particularly in the heart and lungs; and quicker recovery.
Actions
Access: The local anesthetic enters the body. Under ultrasound guidance, a guidewire and catheter are percutaneously cannulated and placed, usually into the femoral vein for venous circulation and the groin for arterial circulation. Options include the popliteal or subclavian arteries, or less frequently, the brachial or axillary arteries. The lower leg is used to access the long saphenous vein during treatment for varicose veins. If device implantation is to be done, antibiotics are given.
Navigation: A large variety of catheters and guidewires are available. The area of circulation under inquiry or treatment can be selectively catheterized thanks to experience, expertise, and knowledge of anatomy and imaging. Radio-opaque contrast is injected during an angiography procedure in order to plan, direct, and evaluate therapy.
Angioplasty: Lesion distance from access site, stenosis length, and native artery size are taken into consideration when choosing balloon catheters. Following the insertion of the balloon over the lesion, inflation of the balloon is carried out using contrast to enable fluoroscopic observation of the balloon's contour during dilatation, along with the monitoring of inflation pressures.
Stents: They can be self-expanding or balloon mounted. Stents come in many varieties, including as coated, drug-eluting, and baremetal. Certain types of stents, such as those put in the carotid artery, use embolic protection devices to trap plaque fragments that have come loose and could embolize and result in stroke.
Stent graft: An EVAR technique in which grafts are held up by a stiff stent framework.
Coils: Usually composed of nitinol, tungsten, or platinum. The coil is advanced to the intended intravascular site through the microcatheter by a delivery wire, often known as a "coil pusher." After being deployed, the flexible coils return to their former shape, preventing additional blood flow into the aneurysm or vessel.
Closure: The percutaneous catheter is removed, and the site is compressed manually or with the help of closure equipment.
Complications
Entry point: bleeding, pseudoaneurysm, arteriovenous fistula, infection in the groin, blockage of a vascular.
In the vessel during the insertion of a wire or catheter: embolism, perforation, false plane, and thrombosis.
Dissection, rethrombosis, intimal flap, perforation, restenosis, endoleak, graft infection, and stent migration can all occur at the intervention site.
Thrombosis and embolism are downstream.
Indications
minimally invasive techniques, often known as "interventional radiology," are used to diagnose and treat venous or artery diseases endoscopically. carried out by a variety of specialists, such as gastroenterologists, cardiologists, neurosurgeons, radiologists, and vascular surgeons.
Endovascular procedures include :
Angioplasty and stents for arterial occlusive disease, such as those in the leg, renal, iliac, coronary, or carotid arteries.
Stenting of aneurysms, e.g. EVAR and popliteal aneurysms.coil embolization of aneurysms, such as those in the brain.
coil embolization of bleeding vessels, such as the duodenal artery when bleeding from a duodenal ulcer.
coil embolization of veins that have dilated, such as pelvic varicose veins and varicocoele.
catheter-directed thrombolysis or thrombectomy. tissue embolization, such as liver metastases through chemotherapy or embolization of uterine fibroids.
Shunts: in portal hypertension, transjugular intrahepatic portosystemic shunts (TIPS).
Filters: To avoid a venous embolism: vena cava inferior filters.
Vein ablation: Radiofrequency ablation of varicose veins or endovenous laser therapy (EVLT).
Benefits include: less pain; fewer incisions, frequently just a puncture wound; local anesthesia as opposed to general anesthesia; lower morbidity and mortality, particularly in the heart and lungs; and quicker recovery.
Actions
Access: The local anesthetic enters the body. Under ultrasound guidance, a guidewire and catheter are percutaneously cannulated and placed, usually into the femoral vein for venous circulation and the groin for arterial circulation. Options include the popliteal or subclavian arteries, or less frequently, the brachial or axillary arteries. The lower leg is used to access the long saphenous vein during treatment for varicose veins. If device implantation is to be done, antibiotics are given.
Navigation: A large variety of catheters and guidewires are available. The area of circulation under inquiry or treatment can be selectively catheterized thanks to experience, expertise, and knowledge of anatomy and imaging. Radio-opaque contrast is injected during an angiography procedure in order to plan, direct, and evaluate therapy.
Angioplasty: Lesion distance from access site, stenosis length, and native artery size are taken into consideration when choosing balloon catheters. Following the insertion of the balloon over the lesion, inflation of the balloon is carried out using contrast to enable fluoroscopic observation of the balloon's contour during dilatation, along with the monitoring of inflation pressures.
Stents: They can be self-expanding or balloon mounted. Stents come in many varieties, including as coated, drug-eluting, and baremetal. Certain types of stents, such as those put in the carotid artery, use embolic protection devices to trap plaque fragments that have come loose and could embolize and result in stroke.
Stent graft: An EVAR technique in which grafts are held up by a stiff stent framework.
Coils: Usually composed of nitinol, tungsten, or platinum. The coil is advanced to the intended intravascular site through the microcatheter by a delivery wire, often known as a "coil pusher." After being deployed, the flexible coils return to their former shape, preventing additional blood flow into the aneurysm or vessel.
Closure: The percutaneous catheter is removed, and the site is compressed manually or with the help of closure equipment.
Complications
Entry point: bleeding, pseudoaneurysm, arteriovenous fistula, infection in the groin, blockage of a vascular.
In the vessel during the insertion of a wire or catheter: embolism, perforation, false plane, and thrombosis.
Dissection, rethrombosis, intimal flap, perforation, restenosis, endoleak, graft infection, and stent migration can all occur at the intervention site.
Thrombosis and embolism are downstream.
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Surgery - Gastrectomies
Indications
Elective: Severe peptic ulcer illness, benign and malignant tumors.
Emergency: bleeding or puncture that cannot be stopped with local anesthesia; stomach necrosis, such as that resulting from gastric volvulus.
Anatomy
The stomach has minor and greater curvatures and is separated into the cardia, fundus, body, antrum, and pylorus.
Vascular: The stomach is supplied by the gastroepiploic, short, left, and right gastric arteries (which are often derived from the hepatic artery). The celiac axis has all of these branches. The portal vein receives venous drainage from matching veins. The location of portal-systemic anastomosis is the gastro-oesophageal junction.
The lymphatic system is made up of several lymph nodes that follow arteries and give rise to lymph nodes in the stomach, colon, pancreaticoduodenal, splenic, gastroepiploic, portahepatic, paraoesophageal, and para-aortic regions.
nerve supply Terminal branches of the left and right vagus nerves are parasympathetic.
T6–T9 segments that travel via the celiac plexus and are dispersed across the larger splanchnic nerve are considered sympathetic.
Investigational studies
Imaging: If a perforation is suspected, perform an emergency AXR and CXR (erect). CT scan: For determining resectibility and staging.
Endoscopy: endoscopic ultrasound tumor staging, optical generalization for biopsies.
Pre-op: FBC, U&Es, clotting, and crossmatch are the appropriate blood types. Before a final procedure, a staging laparoscopy may be carried out on stomach tumors to determine their resectibility.
After surgery: IV fluids, urine catheter, and NG or nasojejunal tube. prevention of DVT. Parenteral feeding could be required in the first several days following surgery.
Actions
Cutting: Open: Usually a diagonal "sabreslash" incision or an upper midline incision. increased the amount of laparoscopic procedures.
Gastrectomy types:
Subtotal distal gastrectomy (Billroth I). After reconstruction, the proximal stomach's smaller curve is anastomosed to the duodenum. less frequently carried out these days.
Polya partial gastrectomy, or Billroth II: A gastrojejunostomy is created when the proximal gastric remnant is anastomosed to the jejunum following distal stomach resection. A blind loop is created by the oversewing of the duodenum at its proximal end. Bile reflux is a possible side effect of Billroths I and II.
Roux-en-Y partial gastrectomy: The jejunum is divided after the distal stomach is removed, with the proximal jejunum being anastomosed further along the jejunum to form a Roux loop and the distal end being anastomosed to the gastric remnant.
Complete gastrectomy: The entire stomach is removed, and typically a Roux-en-Y loop is used to anastomose the distal oesophagus to the jejunum in order to restore intestinal continuity. The terms "D1 or D2 gastrectomies" refer to the radicality of lymph node clearance. While D2 entails more radical nodal clearance (coeliac, splenic, and common hepatic nodes), D1 requires clearing the N1 or first tier of perigastric nodes. It is possible to do distal pancreatectomy and splenectomy, although doing so raises the rate of operational death (from 4% to 15%) without improving cancer survival.
Oesophagogastrectomy in two phases: carried out for oesophageal or gastrooesophageal junction tumors. The chest phase includes oesophagectomy, lymphadectomy, gastric pull up into the chest, and construction of a gastric tube conduit after abdominal gastric mobilization and lymphadenectomy.
Complications
Early symptoms include bleeding, fistula formation, pancreatitis, anastomotic leak, infection, and duodenal stump leakage.
Long-range: Vitamin B12 deficiency, dumping syndromes (early and late), weight loss, reflux, diarrhea, stomal ulceration, blind loop syndrome, anemia, and metabolic bone disease
Indications
Elective: Severe peptic ulcer illness, benign and malignant tumors.
Emergency: bleeding or puncture that cannot be stopped with local anesthesia; stomach necrosis, such as that resulting from gastric volvulus.
Anatomy
The stomach has minor and greater curvatures and is separated into the cardia, fundus, body, antrum, and pylorus.
Vascular: The stomach is supplied by the gastroepiploic, short, left, and right gastric arteries (which are often derived from the hepatic artery). The celiac axis has all of these branches. The portal vein receives venous drainage from matching veins. The location of portal-systemic anastomosis is the gastro-oesophageal junction.
The lymphatic system is made up of several lymph nodes that follow arteries and give rise to lymph nodes in the stomach, colon, pancreaticoduodenal, splenic, gastroepiploic, portahepatic, paraoesophageal, and para-aortic regions.
nerve supply Terminal branches of the left and right vagus nerves are parasympathetic.
T6–T9 segments that travel via the celiac plexus and are dispersed across the larger splanchnic nerve are considered sympathetic.
Investigational studies
Imaging: If a perforation is suspected, perform an emergency AXR and CXR (erect). CT scan: For determining resectibility and staging.
Endoscopy: endoscopic ultrasound tumor staging, optical generalization for biopsies.
Pre-op: FBC, U&Es, clotting, and crossmatch are the appropriate blood types. Before a final procedure, a staging laparoscopy may be carried out on stomach tumors to determine their resectibility.
After surgery: IV fluids, urine catheter, and NG or nasojejunal tube. prevention of DVT. Parenteral feeding could be required in the first several days following surgery.
Actions
Cutting: Open: Usually a diagonal "sabreslash" incision or an upper midline incision. increased the amount of laparoscopic procedures.
Gastrectomy types:
Subtotal distal gastrectomy (Billroth I). After reconstruction, the proximal stomach's smaller curve is anastomosed to the duodenum. less frequently carried out these days.
Polya partial gastrectomy, or Billroth II: A gastrojejunostomy is created when the proximal gastric remnant is anastomosed to the jejunum following distal stomach resection. A blind loop is created by the oversewing of the duodenum at its proximal end. Bile reflux is a possible side effect of Billroths I and II.
Roux-en-Y partial gastrectomy: The jejunum is divided after the distal stomach is removed, with the proximal jejunum being anastomosed further along the jejunum to form a Roux loop and the distal end being anastomosed to the gastric remnant.
Complete gastrectomy: The entire stomach is removed, and typically a Roux-en-Y loop is used to anastomose the distal oesophagus to the jejunum in order to restore intestinal continuity. The terms "D1 or D2 gastrectomies" refer to the radicality of lymph node clearance. While D2 entails more radical nodal clearance (coeliac, splenic, and common hepatic nodes), D1 requires clearing the N1 or first tier of perigastric nodes. It is possible to do distal pancreatectomy and splenectomy, although doing so raises the rate of operational death (from 4% to 15%) without improving cancer survival.
Oesophagogastrectomy in two phases: carried out for oesophageal or gastrooesophageal junction tumors. The chest phase includes oesophagectomy, lymphadectomy, gastric pull up into the chest, and construction of a gastric tube conduit after abdominal gastric mobilization and lymphadenectomy.
Complications
Early symptoms include bleeding, fistula formation, pancreatitis, anastomotic leak, infection, and duodenal stump leakage.
Long-range: Vitamin B12 deficiency, dumping syndromes (early and late), weight loss, reflux, diarrhea, stomal ulceration, blind loop syndrome, anemia, and metabolic bone disease
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Surgery -Laparoscopic Abdominal Surgery
Indications
minimal access surgery of the abdomen or pelvis, in which a laparoscopic camera (either at a 0°, 30°, or 45° angle) is inserted through a port into the peritoneal cavity for inspection and to direct the manipulation of additional instruments inserted through other ports after a CO2 pneumoperitoneum has been created.
Diagnostic: Used for directed biopsy or emergency assessment of abdominal trauma, as well as for the study of abdominal or pelvic pain, focused liver illness, abdominal masses, and the staging of malignant disease.
Therapeutic: A lot of procedures involving the abdomen can now be completed with minimally invasive techniques. Laparoscopic cholecystectomy, appendixectomy, fundoplication, colectomies, hernia repairs, nephrectomy, prostatectomy, and bariatric operations are among the frequently performed procedures. Other operations, such as laparoscopic-assisted hysterectomy, can benefit from laparoscopy assistance.
Relative contraindications include respiratory insufficiency, the existence of dilated colon, and untreated coagulopathy. Conversion to open surgery may be more likely if prior open surgery was performed ("likelihood of adhesions").
Anatomy
In otherwise healthy patients, the physiological effects of a pneumoperitoneum are typically well tolerated; however, patients with heart disease may find them more difficult to bear.
Cardiovascular: decreased cardiac output; elevated pulmonary and systemic vascular resistance; elevated cardiac preload; decreased renal, hepatic, and splanchnic flow.
Renin and aldosterone, sympathomimetic reaction, and renal vasoconstriction are examples of metabolic and autonomic processes.
Investigational studies
Blood: coagulation and FBC.
as suitable for the planned process.
Actions
carried out while under general anesthesia.
Preparation: Depending on the planned procedure, a nasogastric tube or urinary catheterization can be used to decompress the bladder and stomach, respectively. The abdominal cavity is prepared and draped.
Pneumoperitoneum: There are three ways to gain access to the peritoneal cavity:
Open (Hassan): The fascia is visible after the initial incision. This is separated, and the Hassan trocar can be fastened using fascial sutures. Using two tissue forceps, the peritoneum is gripped, then the peritoneal cavity is forcefully opened, the Hassan trocar is put into it under direct vision, and insufflation is initiated.
Closed Veress needle: The peritoneal cavity is punctured using a Veress needle. There are two areas of resistance in the midline—the fascia and the peritoneum—and three points of resistance farther laterally—the anterior and posterior sheaths and the peritoneum. The free passage of salt aids in verifying accurate positioning. Low CO2 insufflation pressure is ideal; if it's high, move the needle. After the establishment of the pneumoperitoneum, the trocar is placed and the needle is removed. Because this is a blind treatment, there is a greater risk of injury to blood vessels or the bowel.
Optical trocar: Using a transparent, bladeless trocar and a 0 degree laparoscope, the layers of the abdominal wall can be seen while the trocar is being advanced through the wall by applying direct pressure and twisting. beneficial for those who are fat.
Laparoscope insertion: The laparoscope is used to view the peritoneal cavity and safely direct the insertion of additional ports. It is inserted after the white balance has been adjusted to account for the yellow light of the halogen bulb.
Closure: To ensure there is no bleeding, the instruments and ports are removed under direct eyesight, in accordance with the intended process. Pneumoperitoneum deflation and proper wound closure are carried out. Fascial closure is often not necessary for 5mm ports, but depending on their location, bigger ports (10–12 mm) frequently require it to prevent herniation.
Complications
Immediate : Extraperitoneal insufflation, damage to the viscera or vessels (vascular injuries reported to occur 0.04–0.5%, visceral injuries 0.06–0.12%), and open Hassan technique against Veress needle or optical trocar had fewer incidences. diaphragmatic splinting brought on by a high inhalation pressure. Pneumothorax and gas embolism are uncommon.
Early signs and symptoms include shoulder tip pain, wound infection, and the aftereffects of an undiagnosed visceral injury (such as peritonitis after a bowel injury or bile duct damage).
Late : Incisional hernia
Indications
minimal access surgery of the abdomen or pelvis, in which a laparoscopic camera (either at a 0°, 30°, or 45° angle) is inserted through a port into the peritoneal cavity for inspection and to direct the manipulation of additional instruments inserted through other ports after a CO2 pneumoperitoneum has been created.
Diagnostic: Used for directed biopsy or emergency assessment of abdominal trauma, as well as for the study of abdominal or pelvic pain, focused liver illness, abdominal masses, and the staging of malignant disease.
Therapeutic: A lot of procedures involving the abdomen can now be completed with minimally invasive techniques. Laparoscopic cholecystectomy, appendixectomy, fundoplication, colectomies, hernia repairs, nephrectomy, prostatectomy, and bariatric operations are among the frequently performed procedures. Other operations, such as laparoscopic-assisted hysterectomy, can benefit from laparoscopy assistance.
Relative contraindications include respiratory insufficiency, the existence of dilated colon, and untreated coagulopathy. Conversion to open surgery may be more likely if prior open surgery was performed ("likelihood of adhesions").
Anatomy
In otherwise healthy patients, the physiological effects of a pneumoperitoneum are typically well tolerated; however, patients with heart disease may find them more difficult to bear.
Cardiovascular: decreased cardiac output; elevated pulmonary and systemic vascular resistance; elevated cardiac preload; decreased renal, hepatic, and splanchnic flow.
Renin and aldosterone, sympathomimetic reaction, and renal vasoconstriction are examples of metabolic and autonomic processes.
Investigational studies
Blood: coagulation and FBC.
as suitable for the planned process.
Actions
carried out while under general anesthesia.
Preparation: Depending on the planned procedure, a nasogastric tube or urinary catheterization can be used to decompress the bladder and stomach, respectively. The abdominal cavity is prepared and draped.
Pneumoperitoneum: There are three ways to gain access to the peritoneal cavity:
Open (Hassan): The fascia is visible after the initial incision. This is separated, and the Hassan trocar can be fastened using fascial sutures. Using two tissue forceps, the peritoneum is gripped, then the peritoneal cavity is forcefully opened, the Hassan trocar is put into it under direct vision, and insufflation is initiated.
Closed Veress needle: The peritoneal cavity is punctured using a Veress needle. There are two areas of resistance in the midline—the fascia and the peritoneum—and three points of resistance farther laterally—the anterior and posterior sheaths and the peritoneum. The free passage of salt aids in verifying accurate positioning. Low CO2 insufflation pressure is ideal; if it's high, move the needle. After the establishment of the pneumoperitoneum, the trocar is placed and the needle is removed. Because this is a blind treatment, there is a greater risk of injury to blood vessels or the bowel.
Optical trocar: Using a transparent, bladeless trocar and a 0 degree laparoscope, the layers of the abdominal wall can be seen while the trocar is being advanced through the wall by applying direct pressure and twisting. beneficial for those who are fat.
Laparoscope insertion: The laparoscope is used to view the peritoneal cavity and safely direct the insertion of additional ports. It is inserted after the white balance has been adjusted to account for the yellow light of the halogen bulb.
Closure: To ensure there is no bleeding, the instruments and ports are removed under direct eyesight, in accordance with the intended process. Pneumoperitoneum deflation and proper wound closure are carried out. Fascial closure is often not necessary for 5mm ports, but depending on their location, bigger ports (10–12 mm) frequently require it to prevent herniation.
Complications
Immediate : Extraperitoneal insufflation, damage to the viscera or vessels (vascular injuries reported to occur 0.04–0.5%, visceral injuries 0.06–0.12%), and open Hassan technique against Veress needle or optical trocar had fewer incidences. diaphragmatic splinting brought on by a high inhalation pressure. Pneumothorax and gas embolism are uncommon.
Early signs and symptoms include shoulder tip pain, wound infection, and the aftereffects of an undiagnosed visceral injury (such as peritonitis after a bowel injury or bile duct damage).
Late : Incisional hernia
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Surgery - Cataracts
Introduction
Opacification of the ocular lens.
Etiology
The majority of occurrences are age-related idiopathic cataracts, or "senile cataracts."
Among the many secondary reasons are the following:
Local: Intraocular tumors, uveitis, and prior eye trauma.
Systemic conditions include diabetes, myotonic dystrophy, X-ray and UV radiation, medications (steroids), skin conditions (atopic dermatitis, scleroderma), metabolic abnormalities (galactosaemia, hypocalcaemia, Wilson's disease), and genetic syndromes (Down's).
Congenital: Rubella syndrome in children.
Epidemiology
primary global cause of curable blindness. Age-related increases in cataracts, which impair vision, affect 30% of those over 65 in one or both eyes.
History
gradual, painless blindness that occurs.
glare from bright lights: In strong light, eyesight might get worse (particularly if the center lens is opacified).
Some people may see haloes surrounding lights and suffer from monocular diplopia.
Some people may discover that they have "lens convergent power" (nuclear sclerotic cataract) and can read without glasses.
Nystagmus or amblyopia may occur in babies.
Examination
blurry lens look and loss of red reflex. less sharpness in the eyes.
Investigation
In order to choose the best intraocular lens (IOL) implant, biometry is necessary.
Others are superfluous unless they happen early in life or are connected to a systemic illness.
Management
To prevent amblyopia, congenital cataracts need to be treated as away.
The impact of the cataracts on the patient's life and vision will determine whether or not surgery is necessary.
Operative: It is therapeutic to do phacoemulsification (with an ultrasonic probe), aspirate the lens material, and then install the intraocular lens implant. Particular side effects include endophthalmitis, vitreous humour loss, and posterior capsule opacification. usually performed as day surgery under local anesthesia. Steroid drops (for inflammation), antibiotic drops (for infection prophylaxis), avoiding intense exercise, and ocular trauma should all be part of the post-operative treatment.
Complications
None other from a lower standard of living due to diminished visual acuity.
Prognosis
good in treating cataracts brought on by aging.
Introduction
Opacification of the ocular lens.
Etiology
The majority of occurrences are age-related idiopathic cataracts, or "senile cataracts."
Among the many secondary reasons are the following:
Local: Intraocular tumors, uveitis, and prior eye trauma.
Systemic conditions include diabetes, myotonic dystrophy, X-ray and UV radiation, medications (steroids), skin conditions (atopic dermatitis, scleroderma), metabolic abnormalities (galactosaemia, hypocalcaemia, Wilson's disease), and genetic syndromes (Down's).
Congenital: Rubella syndrome in children.
Epidemiology
primary global cause of curable blindness. Age-related increases in cataracts, which impair vision, affect 30% of those over 65 in one or both eyes.
History
gradual, painless blindness that occurs.
glare from bright lights: In strong light, eyesight might get worse (particularly if the center lens is opacified).
Some people may see haloes surrounding lights and suffer from monocular diplopia.
Some people may discover that they have "lens convergent power" (nuclear sclerotic cataract) and can read without glasses.
Nystagmus or amblyopia may occur in babies.
Examination
blurry lens look and loss of red reflex. less sharpness in the eyes.
Investigation
In order to choose the best intraocular lens (IOL) implant, biometry is necessary.
Others are superfluous unless they happen early in life or are connected to a systemic illness.
Management
To prevent amblyopia, congenital cataracts need to be treated as away.
The impact of the cataracts on the patient's life and vision will determine whether or not surgery is necessary.
Operative: It is therapeutic to do phacoemulsification (with an ultrasonic probe), aspirate the lens material, and then install the intraocular lens implant. Particular side effects include endophthalmitis, vitreous humour loss, and posterior capsule opacification. usually performed as day surgery under local anesthesia. Steroid drops (for inflammation), antibiotic drops (for infection prophylaxis), avoiding intense exercise, and ocular trauma should all be part of the post-operative treatment.
Complications
None other from a lower standard of living due to diminished visual acuity.
Prognosis
good in treating cataracts brought on by aging.
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Surgery - Neck of Femur Fracture
Introduction
disruption in the femur's cortical bone continuity at or above the lesser trochanter.
There are two categories into which fractures fall:
Intracapsular: Including subcapital, transcervical, and basicervical; occurs close to the point where the hip joint capsule joins the femur.
Extracapsular: Subtrochanteric or trochanteric
Etiology
osteoporosis and a higher frequency of falls among the elderly; additional risk factors include smoking at the moment, having a BMI below 18.5, having had a mild trauma fracture after age 50, having a mother who has had a hip fracture, hyperparathyroidism, and Paget's disease.
anatomy Since the retinacular arteries that travel back along the capsule are the primary source of blood supply to the femoral head, intracapsular fractures have the potential to disrupt this supply and cause avascular necrosis.
Epidemiology
Frequent in the elderly; lifetime risk for women is 18%, for men it is 6%. 12/100 (over 85 years old), 3/100 (65–74 years old).
History
Hip pain and movement restriction may arise from a slight fall in the past.
Examination
There is hip pain and the affected leg is shortened, adducted, and externally rotated.
Investigations
Blood: coagulation, G&S, U&Es, and FBC.
Imaging: Lateral images of the hip and plain AP radiographs. If the diagnosis is unclear, an MRI, a bone scan, or further plain radiographs should be taken 24 to 48 hours later. CXR in case elderly patients need surgery.
Management
Prevention: Risk evaluation and fall-risk reduction measures.
Medical: For primary or secondary prophylaxis, calcium, vitamin D, HRT, selective oestrogen receptor modulators, bisphosphonates, calciumitonin, fluoride, and thiazides have been utilized.
Prompt: Analgesia, resuscitation, electrolyte and fluid imbalance correction, pressure area care. It is recommended that patients undergo surgery within a day to minimize the possibility of thrombotic problems and pressure damage.
Undisplaced intracapsular fractures: Hemiarthroplasty may be taken into consideration in the extremely old; internal fixation permits early mobilization and lowers the chance of fractures becoming displaced.
Displaced intracapsular fractures: Hemiarthroplasty or total hip replacement (may be acceptable in patients with pre-existing joint illness, good activity levels, and a fair life expectancy), open reduction and internal fixation (for younger, more active patients).
Unless there is a medical reason not to, extracapsular fractures should be surgically treated with reduction and internal fixation using either intramedullary (such as gamma nail implants) or extramedullary (such as sliding screws and plates).
Antibiotic prophylaxis during induction and DVT prevention have to be administered to all patients.
Complications
Early symptoms include pain, immobility, infections, pressure sores (20%), pulmonary problems (ARDS, fat embolism, pneumonia), DVT (asymptomatic up to 45%, symptomatic up to 11%), and PE (3–13%).
Implant failure, non-union, and avascular necrosis of the femur head are late symptoms.
Prognosis
After a hip fracture, the elderly have a high death rate (30% at one year), with 25% needing more extensive long-term care.
Introduction
disruption in the femur's cortical bone continuity at or above the lesser trochanter.
There are two categories into which fractures fall:
Intracapsular: Including subcapital, transcervical, and basicervical; occurs close to the point where the hip joint capsule joins the femur.
Extracapsular: Subtrochanteric or trochanteric
Etiology
osteoporosis and a higher frequency of falls among the elderly; additional risk factors include smoking at the moment, having a BMI below 18.5, having had a mild trauma fracture after age 50, having a mother who has had a hip fracture, hyperparathyroidism, and Paget's disease.
anatomy Since the retinacular arteries that travel back along the capsule are the primary source of blood supply to the femoral head, intracapsular fractures have the potential to disrupt this supply and cause avascular necrosis.
Epidemiology
Frequent in the elderly; lifetime risk for women is 18%, for men it is 6%. 12/100 (over 85 years old), 3/100 (65–74 years old).
History
Hip pain and movement restriction may arise from a slight fall in the past.
Examination
There is hip pain and the affected leg is shortened, adducted, and externally rotated.
Investigations
Blood: coagulation, G&S, U&Es, and FBC.
Imaging: Lateral images of the hip and plain AP radiographs. If the diagnosis is unclear, an MRI, a bone scan, or further plain radiographs should be taken 24 to 48 hours later. CXR in case elderly patients need surgery.
Management
Prevention: Risk evaluation and fall-risk reduction measures.
Medical: For primary or secondary prophylaxis, calcium, vitamin D, HRT, selective oestrogen receptor modulators, bisphosphonates, calciumitonin, fluoride, and thiazides have been utilized.
Prompt: Analgesia, resuscitation, electrolyte and fluid imbalance correction, pressure area care. It is recommended that patients undergo surgery within a day to minimize the possibility of thrombotic problems and pressure damage.
Undisplaced intracapsular fractures: Hemiarthroplasty may be taken into consideration in the extremely old; internal fixation permits early mobilization and lowers the chance of fractures becoming displaced.
Displaced intracapsular fractures: Hemiarthroplasty or total hip replacement (may be acceptable in patients with pre-existing joint illness, good activity levels, and a fair life expectancy), open reduction and internal fixation (for younger, more active patients).
Unless there is a medical reason not to, extracapsular fractures should be surgically treated with reduction and internal fixation using either intramedullary (such as gamma nail implants) or extramedullary (such as sliding screws and plates).
Antibiotic prophylaxis during induction and DVT prevention have to be administered to all patients.
Complications
Early symptoms include pain, immobility, infections, pressure sores (20%), pulmonary problems (ARDS, fat embolism, pneumonia), DVT (asymptomatic up to 45%, symptomatic up to 11%), and PE (3–13%).
Implant failure, non-union, and avascular necrosis of the femur head are late symptoms.
Prognosis
After a hip fracture, the elderly have a high death rate (30% at one year), with 25% needing more extensive long-term care.
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Surgery - Septic Arthritis
intra-articular joint infection.
Introduction
Bacteria can penetrate the joint directly, such as through a puncture wound, or they might spread hemorrhagically from nearby osteomyelitis or from a contaminated prosthesis. An inflammatory response in the joint is triggered by bacteria. A joint effusion is caused by permeability and fluid secretion. Activation of neutrophils and macrophages results in the production of proteolytic enzymes, which, in conjunction with bacterial toxins, cause destruction to the articular cartilage. Fibrosis and bony ankylosis may occur as a result of the raw articular surfaces recovering during the healing process.
Staphylococcus aureus, Neisseria gonorrhoeae in adults, and Haemophilus influenzae or coliforms are the most often occurring causal organisms in children under three years old.
R isk Factors
Septic arthritis is more common in those with diabetes, IV drug misuse, immunocompromised individuals, and those with chronic joint diseases (such as rheumatoid arthritis).
Epidemiology
50% of cases in children under three years old, incidence 6/100,000.
History
fever, malaise, and joint or limb pain.
usually only affects one big joint, such as the hip in young children, who may exhibit a limp and a refusal to bear weight. While it can affect any joint, older children and adults are more likely to have knee pain.
Examination
a red, swollen joint; if it's the hip, hold the leg flexed and move it slightly outside to loosen up the ligaments and lessen joint strain.
widespread joint soreness accompanied by a sharp decrease in range of motion.
Skin pustules in the vicinity of the joint may be present if gonococcal arthritis is present.
Investigations
Blood: CRP, ESR, FBC, and blood cultures.
Together with microscopy, culture, and sensitivity, aspiration Aspirate typically murky material including several neutrophils; culture to determine the causing pathogen.
Joint space, soft tissue edema, and in severe cases, subchondral bone loss are all seen on a joint radiograph.
Joint region shows increased absorption on a bone scan.
USS: May direct aspiration in order to detect a joint effusion.
Management
Surgical: To remove pus and infectious material, surgical washout of the joint is usually necessary. may be carried out through an open operation (arthrotomy) or by arthroscopy.
When a prosthetic joint develops sepsis, the prosthesis must be removed in order to completely eradicate the infection.
Health: IV antibiotics for two weeks at first, then oral antibiotics for a further four to six weeks.
For pain relief, analgesics and a splint should be applied to the joint.
To keep joints mobile and avoid fibrosis, physiotherapy is offered.
Complications
Joint damage or dislocation, growth disturbance, ankylosis, avascular necrosis of the epiphysis, or subsequent osteoarthritis.
Prognosis
Outcomes are depending on the virulence of the organism, duration of infection previous to diagnosis, the pre-morbid status of the patient and the joint affected; e.g. knees have better outcomes than ankles. The prognosis is often favorable with prompt, proper therapy.
intra-articular joint infection.
Introduction
Bacteria can penetrate the joint directly, such as through a puncture wound, or they might spread hemorrhagically from nearby osteomyelitis or from a contaminated prosthesis. An inflammatory response in the joint is triggered by bacteria. A joint effusion is caused by permeability and fluid secretion. Activation of neutrophils and macrophages results in the production of proteolytic enzymes, which, in conjunction with bacterial toxins, cause destruction to the articular cartilage. Fibrosis and bony ankylosis may occur as a result of the raw articular surfaces recovering during the healing process.
Staphylococcus aureus, Neisseria gonorrhoeae in adults, and Haemophilus influenzae or coliforms are the most often occurring causal organisms in children under three years old.
R isk Factors
Septic arthritis is more common in those with diabetes, IV drug misuse, immunocompromised individuals, and those with chronic joint diseases (such as rheumatoid arthritis).
Epidemiology
50% of cases in children under three years old, incidence 6/100,000.
History
fever, malaise, and joint or limb pain.
usually only affects one big joint, such as the hip in young children, who may exhibit a limp and a refusal to bear weight. While it can affect any joint, older children and adults are more likely to have knee pain.
Examination
a red, swollen joint; if it's the hip, hold the leg flexed and move it slightly outside to loosen up the ligaments and lessen joint strain.
widespread joint soreness accompanied by a sharp decrease in range of motion.
Skin pustules in the vicinity of the joint may be present if gonococcal arthritis is present.
Investigations
Blood: CRP, ESR, FBC, and blood cultures.
Together with microscopy, culture, and sensitivity, aspiration Aspirate typically murky material including several neutrophils; culture to determine the causing pathogen.
Joint space, soft tissue edema, and in severe cases, subchondral bone loss are all seen on a joint radiograph.
Joint region shows increased absorption on a bone scan.
USS: May direct aspiration in order to detect a joint effusion.
Management
Surgical: To remove pus and infectious material, surgical washout of the joint is usually necessary. may be carried out through an open operation (arthrotomy) or by arthroscopy.
When a prosthetic joint develops sepsis, the prosthesis must be removed in order to completely eradicate the infection.
Health: IV antibiotics for two weeks at first, then oral antibiotics for a further four to six weeks.
For pain relief, analgesics and a splint should be applied to the joint.
To keep joints mobile and avoid fibrosis, physiotherapy is offered.
Complications
Joint damage or dislocation, growth disturbance, ankylosis, avascular necrosis of the epiphysis, or subsequent osteoarthritis.
Prognosis
Outcomes are depending on the virulence of the organism, duration of infection previous to diagnosis, the pre-morbid status of the patient and the joint affected; e.g. knees have better outcomes than ankles. The prognosis is often favorable with prompt, proper therapy.
