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Enclose both the Documentation Basic right and left vagus nerves in the latex drain and divide all the phrenoesophageal attachments behind the esophagus 60caps confido amex. If • Findings the right (posterior) vagus trunk courses at a distance from • Placement of wrap relative to vagus nerves the esophagus 60caps confido with visa, it is easier to dissect the nerve away from • Closure of hiatus? Some exclude both vagus trunks from the wrap confido 60caps mastercard, but we prefer to include them inside the loose Operative Technique wrap. Before the complete circumference of the hiatus can be visualized, it is necessary to divide not only the phreno- Incision esophageal ligaments but also the cephalad portion of the gastrohepatic ligament, which often contains an accessory Elevate the head of the operating table 10–15°. The midline incision beginning at the xiphoid and continue exposure at the conclusion of this maneuver is seen in about 2–3 cm beyond the umbilicus (Fig. Insert a Thompson or Upper Hand retractor to behind the gastric fundus to identify the gastrophrenic liga- elevate the lower portion of the sternum. Reduce the hiatus ment and divide it carefully down to the proximal short gas- tric vessel (Fig. While the assistant is placing traction on the latex drain to draw the esophagus in a caudal direction, pass the right hand to deliver the gastric fundus behind the esophagus (Fig. Apply Babcock clamps to the two points on the stomach where the first fundoplication suture will be inserted and bring these two Babcock clamps together tentatively to assess whether the fundus has been mobilized sufficiently to accomplish the fundoplication without tension. Generally, there is inadequate mobility of the gastric fun- dus unless one divides the proximal one to three short gastric vessels. On the greater curvature aspect of the esophagogastric junction, there is usually a small fat pad. Insert the first fundoplication suture by taking a bite of the fundus on the patient’s left using 2-0 atraumatic Tevdek. Attach a hemostat to A number of surgeons place sutures fixing the upper tag this stitch but do not tie it. Each bite should contain margin of the Nissen wrap to the esophagus to prevent the 5–6 mm of tissue including submucosa, but it should not entire wrap from sliding downward and constricting the penetrate the lumen. To perform a fundoplication without tension, it after considerable experience, advocated a Nissen wrap is necessary to insert the gastric sutures a sufficient distance measuring only 1 cm in length, claiming that longer wraps lateral to the esophagogastric junction. Each suture should contain one bite of fundus, then wrap has effectuated excellent control of reflux. No structed this wrap employing one horizontal mattress suture more than 2–3 cm of esophagus should be encircled by the of 2-0 Prolene buttressed with Teflon pledgets (Figs. If this cannot be plication sutures by inserting a continuous seromuscular done, the wrap is too tight. If a satisfactory repair has been accomplished, 3–4 cm of distal esophagus becomes progressively narrower, tapering to a point at the gastroesophageal junction. If this taper- ing effect is not noted, it suggests that the wrap may be too loose. Successful antireflux procedures, whether by the Nissen, Hill, Belsey, or Collis-Nissen technique, show similar narrowing of Fig. Complications Testing Antireflux Valve Dysphagia, usually transient “gas bloat” (rare) Disruption of fundoplication Ask the anesthesiologist to inject 300–400 ml saline solution Slipping downward of fundoplication with obstruction into the nasogastric tube and then withdraw the tube into the Postoperative paraesophageal hernia if hiatal defect was not esophagus. If the saline cannot be forced into the esophagus by Herniation of fundoplication into thorax moderate manual compression of the stomach, the fundopli- Esophageal or gastric perforation by deep necrosing sutures cation has indeed created a competent antireflux valve. Randomized trial to study the effect of fundic mobilization on long-term results of Nissen fundoplication. Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery. Comparison of long-term outcome of laparoscopic and conventional Nissen fundo- plication: a prospective randomized study with an 11-year follow- up. Scott-Conner Indications necessarily a bit different from those for the open procedure, and several additional features should be noted. Symptomatic reflux esophagitis refractory to medical therapy First, the hiatus is accessed by elevating the left lobe of Barrett’s esophagus (consider mucosal ablation) the liver without dividing its attachments. Second, the esoph- agus is exposed and mobilized by dissecting the crura with minimal manipulation of the esophagus. The resulting exten- Preoperative Preparation sive mediastinal dissection that accompanies esophageal mobilization makes approximation of the crura mandatory. Finally, several short gastric vessels must be divided to ensure creating a floppy wrap. See references at the end for this and other adaptations to newer Injury to the esophagus. We Operative Technique prefer the laparoscopic Nissen fundoplication because it is intended to be virtually identical to a well-established open Room Setup and Trocar Placement procedure when completed. The steps in the dissection are Position the patient with the legs slightly spread and sup- ported on padded stirrups (Fig. We place the primary monitor at the patient’s left shoulder, with a secondary monitor at the C. Scott-Conner shape by tightening the cable in the commodious right sub- phrenic space and is then passed underneath the liver. The liver retractor is properly placed when stable expo- sure is obtained, and the diaphragmatic surface is seen behind the left lobe of the liver. This exposure gen- erally requires that the retractor be “toed in” so the part of the retractor closest to the hiatus has maximal lift applied. The laparoscope and instruments are then insinuated under- neath the left lobe of the liver in the working space thus created. Generally, the stomach and some omentum partially or completely obscure the hiatus even with the liver retracted. Therefore the second part of obtaining exposure entails plac- ing an endoscopic Babcock clamp on the stomach and pull- ing toward the left lower quadrant (Fig. Dissecting the Hiatus The esophagus is dissected by clearing the peritoneum off the hiatus and carefully exposing the muscular crura. Properly performed, this maneuver automatically exposes the esophagus and creates a posterior window. A grasper is used to elevate the flimsy lesser omentum close New York: Springer; 1999) to the hiatus, and ultrasonic dissecting scissors are used to divide the omentum (Fig. It is tempting to begin this dissection by opening the directly facing the hiatus (Fig. If you tial puncture site (to be used for the laparoscope), recall that begin your omental window high, however, near the hiatus, the hiatus is quite high and deep. A trocar pattern must be indi- additional advantage of keeping the window in the lesser vidualized according to the patient’s body habitus.

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In adolescent coxa vara order discount confido, the attitude is one of marked external rotation with slight adduction possibly due to eversion of the femur resulting from upper epiphyseal separation discount confido 60 caps fast delivery. In congenital dislocation of the hip confido 60caps visa, the attitude is one of lordosis, which is particularly marked in bilateral cases with undue protrusion of the abdomen anteriorly and the buttock posteriorly. In unilateral cases the grooves between the labia (girls are more often affected) and the thigh are Fig. Note the deformity of of flexion, abduction and flexion, adduction and can be noticed. It must be remembered that flattening of the buttock and loss of gluteal fold may be brought about by flexion of the limb besides muscular wasting. Tenderness — of the hip joint is elicited by applying steady pressure inwards over the two greater trochanters (Fig. Tenderness over the joint a little below the midinguinal point can be elicited in any arthritis. Palpation of the greater trochanter is important to note whether it is broadened or tender and whether it is displaced upwards or not. As the hip joint lies in its socket and is heavily clothed with strong muscles all around, this joint is almost inaccessible. The deformity is one of marked finger is pressed deep to detect if there is any tenderness or not. For cold abscess one should search the following regions : (a) in front of and medial of the greater trochanter, (b) on the medial side of the femoral vessels, (c) posteriorly in the gluteal region and (d) rarely in the pelvis from perforation of acetabulum. Such abscess may gravitate towards the ischio-rectal fossa and may burst to form fistula-in-ano. This artery passes over the head of the femur and this bony support helps its palpation. In congenital dislocation the head of the femur is dislocated and this bony support is missing. During examination the clinician must always compare the range of a certain movement of the affected joint with that of the sound counterpart. This is because of the fact that the range of each movement varies according to the individuals. Simultaneous steady pressure Flexion — with the knee extended cannot be done inwards over the two greater trochanters elicits more than 90° due to the tension of the hamstring pain on the affected side. Extension — is permitted to about 15°; Abduction — to about 40°; Adduction — to about 30°, that means the limb can be made to cross the middle third of the other thigh. Internal rotation — is possible to about 30° and external rotation — to about 45°. During testing the movements (both active and passive movements) one must make sure that the pelvis does not move. When there is a "fixed feel in congenital dislocation of hip because flexion deformity", the exact range of free flexion present of loss of bony support. The thigh of the sound side is held and the patient is asked to make an attempt to flex the affected hip. Any bending of the thigh beyond the position of "fixed flexion" is the range of free flexion permissible to the joint. When there is no fixed flexion deformity, extension of the hip joint is best tested by lying the patient ■“■■■■ ■ in prone position on the table and asking him to lilt allected limb (fig. In case of children the thumb and the middle finger of the left hand of the clinician are used to touch the two anterior superior iliac spines so that any movement of the pelvis will be detected Fig. It may be noted that the abduction is the first movement to be restricted in tuberculous arthritis. It is noted whether the limb crosses the sound thigh at its upper third or middle third or lower 5. Note that the clinician touches the two anterior clinician places the Hk superior iliac spines to detect any flat of his hand upon movement of the pelvis. Rotatory movement can also be tested by flexing both the hip and the knee joints of the affected side to the right angles and then rotating the thigh internally and externally Fig. These movements are also method of testing the abduction move­ tested by asking the patient to lie on his face to flex the ment with acutely flexed knees. The restriction of different movements depends upon the nature of affection of the hip joint. In any arthritis, including tuberculous variety, restriction of all the movements is the characteristic feature. In adolescent coxa vara, there will be limitation of abduction and internal rotation, but adduction and external rotation are not only be free but often exaggerated. In congenital dislocation of the hip, abduction and rotations are limited to varying degree, flexion and extension are free whereas adduction is excessive. So testing rotations of the hip joint the following three tests are performed when this condition keeping both the hip and knee joints is suspected. The hip is now flexed to 90° and the knee is grasped with the other hand of the clinician, who pushes the thigh downwards along the axis of the thigh with this hand, while the other hand notes Fig. This test can be performed in ‘fixed flexion’ defor­ telescopic test" is seen in performed in ‘fixed flexion’ defor­ mity of the hip. The lower limbs are now completely adducted and pressure is exerted downwards along the bony axis of the femur while the little fingers of both the hands are placed on the greater trochanters. The little fingers on the greater trochanter are now pushed inwards simultaneously. When only length of the thigh is measured, measurement is taken from anterior superior iliac spine to the joint line of the knee. It must be remembered before taking the measurement that the interspinous line is brought to the horizontal Fig. While comparing the length of the affected limb with that of the sound limb, the sound limb must be placed in the same position as the affected one. This mark is made on both the limbs and circumferences of the limbs at that level are compared. The greater trochanter is raised in dislocation of the hip, separation of the upper femoral epiphysis (adolescent coxa vara) and to a slight extent when the head of the femur eroded e. Rectal examination should be undertaken in tuberculous arthritis if an intrapelvic abscess is suspected. The thigh of the normal side has of the femur becomes obvious this line will be been adducted the affected hip is deformed in adduction.

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These pass at the levels of 2 inches (5 cm) confido 60caps with amex, 5 inches (12 cm) and 7 inches (17 cm) above the lateral malleolus order confido mastercard. If an individual stands motionless for a long period of time purchase cheap confido, venous pressure at the ankle may rise to 80 to 100 mm. Even with modest activity of the calf muscles and with competent venous valves, this pressure is reduced to 20 or 30 mm. The superficial veins have loose fatty tissue to support them and thus suffer from varicosity. There are three types of varicosity — primary varicose veins, secondary varicose veins and congenital varicose veins. The defects may be congenital or acquired (either due to thrombosis or due to inflammation in the veins. These cases are mostly due to either congenital arteriovenous fistula or cavernous (venous) haemangioma. This causes failure of the valves quickly giving rise to varicosity of the long or short saphenous vein. During prolonged standing the calf muscles also do not work quite often so the calf pump mechanism also cannot push the venous blood upwards. Pregnancy acts in various ways — (i) Progesterone causes dilatation and relaxation of the veins of the lower limb. This hormonal effect is maximum in the first trimester of pregnancy, (ii) Pregnant uterus causes pressure on the inferior vena cava, thus causing obstruction to the venous flow. After each pregnancy both hormonal and mechanical effects are removed and there is improvement of varicosity. During the subsequent pregnancy these factors again cause the varicosities to develop in a bigger way. Forcible contraction of the calf muscles may force blood through the perforating veins in reverse direction. Such cramp is usually due to sudden change in the calibre of communicating veins which stimulates the muscles through which they pass. These dilated veins may or may not be associated with the following complications. When this varix is tapped with a finger, a fluid thrill may be obtained in the long saphenous vein lower down in the limb. One must assess in inspection whether varicosity has affected the long saphenous vein or the short saphenous vein or the both. The skin of the lower part of the leg should be particularly inspected to exclude oedema, pigmentation, eczema or ulceration. In both the methods, the patient is first placed in the recumbent position and his legs are raised to empty the veins. The sapheno-femoral junction is now compressed with the thumb of the clinician and the patient is asked to stand up quickly, (i) In first method, the pressure is released. If the varices fill very quickly by a column of blood from above, it indicates incompetency of the sapheno-femoral valve. This is called a positive Trendelenburg test, (ii) To test the communicating system, the pressure is not released but maintained for about 1 minute. Gradual filling of the veins during the period indicates incompetency of the communicating veins, mostly situated on the medial side of the lower half of the leg allowing the blood to flow from the deep to the superficial veins. This is also considered as a positive Trendelenburg test and the positive tests are indications for operation. In this test the tourniquet is tied around the thigh or the leg at different levels after the superficial veins have been made empty by raising the leg in recumbent position. Firstly the varicosed- below it remain collapsed, it indicates presence of leg is to be raised to empty the veins. Now the sapheno-femoral junction is Similarly if the veins below the tourniquet fill rapidly compressed as in this figure with the whereas veins above the tourniquet remain empty, the thumb of the clinician and the patient is incompetent communicating veins must be below the asked to stand up. Thus by moving the tourniquet down the leg continued for about 1 minute gradual in steps one can determine the position of the incompetent filling of the veins during this period communicating vein. Firstly an Esmarch it indicates incompetency of the sapheno­ elastic bandage is applied from toes to the groin. The students are referred tourniquet is then applied at the groin at the upper end of to Figs. A tourniquet is tied round the upper part of the thigh tight enough to prevent any reflux down the vein. If the communicating and the deep veins are normal the varicose veins will shrink whereas if they are blocked the varicose veins will be more distended. An expansile impulse if felt in the long saphenous varicose vein, it may be presumed that the sapheno-femoral valve is incompetent. Similarly if the patient coughs and the sapheno-femoral junction is incompetent a bruit may be heard on auscultation. The examiner palpates along the line of the marked varicosities carefully, so that he can find gap or small pit in the deep fascia which transmits the incompetent perforator. These veins develop due to inferior vena caval obstruction particularly thrombosis. Such veins are more often seen in the flanks communicating with the veins of the chest wall, tributaries of the superior vena cava. Ulcers in the lower limb with presence of varicose veins may not necessarily be the venous ulcers. In these cases varicose vein is the second pathology and not the cause of the ulcer. Of the above-mentioned methods ascending phlebography is the most practical and valuable in the average hospitals. A narrow tourniquet is applied just above the malleoli to direct blood flow into the deep veins. It is a useful investigating procedure for suspected deep vein thrombosis when ultrasonography is not available. Descending venography is performed by inserting a cannula in the femoral vein and the contrast material is injected with the patient standing.

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