By G. Daryl. Greenleaf University. 2019.

Make a small enterotomy in the center of the purse-string suture and pass a suction catheter through it purchase zocor online now, threading the catheter across the ileocecal valve into the Operative Position cecum cheap 20mg zocor overnight delivery. If there is a possibility that the colectomy and total proctec- tomy will be performed in one stage order zocor 20mg line, position the patient in Lloyd-Davies leg rests (see Fig. Otherwise, the Dissection of Right Colon and Omentum usual supine position is satisfactory. Make an incision in the right paracolic peritoneum lateral to the cecum and insert the left index finger to elevate the avas- Incision cular peritoneum, which should be divided by scissors in a cephalad direction (Fig. If local inflammation has pro- We prefer a midline incision because it does not interfere duced increased vascularity in this layer, use electrocautery with the ileostomy appliance. Throughout the dissection keep lower quadrant free of scar in case ileostomy revision and manipulation of the colon to a minimum. On the colic incision around the hepatic flexure, exposing the ante- other hand, many surgeons use a left paramedian incision rior wall of the duodenum. Mobilize the splenic to the transverse mesocolon, it may be divided simultane- flexure as described in Chap. In patients who suffer from toxic megacolon, per- ations, the omentum can be dissected off the transverse colon form this dissection with extreme caution so as not to perfo- through the usual avascular plane (Fig. Dissection of Left Colon Division of Mesocolon Remain at the patient’s right side and make an incision in the Turn now to the ileocecal region. If the terminal ileum is not peritoneum of the left paracolic gutter in the line of Toldt, involved in the disease process, preserve its blood supply and beginning at the sigmoid. With the aid of the left hand elevate select a point of transection close to the ileocecal valve. Apply an Allen clamp to the specimen side of the ileum, and ligate the ileocolic branches and the right colic, middle and with a scalpel transect the ileum flush with the stapler. Inspect the staple line to ensure that proper B formation of the staples has occurred. Divide the mesentery of the rectosigmoid up to the point Ileostomy and Sigmoid Mucous Fistula on the upper rectum that has been selected for transection, which is generally opposite the sacral promontory. Apply a The technique of fashioning a permanent ileostomy, includ- right-angle renal pedicle clamp to the colon to exclude ing suturing the cut edge of the ileal mesentery to the right colonic contents from the field. After the sigmoid mesentery a linear scratch mark on the antimesenteric border of the has been divided up to a suitable point on the wall of the ileum beginning at a point 1 cm proximal to the staple line distal sigmoid, divide the colon with De-Martel clamps (as and continuing in a cephalad direction for a distance equal to shown) or a linear cutting stapler. After the sutures are tied, cut all the tails the appendices epiploicae to the anterior rectus fascia. Close except for the two end sutures, to which small hemostats the abdominal incision around the mucous fistula. Then make incisions on the antimesen- Alternatively, the closed distal bowel can be returned to teric border of the ileum and the back wall of the rectum the abdomen as a Hartmann’s pouch. Initiate closure of the posterior mucosal layer by tional tips on safe construction of a Hartmann’s pouch. With one needle insert a continuous locked suture to approximate all the coats of the Ileoproctostomy posterior layer, going from the midpoint to the right corner of the anastomosis. Use the other needle to perform the same When an ileorectal anastomosis is elected, we prefer the maneuver going from the midpoint to the left (Fig. Close the final anterior seromuscular layer edge of the right lateral paracolic peritoneum with a continu- with interrupted 4-0 silk Cushing sutures (Fig. Apply an Allen clamp to the specimen side of the colon, which should be transected with removal of the specimen. This eliminates the colon and any source of con- Closure of the Abdominal tamination in cases of toxic megacolon. Then perform Incision abdominoperineal proctectomy by the technique described in Chap. If there was no operative contamination, discontinue the operative antibiotics within 6 h. Otherwise, continue antibiotics, modi- fying as indicated by the operative findings and the postop- erative course. In the operating room apply a Stomahesive disk to the ileostomy after cutting a properly sized opening. Instruct the patient in the details of ileostomy management and encourage him or her to join one of the organizations of ileostomates, where considerable emotional support can be derived by meeting patients who have been successfully rehabilitated. Intra - abdominal abscess is more common after colon resec- tion for inflammatory bowel disease than for other condi- Further Reading tions. Colectomy and ileorectal anas- Intestinal obstruction due to adhesions is not rare tomosis in patients with Crohn’s disease. Outcome of following this group of operations because of the extensive ileorectal anastomosis for Crohn’s colitis. Restorative Proctocolectomy 5 7 with Mucosal Proctectomy and Ileal Reservoir Carol E. Chassin† Indications Pitfalls and Danger Points Patients with chronic ulcerative colitis or familial polyposis Performing an inadequate mucosectomy, which may pro- in whom total proctocolectomy is indicated but preserva- duce a cuff abscess and possibly lead later to carcinoma tion of continence is desired Establishing inadequate pelvic, reservoir, or anastomotic hemostasis, which may result in postoperative hemor- rhage or hematoma Contraindications Injuring the nervi erigentes or the hypogastric nerves so sex- ual impotence or retrograde ejaculation results Cohn’s disease Failing to diagnose Crohn’s disease, resulting in Crohn’s Perianal fistulas ileitis in the reservoir Rectal muscular cuff that is strictured and fibrotic, not soft Using improper technique when closing the temporary loop and compliant ileostomy (if one is utilized), which leads to postoperative leakage or obstruction Preoperative Preparation Operative Strategy Treat inflammation and ulcerations of the lower rectum pre- operatively. If the patient has had a subtotal colectomy Multiple techniques have been described for restorative and ileostomy, it may be necessary to treat the rectum proctocolectomy. The method described here has served with steroid enemas or free fatty acid enemas to restore well and accomplishes maximum ablation of the abnormal rectal mucosal integrity. An alternative technique avoids the mucosal proc- Nutritional rehabilitation is applied when necessary. A roticulating linear stapler and circular stapler Foley catheter is placed in the bladder. The anastomosis is constructed 1–2 cm above the den- Crohn’s disease is suspected after subtotal colectomy. If one-stage colectomy with reconstruction is anticipated, This double-stapled technique may be simpler in obese appropriate mechanical and antibiotic bowel preparation patients and is preferred by some surgeons. Chassin Mucosectomy to the tip of the coccyx, it is not possible to expose the lower rectum down to the level of the puborectalis muscle.

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While waiting for the ophthalmologist order cheap zocor on-line, administer systemic carbonic anhydrase inhibitors (such as acetazolamide) and apply topical beta-blockers and alpha-2–selective adrenergic agonists cheap 10 mg zocor otc. The eyelids are inflamed purchase zocor 10 mg free shipping, tender, red, and swollen; and the patient is febrile—but the key finding when the eyelids are pried open is that the pupil is dilated and fixed, and ocular motion is very limited. Chemical burns of the eye require massive irrigation, like their counterparts elsewhere in the body. Start irrigation with plain water as soon as possible, and do not wait until arrival at the hospital. At the hospital, irrigation with saline is continued, corrosive particles are removed from hidden corners, and before the patient is sent home, pH is tested to assure that no harmful chemicals remain in the conjunctival sac. Retinal detachment is another emergency that should be recognized by all physicians. The person with 1 or 2 floaters may only have vitreous tugging at the retina, with little actual detachment. The person who describes dozens of floaters, or “a snow storm” within the eye, or a big dark cloud at the top of his visual field has a big horseshoe piece of the retina pulled away, and is at risk for detachment of the remaining retina. Emergency intervention, with laser “spot welding,” will protect the remaining retina. Embolic occlusion of the retinal artery is also an emergency, although little can be done about it. Retinal damage may have already occurred, and proper treatment may prevent its progression. Young people diagnosed with type I often develop eye problems after 20+ years of living with diabetes. Congenital masses (seen in young people) are typically present for years before they become symptomatic (get infected). Inflammatory masses are typically measured in days or weeks; after a few weeks an inflammatory mass has reached some kind of resolution. Surgical removal includes the cyst, the middle segment of the hyoid bone, and the track that leads to the base of the tongue (Sistrunk procedure). Branchial cleft cyst occurs laterally, along the anterior edge of the sternomastoid muscle, anywhere from in front of the tragus to the base of the neck. It is typically several centimeters in diameter, and sometimes has a little opening and blind tract in the skin overlying it. Cystic hygroma (lymphatic malformation) is found at the base of the neck as a large, spongy, ill-defined mass that occupies the entire supraclavicular area and seems to extend deeper into the chest. Persistent enlarged lymph node (a history of weeks or months) could still be inflammatory, but neoplasia has to be ruled out. There are several patterns that are suggestive of specific diagnosis, as detailed below. Lymphoma is typically seen in young people; they often have multiple enlarged nodes (in the neck and elsewhere) and have been suffering from low-grade fever and night sweats. Metastatic tumor to supraclavicular nodes invariably comes from below the clavicles (and not from the head and neck). It is commonly on the left side (Virchow’s node) close to where the thoracic duct empties into the L-subclavian vein. Squamous cell carcinoma of the mucosae of the head and neck is seen in older men who smoke, drink, and have rotten teeth. Often the first manifestation is a metastatic node in the neck (typically to the jugular chain). The ideal diagnostic workup is a triple endoscopy (or panendoscopy) looking for the primary tumor. Treatment involves resection, radical lymph node dissection, and very often radiotherapy and platinum-based chemotherapy. Other presentations of squamous cell carcinoma include persistent hoarseness, persistent painless ulcer in the floor of the mouth, or persistent unilateral earache. Facial nerve tumors produce gradual unilateral facial nerve paralysis affecting both the forehead and the lower face, as opposed to sudden onset paralysis which suggests Bell’s palsy. Parotid tumors are visible and palpable in front of the ear, or around the angle of the mandible. Most are pleomorphic adenomas, which are benign but have potential for malignant degeneration. A hard parotid mass that is painful or has produced paralysis is a parotid cancer. A formal superficial parotidectomy (or superficial and deep if the tumor is deep to the facial nerve) is the appropriate way to excise—and thereby biopsy —parotid tumors, preventing recurrences and sparing the facial nerve. In malignant tumors the nerve is sacrificed and a nerve interposition graft performed. A 2-year- old with unilateral earache, unilateral rhinorrhea, or unilateral wheezing has a little toy truck (or another small toy) in his ear canal, up his nose, or into a bronchus. Airway Foreign Body Noted on Chest X-ray Copyright 2007 Gold Standard Multimedia Inc. The usual findings of an abscess are present, but the special issue here is the threat to the airway, which arises from swelling of the tongue. Incision and drainage are done, but intubation and tracheostomy may also be needed to protect the airway. Bell’s palsy produces sudden paralysis of the facial nerve for no apparent reason. Although not an emergency per se, current practice includes the use of antiviral medications—and as is the case for other situations in which antivirals are used, prompt and early administration is the key to their success. Patients who have normal nerve function at the time of admission and later develop paralysis are likely to have swelling that will resolve spontaneously. Cavernous sinus thrombosis is heralded by the development of diplopia (secondary to paralysis of extrinsic eye muscles) in a patient suffering from frontal or ethmoid sinusitis. Epistaxis in children is typically from nosepicking; the bleeding comes from the anterior septum, and phenylephrine spray and local pressure control the problem. In teenagers the prime suspects are cocaine abuse (with septal perforation) or juvenile nasopharyngeal angiofibroma. Posterior packing may be needed for the former, and surgical resection is mandatory for the latter (the tumor is benign, but it can erode into nearby structures). Sometimes angiographic or surgical ligation of feeding vessels is the only way to control the problem.

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The regional lymph node is enlarged buy online zocor, which may be supratrochlear lymph node or axillary lymph node buy generic zocor online. In tuberculous dactylitis order zocor toronto, the affected bone becomes enlarged, spindle-shaped and painful. First the proximal phalanx and then - I the middle phalanx are flexed but the terminal phalanx Fig. The little and the Volkmann’s ischaemic contracture — is due to rinS fingers are affected by contracture. The vascular injury which result in muscular infarction and thickened nodule is shown by an arrow, subsequent contracture. The radial pulse is constantly absent and the skin temperature of the affected hand will definitely be lower than its healthy counterpart. Congenital contracture of the little finger — is commonly seen during early childhood. Mallet finger is a typical deformity in which there is persistent flexion of the terminal phalanx. This is due to rupture of the extensor tendon either at its insertion or due to an avulsion fracture of the base of the terminal phalanx. The middle-aged women are frequently the victims and the most commonly affected finger is the middle or the ring finger. A palpable nodular thickening may develop in the long flexor tendon opposite the head of the metacarpal or there may be a constriction in the tendon sheath which is responsible for this condition. Attrition rupture of the extensor pollicis longus is also a condition most commonly seen in middle-aged women. While working with the thumb suddenly the patient experiences a snap and the thumb falls adducted helplessly and the patient fails to extend the terminal interphalangeal joint of the thumb. In the beginning there will be hypertrophy of the synovial membrane of the joints (Pannus). Deformity is the most prominent feature in late cases — (i) Ulnar drift is common at the metacarpo-phalangeal joint as the normal line of the pull of the finger tendon is slightly towards the ulnar side, synovial swelling tends to push the extensor tendon medially and in the normal resting posture gravity favours ulnar deviation; (ii) Swan- neck deformity, i. It is felt as definite bony ridge across the palmar and dorsal surfaces of the affected joints. These nodes are due to osteoarthrosis, though these do not herald osteoarthrosis of other joints. Women near menopause are usually involved, though males are also rarely involved due to repeated trauma to the finger in games like cricket or baseball and the lesion is almost always solitary in males. Barbers may have interdigital pilonidal sinus at the web space often between the middle and ring fingers of the right hand. Clipped hairs usually have bevelled tips like those of hypodermic needles which may penetrate the skin of the web space which does not have hair follicles. In female hair dressers such lesion may be seen in interdigital clefts between the toes in those who are accustomed not to use stockings particularly in hot climate. A soft cystic swelling is found mostly in the finger and occasionally in the hand which is neither attached to the skin nor to the deeper structures. The tumour is derived from a glomus body — an arteriovenous anastomosis incorporating nerve tissue. A peculiar characteristic feature is that the tenderness is reduced considerably by applying a sphygmomanometer cuff and inflating it above the systolic blood pressure. The main feature is an hour-glass shaped swelling bulging above and below the flexor retinaculum. Cross fluctuation can be elicited from the swelling above and below the flexor retinaculum. With careful palpation one can feel movements of the melon-seed bodies within the bursa. When the patient complains of pain, a careful enquiry must be made as to the site of the pain, onset of the pain and duration of the pain. Pain at the neck of the 2nd metatarsal bone after a long walking is probably due to march fracture (stress fracture). Plantar fasciitis gives rise to pain on the ball of the heel particularly on walking. In case of deformity one should carefully note the type of deformity, its duration and whether it is associated with any other deformity in the body. In pes planus the longitudinal arch is flattened so that the navicular region may be seen bulging. There may be swelling, ulcer or sinus in the foot, which is examined in the usual way as described in the respective chapters. Tenderness beneath the heel may be due to plantar fasciitis or a bony spur underneath the calcaneal tuberosity. Tenderness at the neck of the 2nd metatarsal bone after a long march is due to march fracture. In dorsiflexion the angle between the front of the leg and the dorsum of the foot is diminished. In plantar flexion this angle is increased, the heel is raised and the toes point downwards. A considerable range of rotatory movement is permitted at both talocalcanean (subtalar) joint and talocalcaneonavicular joint. The calcaneus and the navicular carrying the foot with them can be moved medially on the talus and this movement results in elevation of the medial border and corresponding depression of the lateral border of the foot so that the plantar aspect of the foot faces medially and this is called inversion of foot. The obliquity of this axis accounts for the adduction and slight flexion of the foot that accompany inversion. The opposite movement of this is known as eversion, the range of which is much more limited due to tension of the Tibialis anterior and Tibialis posterior and the strong deltoid (medial) ligament of the ankle joint. Both active and passive movements of these should be carefully measured to know the excessive limitation of a particular movement. Since flexion and extension take place at the talocrural (ankle) joint, the passive movements of these can be tested by holding with one hand the lower end of the leg and with the other hand the proximal part of the foot so as to include the talus within the hand and both flexion and extension passive movements are tested. In case of inversion and eversion the passive movements are tested by holding the very lower end of the leg with one hand to fix the talus and then with other hand hold the heel of the foot and then twist the foot medially and laterally.

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Division of this nerve may result in atrophy and hemostat buy zocor 20 mg cheap, simply apply a suture-ligature to control it discount zocor 40mg with amex. Dissect the fat and When the lateral margin of the major pectoral muscle has fascia off the anteroinferior edge of the coracobrachialis been reached discount 10 mg zocor amex, use a combination of blunt and sharp dissec- muscle using a scalpel. Directly inferior to this muscle is tion to elevate the edge of the pectoral muscle from its invest- the brachial plexus and the axillary vessels. This maneuver maintains continuity between the dissection of the inferior border of the coracobrachialis in a breast, the pectoral fascia, and the lymph nodes of the axilla. If it is necessary to divide the muscle, use coagulating the major pectoral muscle, which is then elevated with a current to divide this muscle near its insertion (Fig. Deep to the minor pectoral muscle that was divided is a well-defined fat pad Axillary Vein Dissection overlying the junction of the cephalic and axillary veins. Not only is it unnecessary to strip all of the fat from the the scalpel can accomplish this, most surgeons prefer to use brachial plexus, this maneuver produces lifelong painful Metzenbaum scissors. Do not divide the lary vein from the region of the latissimus muscle to the subscapular vein, which enters the axillary vein from clavicle, it is necessary to flex the upper arm. Many pathologists prefer that a third label be attached at the point where the minor pectoral muscle crosses the axillary specimen. The upper boundary of the axillary dissection is the crossing of the clavicle over the axillary vein. Detach the lymphatic and areolar tissue at this point with the electro- coagulator. Now make a scalpel incision in the clavipectoral fascia on a line parallel to and 1 cm below the axillary vein. Do not retract the axillary vein in a cephalad direction, as it might expose the underlying axillary artery to injury during this step. If suspicious nodal tissue is identified cephalad to the axillary neurovascular bundle, biopsy it to document the extent of disease. Dissect the areolar and lymphatic tissues off the inter- costal muscles and ribs going from medial to lateral. When the minor pectoral muscle is encountered, divide it 2–3 cm from its origin with the electrocoagulator (Fig. If this muscle was not divided earlier in the operation, it is not necessary to resect it. As the chest wall is cleared laterally, one or two intercostobrachial nerves are seen emerging from the intercostal muscle on their way to innervate the skin of the upper inner arm. Because these nerves penetrate the specimen, divide them even though it results in a sen- sory deficit in the upper inner arm (Fig. This maneuver exposes the long thoracic nerve that runs along the rib cage in the anterior axillary line in a vertical direction from above downward to innervate the anterior serratus muscle. The thoracodorsal nerve can be identified as it leaves the area of the subscapular vein and runs both laterally and downward together with the thoracodorsal artery and vein to innervate the latissimus dorsi muscle. Because these two nerves run close to the peripheral boundary of the dissection, they should be preserved when no metastatic lymph nodes are seen in their vicinity. Detach the lymphatic tissue inferior to the portion of the axillary vein that crosses over the latissimus muscle. Preserving the long thoracic nerve is complicated by the fact that a number of small veins cross over the nerve in its distal portion. Circumvent this difficulty by moving the partly detached breast in a medial direction so it rests on the patient’s chest after freeing the specimen from the anterior border of the latissimus muscle. Then make an incision in the fascia of the serratus muscle 1 cm medial to the long thoracic nerve. Dissecting this fascia a few centimeters in a medial direction detaches the entire specimen from the chest wall (Fig. We use sterile water, which lyses not only clot and blood, making it easier to spot Fig. Insert two large closed suction drains through puncture wounds into the lower axilla. Bring one catheter deep to the axillary vein and the other catheter across the thoracic wall from the puncture wound to the region of the sternum. Suture each catheter to the skin at the site of the puncture wounds and attach to closed suction drainage (Fig. Be certain there is no signifi- cant tension on the incision; otherwise, postoperative necro- sis of the skin flap may be anticipated. Do not permit either of the skin flaps at the lateral margin of the incision to become bunched up in such a fashion that a “dog-ear” forms. The “dog-ear” deformity can be eliminated by excising a triangular wedge of skin as noted in Figs. When closed suction drainage is used postoperatively, it is not necessary to apply a bulky pressure dressing. Consequently, skin necrosis should be anticipated when purple discoloration Leave the two closed suction drainage catheters in place until appears in the skin flap on the fifth or sixth day following the daily drainage diminishes to 30–40 ml/day or about mastectomy. We use a standardized series of graded ensued, and primary healing of the skin graft may be antici- physical exercises to ensure that the woman regains full pated. It is, of course, Take appropriate steps throughout postoperative treatment to far preferable to prevent skin necrosis in the first place by ensure the patient’s emotional and physical rehabilitation. Wound Infection Aspirate any significant collections of serum underneath the skin flaps with a sterile syringe and needle as Wound infection is uncommon in the absence of skin necessary. Refer the patient for adjuvant chemotherapy or for participa- tion in one of many clinical trials. Follow the patient for local recurrence or the development of Seromas cancer in the opposite breast. Once the initial period of close follow-up is completed, we Collections of serum underneath the skin flap, seromas occur follow these patients annually for life. This problem edema, which can become a disabling complication if appears more commonly in obese patients. On rare occa- trauma, including sunburn, to the arm and forearm of sions, this process continues for several months. If at any time the hand is traumatized case, it is preferable to make an incision under local anesthe- or there is any evidence of infection in the hand or arm, sia and insert a drain.

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