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Instead of passing the silk order viagra soft 50mg amex erectile dysfunction medication side effects, a stainless steel wire may be passed round the deeper part of the track purchase genuine viagra soft line impotence with antihypertensives. Horse-shoe fistula is usually not treated by radical unroofing procedure (fistulotomy). Instead a posterior midline internal sphincterotomy combined with laying open the deep part of the fistula track is performed. Haemorrhoids are clearly divided into two categories — internal and external haemorrhoids. Internal haemorrhoid means it is within the anal canal and internal to the anal orifice. The external haemorrhoid is situated outside the anal orifice and is covered by skin. The two varieties may coexist and the condition is called intero-external haemorrhoids. There are two peculiar conditions which are associated with external haemorrhoid — (i) Dilatation ofthe veins at the anal verge is sometimes seen in persons of sedentary life particularly during straining, (ii) Perianal haematoma or thrombosed external haemorrhoid. This condition is due to back pressure on the anal venule consequent upon straining at stool, coughing or lifting heavy weight. If untreated, it may resolve by itself or may suppurate or may fibrose giving rise to a cutaneous tag or may burst giving rise to bleeding. The opening in the skin is packed with gauze wrung in light antiseptic solution to allow the wound to heal by granulation tissue. The more problem appears in cases of anteriorly or posteriorly placed perianal haematoma. Once dilatation of the venous plexus as well as partial prolapse would occur with each bowel movement it would stretch the mucosal suspensory ligament. The pathology of the so called haemorrhoidal plexus is in fact a corpus cavemosum with direct arteriovenous communication. This plexus is termed corpus cavernosum rectum, which is a normal constituent in the upper third of the anal canal. Hyperplasia of the corpus cavemosum rectum may result from failure of mechanism controlling the arteriovenous shunts producing superior haemorrhoidal veins varicosity and haemorrhoids. These are:— (a) Carcinoma of the rectum — compresses on the superior rectal veins and gives rise to haemorrhoid. The pedicle is covered vyith pale pink mucosa and through it a large tributary of the superior rectal vein can be seen. Associated external haemorrhoid is present in long continued cases of internal haemorrhoid. Each primary internal haemorrhoid contains main terminal divisions of superior rectal artery and vein. There are three main terminal divisions of such superior rectal vessels arranged in the lefrlateral, right anterior and right posterior positions. Besides these three primary haemorrhoids, there may be small secondary haemorrhoids in between. As the veins become larger and heavier, partial prolapse will occur with each bowel movement gradually stretching the mucosal suspensory ligament at the dentate line until the 3rd degree haemorrhoid results. This mucosal haemorrhoid alongwith the prolonged dilatation of internal haemorrhoid may also cause 3rd degree or prolapsed haemorrhoids. At this stage great discomfort is complained of with a feeling of heaviness in the rectum. During second and third degree haemorrhoid, internal haemorrhoids may be seen only when patient strains and that too transiently and the prolapse disappears after the straining is over. The obturator is then removed and with an illuminator the inside of the anal canal is visualised. The proctoscope is now withdrawn slowly and the internal haemorrhoid will be seen bulging into the proctoscope. Besides these there are a few complication which may occur in a haemorrhoid and are described below. A patient, with first degree haemorrhoid for quite a long time will become anaemic. Only when a bleeding haemorrhoid is retracted, it may bleed internally into the rectum. The patient notices an acute swelling at the anal verge which is extremely painful. This possibly occurs due to high venous pressure during excessive straining efforts. Pain may continue for a week or so until the oedema subsides and the thrombosis is absorbed. When the internal haemorrhoid prolapses and becomes gripped by the external sphincter, further congestion occurs as the venous return becomes impeded and strangulation occurs. Strangulation is associated with considerable pain and it is often called ‘acute attack of piles’. Unless the internal haemorrhoid is reduced immediately strangulation is followed by thrombosis. Sloughing occurs which is usually superficial, but occasionally the whole haemorrhoid may slough off leaving an ulcer which gradually heals by itself. Very occasionally massive gangrene may initiate spreading anaerobic infection and portal pyaemia. Fibrosis of external haemorrhoid is much more common than that of an internal haemorrhoid. In the beginning, the fibrosed pile is sessile, but by repeated traction during defaecation it becomes pedunculated. This usually follows infection and suppuration of the haemorrhoid, which ultimately causes portal pyaemia and liver abscesses. Therefore any haemorrhoid treatment must be preceded by sigmoidoscopy and barium enema. Associated fissure-in-ano should also be excluded and if present should be treated first. Treatment of haemorrhoid should start with bowel regulation which has a prophylactive effect, but once the haemorrhoid is established there is no evidence that the process is readily irreversible. Topical ointments for local applications may do good by reducing oedema and pruritus. During an attack of piles some relief of discomfort may be obtained by use of suppositories. Manual dilatation of the anus is frequently successful in relieving symptoms probably by preventing congestion of haemorrhoidal veins. The most commonly used sclerosant is 5% phenol in almond or arachis oil with 140 mg of menthol to make 30 ml solution (Albright solution). This solution is injected into the submucosa around the pedicle of the haemorrhoid with two objects in view.

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Similarly viagra soft 100 mg low cost erectile dysfunction pills for diabetes, with the index finger leading the minimal manipulation of the tumor while they use the oper- way buy cheap viagra soft 100mg on line erectile dysfunction pills images, use Metzenbaum scissors to complete the incision in a cau- ative sequence of first liberating the left colon and then dal direction, liberating the sigmoid colon from its lateral attach- ligating the lymphovascular attachments. Division of Renocolic Ligament Technique of Anastomosis With the descending colon retracted toward the patient’s right, a filmy attachment can be visualized covering the renal Because the anastomosis is generally intraperitoneal and the capsule and extending medially to attach to the posterior sur- rectal stump is largely covered by peritoneum, the leak rate face of the mesocolon (see Fig. Anastomosis may be done disrupt this renocolic attachment, which resembles a liga- by the end-to-end technique or the Baker side-to-end method ment, using a gauze pad in a sponge holder, but this maneu- based on the preference of the surgeon. Instead, divide this struc- end-to-end anastomosis (please refer to the section below on ture with Metzenbaum scissors near the junction of the Stapled Colocolonic Functional End-to-End Anastomosis). Insert the right index finger underneath the upper Splenic Flexure Dissection portion of this ligament and pinch it between the index finger and thumb; this maneuver localizes the lienocolic ligament The lower pole of the spleen can now be seen. The ligament should be divided by the first assis- divide any adhesions between the omentum and the cap- tant guided by the surgeon’s right index finger. By inserting the sule of the spleen to avoid inadvertent avulsion of the index finger 5–6 cm farther medially, an avascular pancreatico- splenic capsule (due to traction on the omentum). It is an ing occurs because the splenic capsule has been torn, it can upper extension of the transverse mesocolon. After this struc- usually be controlled by applying a piece of topical hemo- ture has been divided, the distal transverse colon and splenic static agent. Occasionally sutures on a fine atraumatic nee- flexure become free of all posterior attachments. At this stage identify and divide the attachments between the omentum and the lateral aspect of the trans- verse colon. Remember to differentiate carefully between Ligation and Division of Inferior the fat of the appendices epiploica and the more lobu- Mesenteric Artery lated fat of the omentum (see Operative Strategy, above). Free the omentum from the distal 10–12 cm of transverse Make an incision on the medial aspect of the mesocolon colon (Fig. If the tumor is located in the distal from the level of the duodenum down to the promontory transverse colon, leave the omentum attached to the of the sacrum. Sweep Division of Mesocolon the lymphatic tissue in this vicinity downward, skeleton- izing the artery, which should be double ligated with 2-0 Depending on the location of the tumor, divide the mesoco- silk at a point about 1. It is not necessary to skele- tonize the anterior wall of the aorta, as it could divide the preaortic sympathetic nerves, which would result in sex- Ligation and Division of Mesorectum ual dysfunction in male patients. If the preaortic dissec- tion is carried out by gently sweeping the nodes laterally, Separate the distally ligated pedicle of the inferior mesenteric the nerves are not divided inadvertently. Now divide the artery and the divided mesocolon from the aorta and iliac vessels inferior mesenteric vein as it passes behind the duodeno- down to the promontory of the sacrum. Now divide the stump of surrounding fat and areolar tissue at the point selected upper rectum and remove the specimen. Completely clear surrounding fat and areolar tissue from a cuff of rectum 1 cm in width so seromuscular sutures may be inserted accurately. Insertion of Wound Protector Insert a Wound Protector ring drape or moist laparotomy End-to-End Two-Layer Anastomosis, Rotation pads into the abdominal cavity to protect the subcutaneous Method panniculus from contamination when the colon is opened. Confirm that a cuff of at least 1 cm of serosa Expose the point on the proximal colon selected for division. Completely clear the areolar tissue enters from the right lateral margin of the anastomosis. If the diameter of the lumen of one of the segments of the distal end of the specimen in the same manner by apply- bowel is significantly narrower than the other, make a 51 Left Colectomy for Cancer 475 Fig. If the rectal stump is not bound to the sacrum and if it can be rotated easily for 180°, it is more efficient to insert the anterior seromuscular layer as the first step of the anastomosis. Insert interrupted 4-0 silk atraumatic Lembert seromus- cular guy sutures, first to the lateral border of the anastomosis and then to the medial border. After all the anterior sutures have been inserted, tie them After all the suture tails are cut, permit the anastomosis to and cut all the suture tails except for those of the two end rotate back 180° to its normal position. Complete this When the rectum and colon cannot be rotated 180° as layer with a continuous locked suture through the full required for the method described above, an alternative thickness of the bowel (Fig. Then, with the same technique must be used in which the posterior seromuscu- two needles and using a continuous Connell or Cushing lar layer is inserted first. At the conclusion of the layer, tie all the sutures and cut all the tails except for those of the suture of 4-0 silk into the left side of the rectum and the two lateral guy sutures. Do not tie this suture; grasp it in a hemo- with a double-armed atraumatic suture of 5-0 Vicryl. Place a second, identi- the suture in mattress fashion in the midpoint of the posterior cal suture on the right lateral aspects of the rectum and layer of mucosa and tie it (Fig. At this point pass the needle from the inside to the outside of the rectum and hold it temporarily in a hemostat. Grasp the remaining needle and insert a continuous locked suture of the same type, beginning at the midpoint and continuing to the right lateral margin of the bowel. Then grasp the needle emerging from the Stapled Colorectal Anastomosis left lateral margin of the incision and insert a similar continu- ous Connell or Cushing stitch. Complete the anterior muco- To construct a stapled colorectal anastomosis, first close the sal layer by tying the suture to its mate and cutting the tails proximal descending colon with a 55/3. Apply an Allen clamp to the specimen Complete the anterior seromuscular layer by inserting side and divide the colon flush with the stapler. Alternatively, divide the colon with closing the mesentery by invaginating the colon through the a cutting linear stapler. Do not remove the specimen; retain it so mild 51 Left Colectomy for Cancer 481 ses, the stapling technique illustrated in Figs. When a stapled anastomosis is constructed distal to the sacral promontory, the circular stapling technique (see Chap. However, for all other intraperito- neal anastomoses of small and large bowel, we have developed a modification of the end-to-end anastomosis. This modifica- tion, described in the following steps, avoids the possibility that six rows of staples are superimposed, one on the other, as may happen with the Steichen method. Align the two open ends of bowel to be anastomosed side by side with the antimesenteric borders of each in contact. Insert the linear cutting stapling instrument, placing one fork in each lumen (Fig. Draw the mesenteric bor- ders of the bowel in the direction opposite to the loca- tion of the stapler. Place the 90 mm linear stapler in the proper position and upward traction on it can stabilize the rectum during applica- fire it (Fig. Finally, insert a single 4-0 atraumatic silk seromuscular the rectal stump at a point 1 cm distal to the staple line Lembert suture at the base of the anastomotic staple line already in place (Fig. This prevents any undue distracting force wounds opposite each other, placing the proximal colonic from being exerted on the stapled anastomosis. Insert the linear cutting stapling device, with one fork in the rectal stump and the other in the proximal colonic segment (Fig. Allis Closure clamps or guy sutures may be used to approximate the rec- tum and colon in the crotch of the stapler. Close the abdominal incision in Carefully inspect all the staple lines to ascertain that the sta- routine fashion without placing any drains in the peritoneal ples have closed properly into the shape of a B. Intracorporeal colorectal anastomosis fol- lowing laparoscopic left colon resection.

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This is due to the fact that acid peptic juice after coming out into the greater sac flows alongthe right paracolic gutter to gravitate down to the right iliac fossa buy viagra soft us erectile dysfunction protocol ebook free download. In a thin patient it is retracted or scaphoid with the rectus muscles thrown into prominence buy viagra soft 100mg cheap injections for erectile dysfunction that truly work. The rigidity is highest at the epigastric and right under the right cupula of the diaphragm which is hypochondriac region. On auscultation the abdomen is silent and there is definite absence of normal peristaltic sound of the intestine. From the moment of perforation this stage takes about 2 to 6 hours depending on the size and site of the perforation. At this stage the patient is relieved, and it cannot be more deplorable if the surgeon also gets relief. The pathology of peptic perforation is being continued and the worst stage of peritonitis is on the way, when it will be difficult to save the patient. At this stage the pulse continues to be high and the temperature gradually rises to normal and higher. The patient looks toxic (facies hippocratica) with pallor, sweating, pinched face, anxious look and bright eyes. On inspection there is gross distension of the abdomen with the accumulation of gas and fluid in the paralysed intestine. Special Investigations — Diagnosis is made mainly on clinical examination, (i) To confirm the diagnosis a straight X-ray of the abdomen with the patient in the erect or sitting position will show gas under the right cupula of the diaphragm in 75% of cases. If the patient is not able to sit or stand, a lateral X-ray film with the patient on one side may show the gas under the diaphragm or the gas bubble has shifted. It must be emphasised that negative X-ray findings do not exclude the diagnosis of perforation, (ii) Aspiration of the peritoneal cavity may show bile-stained fluid which is alkaline and indicates perforation of duodenal ulcer, (iii) Some clinics have used X-ray pictures of the abdomen following injection of 60 ml of 50% Gastrografm down a nasogastric tube. The dye escapes through the perforation, thus making it possible to identify its exact site. Hourly aspiration should be continued, (iii) Intravenous infusion should be started immediately. A specimen of blood is taken for blood count, blood grouping, and electrolyte estimations. Amount of fluid infused should replace the daily fluid requirement (approximately 2. Considering the fact that simple suture treatment has achieved 85% cure rate if the ulcer is acute, but only 25% if the ulcer is chronic, so definitive surgery is indicated, (i) When the ulcer is chronic with a long history; (ii) When there is history of previous perforation, (iii) When there is history of previous haemorrhage; (iv) Those who were treated by medicine; (v) Some surgeons prefer to perform definitive operation when the patient comes within 6 hours of perforation; (vi) Suspicion of malignancy in a perforated gastric ulcer. It is a well known fact that considering total number of cases both acute and chronic, after simple suture operation. Muscle relaxants have added greatly to the ease of performance of the operation and wound closure. On opening the peritoneal cavity there is often an escape of gas and lots of fluid will be seen in the peritoneal cavity. The right lobe of the liver is drawn upwards with a suitable retractor and the stomach is brought out of the wound dragging to the left of the patient exposing whole of the lesser curvature of the stomach, the pylorus and the first part of the duodenum. In case of the stomach the perforation is commonly situated on the anterior aspect of the lesser curvature. If the site of perforation is not obvious, acareful search may reveal a posterior gastric ulcer which has ruptured into the lesser sac. In case of duodenum perforation mostly lies in the anterior or superior aspect of the first part of the duodenum. The simplest method of closing the perforation is to introduce three interrupted sutures of No. The first one is at the upper part of the perforation, the second one at the lower part of the perforation and the third one through the middle of the perforation. During application, the ligatures are not tied immediately, but the ends are held separately with artery forceps. A convenient portion of greater omentum is laid over the perforation and the sutures are then tied gently over the greater omentum. Too much tension on the sutures may cause them to cut out when the gut wall is oedematous. Drainage is necessary when the patient comes after 6 hours of perforation and there is frank pus in the peritoneal cavity. The drain is given to the Rutherford Morison’s pouch and/or to the right paracolic gutter. In addition it is wise to drain the superficial layers of the abdominal incision in obese patient, as peritoneum is more apt to tackle infection than the abdominal wound. When there is definite indication (discussed earlier), when the surgeon is experienced and the facilities are available one can go for definitive operation in peptic perforation. In case of perforated gastric ulcer the definitive operation is partial gastrectomy — Billroth I operation with an end-to-end gastroduodenal anastomosis. A few surgeons often recommend vagotomy plus pyloroplasty and closure of perforated gastric ulcer, but particularly in view of high association of carcinoma with this lesion, Billroth I gastrectomy seems to be more justified. In case of perforated duodenal ulcer the definitive operation is vagotomy and gastrojejunostomy. A few surgeons prefer to perform pyloroplasty through the perforated duodenal ulcer. But in majority of cases there is gross induration and oedema of the duodenum adjacent to the pylorus which is not suitable for pyloroplasty. Pneumoperitoneum is being achieved with carbondioxide and a telescope is inserted through a 10 mm subumbilical port. A needle holder is inserted through a second port of 5 mm diameter and a forceps is inserted through another port of same diameter. If one is not sure of the diagnosis and if the patient shows any sign of general peritonitis, immediate operation as mentioned in the treatment of acute perforation is advised. Residual abscess is not uncommon in these cases which may require aspiration or drainage in the later part of treatment. Peptic Ulcer Haemorrhage Peptic ulceration causing haemorrhage may be either an acute or chronic lesion. But it may also occur from stomal ulcer (following gastrojejunostomy operation), from ulceration of the oesophagus in association with hiatus hernia or Barrett’s ulcer or it may occur from ectopic gastric mucosa in a Meckel’s diverticulum. They may only be diagnosed if endoscopy is performed within a day or two of the bleeding. They may be seen as small, discrete lesions with hyperaemic margin and sometimes with a large vessel exposed at the base of the ulcer. Gastric lesions are often associated with low rate of acid secretion, whereas the duodenal ulcers develop when there is high rate of acid production. There appears to be an increased tendency to haemorrhage if the patient is of blood group ‘O’. In case of gastric ulcer bleeding usually occurs from chronic ulcer near lesser curvature. In case of duodenal ulcer the ulcer is often situated on the posterior wall and bleeding occurs from a branch of gastroduodenal artery. The initial haemorrhage is usually not fatal, except when the bleeding vessel is unusually big.

Serum insulin level is usually high with originating in the Mediterranean area like Arab effective viagra soft 100mg erectile dysfunction treatment alprostadil, Turkish discount viagra soft express l-arginine erectile dysfunction treatment, hypoglycemia. Te teeth are 5 Generalized bone maturation delay and defective and crowded due to micrognathia. Alopecia is ofen 5 Epiphyseal closure occurs after age 16–18 in girls seen in males (. Patients are usually obese due to underdevelopment of 5 Underdeveloped facial bones, with thin diploe of bones and muscles. Hands and 5 Atlantoaxial joint degeneration and spinal stenosis feet are small (acromicria). It is due to failure of the three dens ossification centers to fuse together with the axis body. It is seen as a round ossicle with smooth edges over the axis body in open mouth view (best view to evaluate the dens). It may be impossible to differentiate os odontoideum from a previous old dens fracture without history. Carney’s syndrome is a diferent clinical condi- tion characterized by a triad of several neoplasms including gastric epithelioid leiomyosarcoma, pulmonary chondroma,. Calcification is frequently seen, and the mass shows heterogeneous contrast enhancement. Laron syndrome (primary growth hormone resis- tance or insensitivity): the personal experience 1958– 2003. Cutaneous signs are important in the diagnosis of rare neoplasia syndrome Carney complex. Osteoporosis can arise due to unknown reasons (primary) or due to pathological conditions (secondary). Bones reach their peak density in the third decade of life Further Reading and then decrease gradually at the rate of 0. Pituitary pathology in patients with carney This percentage is higher in women at the menopause, which complex: growth-hormone producing hyperplasia or may reach up to 8% per year. Osteoporosis afects the axial tumors and their association with other abnormalities. Laron syndrome abnormalities: spinal ste- sis seen in patients between 20 and 45 years of age with the nosis, Os odontoideum, degenerative changes of the same clinical features as the juvenile form. Te gas is produced from the surrounding sof tissues, and its accumulation mechanism is poorly understood. Osteonecrosis of the vertebral end plates with negative pressure between the bone fragments is mandatory to release gas from the surrounding tissue, a situation that can be clas- sically seen in osteoporotic vertebral fractures and collapse. Vacuum phenomenon is also seen in osteonecrosis due to long-term corticosteroid therapy, diabetes mellitus, arterio- sclerosis, multiple myeloma, and alcoholism. T e main diferential diagnosis of the intravertebral vac- uum phenomenon is gas produced by osteomyelitis and malignancies. In infectious gaseous production, the gas has high pressure and tends to accumulate in small collections, plus extends into the adjacent sof tissues, which is not seen in vacuum phenomenon where gas is limited to the bony or intradiskal areas. Kümmel’s disease is a term used to describe vacuum phe- nomenon within a vertebra that arises from vertebral end plates osteonecrosis and vertebral collapse. Kümmel’s disease represents healing failure of an osteoporotic vertebral frac- ture with the formation of pseudoarthrosis (false joint). Normally, the cortex in the mid-shaft of the second metacarpal should be almost one third the thickness of the metacarpal width. It is typically seen as long lucent lines parallel to the long axis of the bone (. It can kyphosis of the thoracic vertebrae due to osteoporosis be mistaken with lytic lesions of Ewing’s sarcoma (dowager’s hump) and multiple myeloma (. Patients 10 min of the scan, the vacuum area is seen as a experience progressive pain in one joint that can last from hypointense area on T2W images. Peak intensity of the pain is experienced into T2 hyperintense signal between 20 and usually in the second and third months afer the initial presen- 40 min after positioning. Tere is no history of trauma or signs suggesting joint 5 I n Kümmel’s disease, the vertebral end plates are infection (e. Te symptoms resolve sponta- seen compressing over the fractured area in neously ofen between 4 and 11 months afer presentation. Signs on Radiographs Typically, there is osteopenia of the afected joint compared to the other joint which normally shows no osteopenia (unless the patient is generally osteoporotic). Secondary osteoporosis is seen in association with other clin- 5 Joint effusion is seen in 75 % of patients. The plain radiograph shows no signs of obvious pathology or diminished bone density. Te intravertebral vacuum phenomenon as include low dietary calcium and tobacco smoking. Kummel disease: a not-so-rare complica- Rickets is a group of conditions characterized by accumula- tion of osteoporotic vertebral compression fracture. Metabolic bone disease: osteoporosis and of nonmineralized bony matrix in the mature skeleton of osteomalacia. Bones are made up of bony cells surrounded 5 Congenital rickets due hypophosphatemia (low by extracellular matrix. Te osteoid is secreted by the developing rickets or osteomalacia are loss of the 3 osteoblasts, and it accounts for 35% of the bone mass. Te inor- Patients with rickets ofen present with bowing of the ganic materials are what give bone its density and account legs, swollen joints, bone pain, and muscle weakness. Rickets and osteomalacia are with rickets due to vitamin D resistance may present with diseases of matrix mineralization, while osteoporosis is a alopecia. Afer osteoid mineralization, the mineralized collagens are arranged in either woven or lamellar pattern. Woven bone D i f erential Diagnoses and Related Diseases is immature bone with its fbers not arranged in any direc- tion. Normally it presents in life as a transitional stage and Dent’s disease is a rare disease characterized by X-linked then is replaced by lamellar bone. Woven bone is not found in recessive hypophosphatemic rickets, idiopathic low molecu- mature skeleton normally; however, it is produced during lar weight proteinuria, and X-linked recessive nephrolithia- healing of fractures or remodeling (callus formation). Patients with this disorder commonly present with presence indicates abnormality when found in mature skele- hypercalciuria, nephrocalcinosis, and renal failure at ton. Lamellar bone, on the other hand, is mature bone with its advanced stage of the disease. Radiological investigations in fbers arranged in a certain pattern to withstand mechanical these patients include plain radiographs of the bone to show pressure.

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