Lecture Notes On Surgery - Part II - Dr. Yogiram Bolisetty

Lecture notes on surgery Part II Dr.
Yogiram Bolisetty
DISEASES OF VERMIFORM APPENDIX

Anatomy
Appendix = annexum (a part attached to main structure) It is vestigial diverticulum of large bowel. The three longitudinal coats, i.e., taenia coli of colon fuse to form single sheet of longitudinal coat of appendix. It is situated in the RIF arising from the base of caecum. It has a mesentery transmitting appendicular artery, a branch of ileocolic artery. Its position is variable, but its base is constant at Mc Burneys point. It may be on the left side of abdomen in situs- inversus and non-rotation of gut.
Mc Burneys point
The surface anatomy of the appendix is variable, because of the variable positions of the appendix. But, its base is constant at this point, which is situated on the spino-umbilical line (a line joinig anterior superior iliac spine with umbilicus) at the junction of its lateral one-third to medial two-thirds.
Position of appendix in relation to caecum

Its position is variable Retrocaecal 74% Para caecal 2% Sub caecal 1.5% Pre ileal 1% Post ileal 0.5% Pelvic 21%
Histology
It is same as that of colon. In addition, it contains Kultschitzsky (argentaffin cells) cells.
Congenital anomalies
Rare Agenesis Duplication
Inflammatory disorders Acute appendicitis

Fitz coined the term acute appendicitis and advised early operation. It was called as perityphlitis before Fitz.
Aetiology
The probable causes are
Dr. Yogirams lectures on surgery
Local peritonitis General peritonitis Spread of infection Methods of spread A) Gradual transmural spread B) Intramural oedema causing occlusion of terminal part of appendicular artery gangrene and perforation of the tip spreading peritonitis Abuse of purgatives (promotes peristalsis) Perforation of appendix Extremes of age Pelvic appendix Previous abdominal operations which limit the mobility of greater omentum and Decreased host resistance - Diabetes mellitus, HIV, immuno-suppression therapy
Factors for spreading of infection
2) Localisation of infection
When host resistance is good, the fibrinous exudate collects on the serosal surface of the appendix Adhesions occur between adjacent bowel loops, appendix and greater omentum (infection is localised) Appendicular mass Pus may collect in between the coils of the mass Appendicular abscess
3) Resolution
If the host resistance is good and the inflammation is mild, the inflamed appendix resolves to normal
Obstructive appendicitis - Pathology

Distension of the appendicular lumen distal to the obstruction Raised intramural tension
Gangrene of the appendicular wall Perforation of appendix Peritonitis (generalised) Rarely, a mass may from
Sequelae of acute appendicitis Catarrhal appendicitis

Resolution - Fibrosis at tip - Mucocele Appendicular mass - Appendicular abscess Gangrene and perforation General peritonitis
Obstructive appendicitis
Gangrene Peritonitis Rarely, resolution
Clinical Features
Incidence
Acute appendicitis is the commonest cause of acute surgical abdomen in young adults. Age: - Rare in infants and commonly seen in young adults. - Relatively uncommon after middle age. Sex: - More common in males (M:F = 3:2)
Clinical presentation
It varies according to Nature of inflammation (catarrhal /obstructive appendicitis), Position of appendix
Age of the patient and Associated conditions like pregnancy
Clinical presentation of catarrhal appendicitis General features:

They are like that of any acute inflammation Fever low grade Malaise Tachycardia
Local features:
Symptoms Shifting pain Nausea and vomiting Localised tenderness in RIF with maximum point of tenderness at Mc Burneys point. Localised guarding in RIF
Signs
Shifting pain Pain umbilical area shifting to right iliac fossa is called as shifting pain and is a characteristic feature of acute appendicitis. As the appendix is a midgut structure, pain is felt initially in the umbilical region. After six to eight hours, the infection from the mucosa of the appendix to serosa and later to local peritoneum in right iliac fossa, causing pain in RIF. Nausea and vomiting It is due to reflex pylorospasm. Tenderness It is due to local peritonitis and swollen and turgid appendix. It is felt in right iliac fossa, but with maximum point of tenderness at Mc Burneys point. Rebound tenderness It is due to rubbing of the surfaces of parietal peritoneum and the inflamed appendix on sudden release of the palpating hand in the right iliac fossa. Cough test A bout of cough causes pain in RIF due to same reason. Guarding It is due to reflex spasm of overlying muscles. In paracaecal, ileal and pelvic appendicitis, it is felt in RIF In retrocaecal appendicitis, reflex spasm of psoas muscle occur producing pain on
extension of hip (psoas sign). In pelvic appendicitis, the obturator internus muscle is spastic causing pain on internal rotation of hip (Copes obturator test)
Course of symptoms
The events in a patient with acute appendicitis follow in this order usually Pain umbilical area shifting to RIF in 6-8 hours time Anorexia, nausea, vomiting Pyrexia
Clinical features of obstructive appendicitis

Initially presents as a colic in umbilical region (DD intestinal obstruction) Other features are similar to catarrhal appendicitis, but progresses more rapidly. This condition can progress to general peritonitis with rapidity
Atypical clinical presentation

Pain of visceral or somatic may dominate without the other element of pain. - This occurs in retrocaecal and pelvic positions and in senile patients.
Clinical presentation according to position Retrocaecal acute appendicitis

Localised pain and guarding in RIF may be absent. Fixed flexion deformity of hip and pain on extension of hip
Pelvic acute appendicitis

Strangury due to irritation of bladder Tenesmus due to irritation of rectum Tenderness - It may be absent in RIF, but may be present just above and to the right of symphysis pubis. It is elicited by per rectal examination or by Copes test - Copes test: when the hip is flexed and internally rotated, pain is felt in the hypogastrium.
Pre ileal or post ileal acute appendicitis

Diarrhoea due to irritation of lower ileum
Variations in clinical presentation due to age
Infants and children

Usually, they present with crying Diarrhoea is the presentation in this age group because the appendix is higher up and irritates the bowel loops. (In adults diarrhoea occurs only in pre ileal and post ileal appendicits). Pyrexia of less than 38.50 C. Early general peritonitis can occur due to ill- developed greater omentum
Old people
Muscles are lax and reflexes are dull, hence guarding is minimal or absent, but tenderness is present. It is prone for gangrene and early peritonitis due to atherosclerotic changes in the blood vessels of appendix The compromised haemodynamic system may lead to high mortality.
Clinical presentation according to associated conditions Pregnancy

Appendix is displaced upwards due to growing uterus and hence, pain, tenderness and guarding are felt in right lumbar region and more laterally Inflammatory exudate may irritate the uterus and may cause miscarriage or pre-term labour.
Obese
Difficult to elicit tenderness and guarding.
Clinical features of acute appendicitis with general peritonitis

General features - Pyrexia high grade - Profuse, frequent vomiting and contains bile and intestinal juices. - Tachycardia >120 / min - Dehydration and toxaemia Local features - Generalised tenderness with guarding - Abdominal distension with absent bowel sounds
Differential diagnosis of acute appendicitis

Because of variable clinical presentations, acute appendicitis has to be differentiated from all other acute abdominal conditions.
Upper abdomen diseases Perforated peptic ulcer

Pain first starts in epigastrium or right hypochondrium Well localised, severe, excruciating pain (in acute appendicitis, the pain is dull aching and diffuse.) Tenderness and guarding present over upper abdomen initially Guarding may be seen in RIF due to fluid passing along right para colic gutter to RIF
Acute cholecystitis
Pain felt in right hypochondrium, with radiation to inferior angle of right scapula and sometimes to root of neck Murphys sign is positive
Pancreatitis
Illimitable agony and guarding may be absent (guarding not in proportion to severity of pain) Pain radiates to back
Diseases of lower abdomen Enterocolitis (to be differentiated from post ileal appendicitis)
Presents with nausea, vomiting and diarrhoea Associated with colic No well localised tenderness. No guarding
Amoebic typhlitis
No shifting pain No guarding May be associated with dysentery
Intestinal obstruction
Colicky periumbilical pain (also occur in obstructive appendicitis) No shifting pain Distention, vomiting, VP + ve Guarding only when there is strangulation
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Mesenteric lymphadenitis
Usually occurs in children Shifting tenderness pain and tenderness in RIF shifts to umbilical region, if patient is turned to lateral position No guarding Manifests during 2nd or 3rd week of enteric fever Pain in right lower quadrant of abdomen Features of general peritonitis Patient is toxic
Enteric perforation

Meckels diverticulitis
Clinically, it cannot be differentiated from acute appendicitis
Acute regional ileitis (Crohns disease) or terminal ileitis due to yersinia infection
Diarrhoea precedes pain (Pain precedes everything in appendicitis) Tenderness with out guarding A tender lump may be palpable in RIF
Rectus sheath haematoma

H/O strenuous physical exercise Pain and mass over rectus abdominus muscle with out gastrointestinal symptoms
Diseases of Pelvis Salpingitis

Pain on both sides of pubic tubercles Pyrexia of more than 380 C H/O mucopurulent vaginal discharge P.V: tenderness of cervix and fornices
Ectopic pregnancy
Tubal abortion or rupture may resemble appendicitis in early stages No evidence of shifting pain H/O missed period Tender cervix
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Features of haemoperitoneum (shoulder tip pain, local guarding) may be seen
Twisted ovarian cyst

Pain in umbilical region / loin PV: tender mass felt in the fornix Pain during 14th or 15th day of menstrual cycle Bleeding PV and lower abdominal pain is present Symptoms subside with in hours
Mittelschmerz (Ruptured Ovarian follicle)

Diseases of retroperitoneum Ureteric colic

Pain from loin to groin No guarding Tenderness may be present in the course of ureter Dysuria may be present
Right pyelonephritis
Fever with chills Dysuria Loin pain and tenderness
Right testicular torsion

Pain in scrotum referred to RIF Scrotal examination reveals a tender twisted cord and testis
Neurological Pre herpetic neuralgia of T10 and T11 dermatomes

Shifting pain is absent Guarding is absent Marked hyperaesthesia of affected dermatome is present
Acute radiculitis
Acute radiculitis due to diseases of vertebral column e.g., Tuberculosis, disc prolapse, tumours of vertebra, lumbar spondylosis, osteoporosis
Metabolic causes
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Porphyria crisis
Abdominal and neurological symptoms with intermittent attacks of severe colicky pain in lower abdomen High coloured urine turning to deep orange colour when kept in sunlight Diabetic ketoacidosis Tabetic crisis Henoch-Schonlein purpura
Differential diagnosis depending upon the age In infants and children

Enterocolitis Acute mesenteric lymphadenitis Meckels diverticulitis Intussusception Henoch-Schonlein purpura Lobar pneumonia
In adults
Perforated peptic ulcer Ileal perforation Ureteric colic Intestinal obstruction Regional enteritis Acute pancreatitis Rectus sheath haematoma Torsion of right testis
In adult females
Mittelschmerz Acute salpingitis Ectopic pregnancy - Tubal abortion - Rupture Torsion of ovarian cyst
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Acute pyelonephritis
In elderly
Intestinal obstruction Mesenteric infarction Diverticulitis Aortic aneurysm
Investigations
Blood count - Polymorphonuclear leucocytosis > 15000 / mm3 Urine examination - Microscopic examination to differentiate pyelonephritis, ureteric colic, porphyria - Pregnancy test in suspected cases of tubal pregnancy Plain X- ray abdomen in erect posture to exclude perforation of viscus U/S SCAN - Inflamed appendix may be seen as non-compressible, aperistaltic tubular structure with a dilated lumen and thick wall in RIF - Useful in children - Not very reliable in adults - More useful to exclude pelvic disease, e.g., tubal pregnancy, ovarian cyst Laparoscopy - To differentiate diverticulitis and pelvic conditions
Treatment
The treatment of acute appendicitis is appendicectomy. The surgery should be done with out unnecessary delay.
Contra indications for emergency surgery

Appendicular mass
APPENDICULAR MASS Pathology

It is a mass of inflamed appendix and oedematous caecal wall with adherent loops of oedematous terminal ileum wrapped with greater omentum
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It occurs 48 hours after the onset of acute appendicitis. It is due to the host resistance to contain the infection locally. The infalamed appendix gets circumscribed by fourth or fifth day and forms a mass. The mass increases in size upto tenth day and subsides usually by third week. The mass increases in size after ten days if an abscess has formed.
Clinical features
Classical features of acute appendicitis followed by a painful lump in the RIF Some times the mass may not be palpable due to overlying guarding of abdominal wall General features of inflammation, namely pyrexia, malaise and tachycardia are present
Differential diagnosis
Ileo caecal tuberculosis Carcinoma caecum Amoeboma. Crohns disease. External iliac lymphadenitis
Investigations
Blood counts. Urine examination Stool examination for occult blood. Radiological - US scan - Barium meal after resolution of acute stage Colonoscopy
Management
Aims To help the body to contain inflammation To identify when inflammation spreads to peritoneal cavity and to deal with by surgery To manage the infected appendix after resolution of the mass By conservative management (Ochsner-Sherren regimen), as surgery entails the risk
Method
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of damaging the inflamed and friable bowel in the vicinity and spreading the infection to the general peritoneal cavity.
Ochsner Sherren regimen

1) Rest to bowel - Nasogastric aspiration and nothing by mouth till peristalsis resumes and the pain subsides, usually for one to two days - I.V. fluids for 48 hrs and liquid diet there after - Enemata / purgatives are avoided 2) Antibiotics - Broad spectrum antibiotics with metronidazole 3) Analgesics and sedatives for 2 to 3 days 4) Monitoring for signs of spreading infection - Vomiting - Pain : it becomes severe and diffuse - Pyrexia and tachycardia: a rising pulse rate is the sensitive and earliest sign of spreading peritonitis - Persistence or spreading of guarding / tenderness - Increase in the size of the mass (indicates abscess or diagnosis is incorrect) 5) Dealing with appendix - Once the lump resolves, appendicectomy is done after an interval of 6 weeks - This procedure is called interval appendicectomy
Contra indications for Ochsner Sherrens regime

In children: - As the greater omentum is not well developed, the chances of spreading inflammation and general peritonitis is high In old people - As the incidence of gangrene and perforation is high due to atherosclerotic changes in the vessels Immuno compromised patients When mass has not formed When diagnosis is in doubt
Indications for surgery during the course of conservative treatment
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Signs of spreading infection If the lump fails to resolve, ileocaecal tuberculosis, carcinoma caecum or Crohns disease should be suspected.
Appendicular abscess
Pathology It is formation of pus in the appendicular mass.
Clinical features
The mass and general signs of inflammation continues to increase even after 10th day
Investigations
1) US / CT scan: To see for liquefaction.
Treatment
Once the abscess is well localised, it should be drained extra peritonealy (see drainage of intra peritoneal abscess). If appendix is located, appendicectomy is done. If appendix not located, interval appendicectomy is done.
Appendicitis complicating Crohns disease Treatment

If the caecal wall is healthy at the base of appendix, appendicectomy can be performed. If the caecal wall is inflamed, local resection of involved ileum and caecum is advised
Tumours of appendix Pathology

They are rare
Types
Carcinoid tumour Carcinoma
Carcinoid tumour (argentaffinoma)

It is the commonest neoplasm of the appendix. It arises from Kulschitzsky cells of crypts of Lieberkuhn.
Histology
The cells are stained by immunohistochemical stain for Chromogranin B.
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Clinical features
Mild, recurrent pain in RIF.
Investigations
Laparoscopy
Treatment
Appendicectomy, if the tumour is less than 2cms in size. Right hemicolectomy, if the tumour is larger than 2cms in size or associated with secondaries in liver, carcinoid syndrome or if the appendicular tumour is adherent to surrounding structures.
Carcinoma of appendix
It is extremely rare.
Treatment
Right hemicolectomy. If the diagnosis is made after appendicectomy, a revision operation is done for right hemicolectomy.
Mucocele of appendix Pathology

It is due to collection of mucoid material in the lumen of appendix causing it to distend enormously.
Causes
Stricture Carcinoid Foreign body
Complications
1) Rupture pseudomyxoma peritonei. (The other causes of pseudomyxoma peritoni are colloid carcinoma of rectum, mucinous cystadenoma of ovary) 2) Infection Empyema of appendix
Clinical features
Mild pain and tenderness in the RIF.
Treatment
Appendicectomy.
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Appendicectomy Procedure of appendicectomy

Incision: one of the following is done. Usually, grid iron incision is made. - Grid iron incision or muscle splitting incision made at right angles to spinoumbilical line at Mc Burneys point - Midline / right lower paramedian incision in doubtful cases Skin subcutaneous tissues are incised Ext. oblique aponeurosis incised in the line of its fibres Int. oblique and transversus abdominis muscles are split Fascia transversalis and pre peritoneal fat incised Peritoneum incised Appendix is located by following the taenia coli of caecum to its posterior wall Mesoappendix is transfixed and cut, appendix is crushed at its base and ligated with chromic catgut. ? A purse string suture over the base of caecum around the appendicular stump inverts the stump Peritoneal exudate is mopped away and wound closed in layers
Alterations in the procedure

Lanz incision at Mc Burneys point Rutherford Morissons muscle cutting incision when access to appendix is not sufficient to deliver the caecum Retrograde appendicectomy when appendix is retrocaecal and closely applied to the posterior wall of caecum Some surgeons do not invert the appendicular stump Laparoscopic appendicectomy
Complications of appendicitis and appendicectomy Complications of appendicitis

Generalized peritonitis Appendicular abscess
Complications of appendicectomy
Early postoperative
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Retention of urine Chest complications - Bronchial pneumonia - Atelectasis - Empyema
Bleeding from appendicular vessels Leak of the stump Wound infection: the commonest complication Residual abscess - Paracaecal, pelvic, subphrenic
Postoperative obstruction - Paralytic ileus - Mechanical obstruction from adhesions - Caecocolic intussusception (appendix stump acts as lead point )
Thromboembolism Parotitis Portal pyaemia and thrombosis Ileocaecal actinomycosis Faecal fistula
Late postoperative
Ventral hernia Inguinal hernia due to injury to ileohypogastric nerve Adhesions causing intestinal obstruction
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THE PERITONEUM, OMENTUM, MESENTERY AND RETRO -PERITONEAL SPACE

THE PERITONEUM Anatomy
The peritoneal cavity is the largest cavity in the body. It s divided into greater and lesser sacs. The surface area of the whole peritoneum is 2 m2 (equal to that of the skin) The peritoneum is of two parts The visceral peritoneum (surrounding the viscera) - Innervated by autonomic nerves The parietal peritoneum (lining the inside of the abdominal wall) - Innervated by somatic nerves
Microscopic Anatomy
It is lined by single layered flattened polyhedral cells (mesothelium), which have regenerative capacity. It secretes and absorbs fluid. The fluid is pale yellow and contains mainly lymphocytes. Normally, only few ml of fluid is found in the peritoneal cavity.
Functions of the peritoneum

Pain perception (parietal peritoneum) Visceral lubrication Fluid and particulate absorption Inflammatory and immune responses Fibrinolytic activity
Peritonitis Causes
Microbial infection - e.g. appendicitis, tuberculosis Chemical injury - e.g. bile peritonitis Ischaemic injury - e.g. strangulated bowel, vascular occlusion Direct trauma
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- e.g. operation Allergic reaction - e.g. starch peritonitis
Classification
Acute Chronic - Tuberculosis - Non-specific
ACUTE PERITONITIS Aetiology and pathology

Infection Bacterial - Gastrointestinal bacteria - Non-gastrointestinal bacteria Viral
Gastrointestinal bacteria
They are aerobic and anaerobic bacteria like escherichia coli, aerobic and anaerobic streptococci, and the bacteriodes Less frequently Clostridium welchii, still less frequently staphylococci or Klebsiella preumoniae (Friedlanders bacillus) are the causative organisms These Gram ve bacteria produce endotoxins By transmural migration due to - infection, ischaemia or obstruction of the bowel or - through perforated bowel wall
Source of infection
Non-gastrointestinal bacteria
Chlamydia, gonococcus, beta- haemolytic streptococcus, pneumococcus and Mycobacterium tuberculosis In young girls and women, via the Fallopain tubes Exogenous contamination
Source of infection
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Trauma Via drains - Haematogenous spread - In immuno-deficient patients, opportunistic peritoneal infection, e.g. mycobacterium avis
Pathology
The infection may be localised orgeneralised. The main pathological changes are Copious fluid exudation hypovolaemic shock Endotoxin absorption septicaemia and toxaemia Associated reflex paralytic ileus hypovolaemic shock and distension of abdomen respiratory embarrassment
Factors for localisation

Anatomical The greater sac of peritoneum is divided into various compartments, which localises the infection to these compartments. The compartments are - (a) the subphrenic spaces - (b) supracolic and infracolic compartment - c) the pelvis Pathological - Adhesions around the inflamed organ - Retarded peristalsis of the affected bowel - The greater omentum, by enveloping and becoming adherent to inflamed structures Surgical - Drainage of intra-abdominal collections
Factors for spread of infection

Perforation of hollow viscus - E.g.: appendicular perforation or perforated peptic ulcer may cause gush of contents into the peritoneal cavity, spreading over a large area Stimulation of peristalsis - By the ingestion of food, or water, and administration of purgatives or enemata, which enhances peristalsis of the bowels The virulence of the organism Dr. Yogirams lectures on surgery
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Young children, who have an ill developed greater omentum Disruption of localized collections - Injudicious and rough handling, e.g appendix mass or pericolic abscess
Deficient natural resistance (immune deficiency) - Steroids - AIDS - Old age
Clinical features
Early features
Systemic features of infection and shock (hypovolaemia and septicaemia) - Pyrexia and rapid pulse - Vomiting Local features of infection - Pain and tenderness - Rebound tenderness - Guarding - Associated sequelae paralytic ileus In generalised peritonitis, these features manifest diffusely
Clinical features - Late

Progressive distension of abdomen without bowel sounds Peripheral circulatory failure - Cold, clammy extremities, sunken eyes, dry tongue, thready (irregular) pulse, and drawn and anxious face with over-active ala of nose (Hippocratic facies) The patient finally lapses into unconsciousness.
Investigations
Blood counts: raised leucocyte count, Plain X-ray abdomen: - Dilated gas- filled loops of bowel (paralytic ileus ) - Pneumoperitoneum Serum amylase estimation: - To differentiate acute pancreatitis Dr. Yogirams lectures on surgery
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Ultrasound and CT scanning Peritoneal diagnostic aspiration: the aspirated fluid is examined macroscopically and microscopically. - Macroscopic appearance: Bile : perforation of peptic ulcer, gall bladder, CBD Blood: ruptured ectopic gestation Bloody fluid: acute pancreatitis, gangrene of small bowel Clear: intestinal obstruction, T.B., G.E, rupture of hydatid, ovarian cyst Pus with odour: perforation of viscus Pus-odourless: perforation of peptic ulcer, salpingitis, acute appendicitis
- Microscopy of the fluid may show neutrophils
Treatment The principles of treatment:

Resuscitation Specific treatment for the cause - Surgery - Conservative Peritoneal lavage and drainage
Resuscitation
IV fluids Antibiotics Analgesics Gastrointestinal decompression: Monitoring and vital system (cardiac, pulmonary and renal) support
Specific treatment of the cause:

Depends upon the aetiology of peritonitis - Surgery - Non-operative treatment
Surgery
Timing of operation In any case of doubt, it is always better to look and see rather than to wait and see; Dr. Yogirams lectures on surgery
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for greater numbers of patients die from delay than from an unnecessary laparotomy. Indications: Perforation of the viscus (appendicitis, diverticulitis, peptic ulcer, enteric fever), Gangrenous viscus (cholecystitis, strangulated bowels) Surgery after resuscitation Laparotomy and dealing with the diseased organ Peritoneal lavage and drainage - After laparotomy and dealing with the offending viscus, the peritoneal cavity is washed with saline and abdomen is closed leaving a drain
Procedure:
Non-operative treatment
Indications: Peritonitis due to pancreatitis or salpingitis, or Primary peritonitis of streptococcal or pneumococcal origin (if the diagnosis can be made with certainty).
Prognosis
Mortality depends upon Degree and duration of peritoneal contamination Age of the patient General health of the patient
Nature of the underlying cause Generalised peritonitis carries a bad prognosis. With modern treatment it carries a mortality of about 10 40%.
Complications of peritonitis:
Systemic complications: - Bacteraemic/endotoxic shock - Multi-organ failure - Bronchopneumonia/respiratory failure. - Renal failure - Bone marrow suppression Abdominal complications:
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- Paralytic ileus - Adhesions and small bowel obstruction - Portal pyaemia/ liver abscess - Intraperitoneal abscess
Residual abscess (Intraperitoneal abscess) Sites

Subphrenic space Paracolic RIF Pelvic
Clinical features
General features of infection - Pyrexia (often low-grade) - Tachycardia Local features - Tenderness over the abscess - Later stages a palpable and tender mass Vague systemic disturbance (lassitude, anorexia) with masked local features
Investigations
Leucocyte count US scan / CT scan: - To diagnose the site and size of the abscess - To monitor the course of the abscess
Treatment
Medical treatment: - Indications: small abscess Surgery: - Indications: Failure to resolve Increasing in size
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Procedure:
Extra peritoneal drainage of abscess: With conservative treatment for a few days the abscess becomes adherent to the abdominal wall, so that it can be drained without opening the general peritoneal cavity. Cautious blunt finger exploration should be done to minimize the risk of an intestinal fistula. Ultrasound or CT- guided drainage is also useful
Pelvic abscess
Anatomy of pelvic space
In male: Rectovesical space In female: Rectovaginal (Douglous) pouch
Cause:
(The pelvis is the commonest site of an intraperitoneal abscess.) Diffuse peritonitis Pelvic infections: - Acute appendicitis and acute salpingitis Anastomotic leakage following large bowel and rectal surgery.
Clinical features
Diarrhoea and the passage of mucus in the stools. Tenesmus P.R: bulging of the anterior rectal wall
Course
May burst into the rectum natural recovery
Treatment
Incision and drainage - Through the posterior fornix in females - Through the rectum in the males, if the abscess is pointing into the rectum. Laparotomy is not necessary.
Subphrenic abscess
Anatomy of subphrenic spaces
The space underneath the diaphragm is divided into four intraperitoneal and three extra peritoneal spaces by various peritoneal attachments to the liver. These are
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Intraperitoneal - 1) Right superior intraperitoneal - 2) Left superior intraperitoneal - 3) Right inferior intraperitoneal - 4) Left inferior intraperitoneal
Extra peritoneal - Right and left perinephric spaces - Bare area of liver
1) Right superior (anterior) intraperitoneal (right subphrenic) Boundaries:

It lies between the diaphragm and the right lobe of the liver. Superior: anterior layer of the coronary and the right triangular ligaments, Posterior:liver Anterior: diaphragm and ant abdominal wall Left: the falciform ligament. Right: chest wall Below: opens into general peritoneal cavity, but usually closed due to adhesions
Causes of infection:
Cholecystitis, perforated duodenal ulcer, duodenal cap `blow out' following gastrectomy and appendicitis.
2) Left superior intraperitoneal (left subphrenic) Boundaries:

Above diaphragm, Behind left triangular ligament and the left lobe of the liver, the gastrohepatic omentum and anterior surface of the stomach.
Cause of abscess
Following operations on the stomach, the tail of the pancreas, the spleen or the splenic flexure
3) Right inferior (posterior) intraperitoneal (right subhepatic) (Rutherford Morison's pouch)
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Boundaries:
Anterior: the liver and the gall bladder, Posterior: the upper part of the right kidney and diaphragm. Above: liver, inf coronary ligament Below: transverse colon and hepatic flexure. Right: the right lobe of the liver and the diaphragm. Left: the foramen of Winslow and below this lies the duodenum.
Causes of abscess
Appendicitis, cholecystitis, perforated duodenal ulcer or following upper abdominal surgery. It is the deepest space of the four and the commonest site of subphrenic abscess
4) Left inferior (posterior) intraperitoneal (left subhepatic) lesser sac. Boundaries

Above: inf surface of liver and lt triangular lig Anterior: post surface of liver, lesser omentum, stomach, ant leaf of greater omentum Posterior: diaphragm, pancreas, transverse mesocolon, tr colon, post layer of greater omentum Below: fold of greater omentum Left: hilum of spleen Right: Epiploic foramen
Causes of infection
The commonest cause of infection: - Acute pancreatitis. - A perforated gastric ulcer rarely causes a collection here because the potential space is obliterated by adhesions.
Extraperitoneal spaces
Right and left extraperitoneal which are terms given to perinephric abscesses Midline extraperitoneal: `bare' area of the liver - Cause of abscess: amoebic abscess (commonest cause) and pyogenic liver abscess.
Clinical features
Features due to abscess:
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Vague systemic disturbance (lassitude, anorexia) with masked local features - Pyrexia, tachycardia - `pus somewhere, pus nowhere else, pus under diaphragm Rutherford Morrison
Local - Anterior abscess: tenderness, rigidity or palpable swelling right hypchondrium - Palpable liver due to displaced liver (more often it is fixed by adhesions) - Collapse of the lung or basal effusion or empyema
Investigations
Blood count: leucocytosis. Plain X ray abdomen - Presence of gas with fluid level under the diaphragm - Pleural effusion. - On screening, fixed and elevated (tented) diaphragm Ultrasound or CT scanning
Pyelonephritis, Amoebic abscess, Pulmonary collapse and Empyema
Treatment
Antibiotics If suppuration occurs - Percutaneous drainage tube under ultrasound or CT control (Caution is exercised to prevent entry into the pleural cavity) - Surgery If swelling is obvious I&D through the point of maximum tenderness or erythema or brawny induration If swelling is not apparent CT is done to identify the site Anterior abscess is explored by an anterior subcostal approach Posterior abscess is explored through the bed of l2th rib and care taken to avoid pleural injury
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Special forms of peritonitis Postoperative peritonitis

Causes
Anastomotic leak (usually) Infection from appendicular stump, vault sepsis etc
Clinical features
Deteriorating condition of the patient, with raised pulse and peripheral circulatory failure Local symptoms and signs are ill defined
Investigations
Blood: TC Plain X ray abdomen in erect posture US scan Serum amylase
Treatment
Same as general peritonitis The anastomotic leak must be dealt with by surgery
Peritonitis in senile patient

Tenderness is usually well localised But guarding and rigidity are less marked because the abdominal muscles are thin and weak.
Bile peritonitis
Causes
Perforated duodenal ulcer Traumatic perforation of duodenum Postoperative - Stump blow-out - Anastomotic leak of bile duct surgery - Following cholecystectomy Leak from cystic duct stump
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Injury to bile duct Leak from bed of gall bladder (cholecysto- hepatic duct)
Post ERCP procedures Following perforation or gangrene of gall bladder
Treatment
Depends upon the cause
Meconium peritonitis
Pathology
It manifests in late intrauterine life or neonatal period. It is due to sterile meconium, leaked into the peritoneal cavity from an intestinal perforation Inflammatory exudate causes matting of intestinal loops. After 6 hrs of birth, bacterial peritonitis occur and later, the meconium becomes calcified.
Clinical features
Tense abdomen in a new born with vomiting Failure to discharge meconium.
Neonatal intestinal obstruction.
Radiography
Meconium peritonitis can be diagnosed by radiography of the foetus in utero 2 days before birth Free air in the peritoneal cavity Fluid levels Calcification on the surface of the liver or the spleen
Treatment
Laparotomy and closure of the perforation and drainage of the peritoneal cavity
Prognosis
Bad
Pneumococcal peritonitis
Pathology Types
Primary (common)
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Secondary to pneumonia.
Primary pneumococcal peritonitis: Source of infection:

Via the vagina and Fallopian tubes in undernourished girls of 3-6 years of age. In males, the infection is blood-borne from the upper respiratory tract or the middle ear.
Clinical features
Features of generalized peritonitis with predominant pelvic peritonitis diarrhoea and strangury. Associated features of pneumonitis
Acute appendicitis: - A leucocytosis of 30,000/mm3 suggests pneumococcal peritonitis. Acute pneumonia: - Rigidity is absent.
Treatment
Conservative if diagnosis is made with certainty If no other cause for peritonitis is discovered, laparotomy and thorough peritoneal lavage is done.
Primary streptococcal peritonitis

Types
In children In adults
Of infants and children

The clinical presentation and treatment are similar to those of pneumococcal peritonitis, but the mortality is high
Of adults
Rare Mortality is very high
Peritonitis following abortion/parturition

Cause:
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Perforation of uterine vault Puerperal infection
Clinical features
Rigidity is rarely present The lochia is offensive Diarrhoea is common
Treatment
Same as peritonitis Posterior colpotomy if pelvic abscess forms
Prognosis
With modern treatment, the mortality has fallen to less than 10 per cent.
Familial Mediterranean fever (periodic peritonitis)

Incidence:
Familial and seen in Arabs, Armenians and Jews; other races are occasionally affected.
Aetiology:
Not known.
Clinical features:
Recurrent abdominal pain and tenderness, mild pyrexia with pain in the thorax and joints. The attack lasts 24-72 hours
Treatment:
Colchicine may prevent recurrent attacks.
Tuberculous peritonitis Pathology

Types
Acute Chronic
Acute tuberculous peritonitis

It is rare and presents like acute bacterial peritonitis
Treatment
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Laparotomy and the fluid is evacuated, omentum is removed for histological confirmation of the diagnosis and the wound closed without drainage ATT postoperatively
Chronic tuberculous peritonitis

Pathology Source of the infection:
Abdominal: mesenteric lymph nodes, ileocaecal region, tuberculous pyosalpinx Blood-borne: from pulmonary tuberculosis
Pathogenesis
The disease manifests with multiple tubercles on the peritoneum fluid exudation (rich in proteins). This leads to any of the following conditions. 1) Accumulation of fluid in peritoneal cavity: ascitic form 2) Localised collection in the peritoneal cavity: encysted form 3) Fibrinous adhesions in the peritoneal cavity: plastic (fibrous) form 4) Caseation in the peritoneal cavity: purulent form
Ascitic form Clinical features

Insidious onset General features of tuberculosis Progressive, painless ascites On palpation, - Abdomen is felt doughy - A transverse solid mass of rolled- up greater omentum is palpated.
Investigations
Ascitic fluid analysis: - Clear, pale yellow, and rich in lymphocytes - The specific gravity >1.020 - Protein is >25G/L - Microbiological examination: AFB staining (rarely the organism is found) Culture and guinea-pig inoculation
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Montoux test: - In a child, positive test suggests tuberculosis and negative test excludes tuberculosis. - In adults, it has no value
X-ray chest for any lesion in lungs US scan: to exclude other causes of ascites Laparoscopy: extremely useful investigation
This condition has to be differentiated from other forms of ascites Cirrhosis Carcinoma peritonei Congestive cardiac failure Hypoprotinaemia Nephritis
Treatment
ATT
Encysted form
Pathology
It is a localised ascitic form.
Clinical features
A localised intra-abdominal swelling
Mesenteric cyst in children Ovarian cyst in females
Treatment
Laparotomy and evacuation of encapsulated collection of fluid and ATT
Fibrous form (plastic peritonitis)

Pathology
Widespread adhesions matted coils of intestine
Clinical features
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Subacute or acute intestinal obstruction. Features of `blind loop' steatorrhoea and wasting Recurrent attacks of abdominal pain. Palpable swelling
Treatment
Laparotomy and relief of the obstruction Associated strictures of bowel are also treated ATT
Purulent form
Pathology
Rare, usually due to TB pyosalpinx Amidst a mass of adherent intestine and omentum, tuberculous pus is present. may rupture into bowel or skin faecal fistula
Treatment
ATT Evacuation of cold abscesses If a faecal fistula forms, closure of the fistula + treatment of associated stricture
Prognosis
Poor
ASCITES Definition
Abnormal collection of fluid in the peritoneal cavity
Mechanism of ascites
The ascites forms due to Increased hydrostatic pressure in capillaries Reduced oncotic pressure in capillaries Decreased absorption Increased secretion due to increased capillary permeability
Increased hydrostatic pressure in the capillaries

The causes are Congestive cardiac failure Dr. Yogirams lectures on surgery
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Cirrhosis and portal vein thrombosis Constrictive pericarditis Budd-Chiari syndrome Generalised Na (water) retention
Lowered oncotic pressure of plasma

The causes are Hypoprotinaemia - Nutritional - Nephrotic syndrome - Cirrhosis - Protein losing enteropathy - Malabsorption
Increased permeability of capillaries

The causes are Peritonitis (acute and chronic) Carcinomatosis peritonei Pancreatitis
Impaired absorption of peritoneal fluid

This occurs usually in thoracic duct obstruction
Clinical features
Distended abdomen with fullness of the flanks which are dull to percussion Umbilicus is flat or everted and pushed downwards (pelvic mass causes shift of umbilicus upwards) If fluid is < 300 ml = Puddles sign - Dullness around umbilicus in knee-elbow position If fluid is around 1500 ml = Shifting dullness If fluid is < 300 ml = Puddles sign - Dullness around umbilicus in knee-elbow position If fluid is around 1500 ml = Shifting dullness If fluid is in large quantities, shifting dullness is not elicited and fluid thrill is diagnostic
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Clinical features due to the cause

Common causes of ascites in surgical practice are - TB - Carc - Cirrhosis (In general, the commonest cause is CHF) Engorged neck veins, tender hepatomegaly with hepato-jugular reflux, paedal oedema and tachycardia = CHF Caput medusae, splenomegaly with h/o oesophageal varices = cirrhosis Rapid ascites, supraclvicular nodes, rectal shelf of Blumer, +/ mass abdomen (detected by dipping method) = malignancy Doughy abdomen with rolled up omentum in epigastrium and general features of TB / pulm TB = TB Associated with bil pleural effusion = Meigs syndrome (solid fibroma of ovary with serosal effusions) or Picks disease (constrictive pericarditis) Associated with anasarca = Hypoprotinaemia, CHF
Large ovarian cyst - Differentiated by ruler sign. - Tympanitic epigastrium and flanks in ovarian cyst
Investigations
Urine analysis albuminuria suggests nephrotic syndrome. X-ray of chest - for pulmonary tuberculosis or secondary deposits, cardiac enlargement, medaistinal mass and pleural effusions. Blood count and protein estimation. Peritoneal fluid analysis Blood stained (TB, malignancy) Cell count and for malignant cells Grams stain AFB staining in selected cases Protein estimation*
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- >25gms/L exudates (infections, malignancy) - < 25gms/L transudate (increased hydrostatic pressure or decreased oncotic pressure) - *SAAG (serum-ascites albumin gradient = albumin in serum minus albumin in ascitic fluid)
> 10 = transudate <10 = exudate
U/S scan - For presence of fluid in the peritoneal cavity - For cirrhosis and - For any mass in the pelvis or ovaries
Laparoscopy - Multiple nodules on the peritoneum and greater omentum (DD: TB, secondaries, fat necrosis, hydatidosis) - Nodules can be taken for histopathological examination
Treatment
Treatment of the cause Dietary sodium restriction to 200 mg per day may be helpful Diuretics - Spironolactone + loop diuretics Complications: Hyper kalemia, renal failure, gynaecomastia Paracentesis abdominis - Unless other measures are taken, the fluid soon reaccumulates and repeated tappings remove valuable protein Paracentesis with IV albumin infusion Permanent drainage of ascitic fluid in cirrhosis by surgery
Peritoneovenous shunt (e.g. LeVeen or Denver)

Indications: In rare cases where ascites accumulates rapidly after paracentesis in a fit patient A catheter (e.g. of silicone) with a valve is placed connecting peritoneum to a central vein (e.g. internal jugular). Procedure:
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Complications Cardiac overload CHF DIC
Other operations for ascites with cirrhosis

A) Porta caval shunt operation reserved for those patients who are fit to undergo surgical intervention B) TIPSS: - It is not advised for treatment of ascites C) Liver transplantation: - Indications: Drug resistant ascites with deteriorating liver function
Chylous ascites
The condition is rare.
Causes
Posterior mediastinal lymphomas Filariasis Rarely, due to cirrhosis, tuberculosis, nephrotic syndrome, abdominal trauma (including surgery), constrictive pericarditis, sarcoidosis and congenital lymphatic abnormality.
Prognosis
Poor unless the underlying condition can be cured.
Treatment
Treatment of ascites Fat-free diet with medium-chain triglyceride supplements.
Peritoneal loose bodies (peritoneal mice)

Causes:
Detached appendix epiploica following axial rotation followed by necrosis of its pedicle The hyaline bodies of fat necrosis in pancreatitis
Neoplasms of the peritoneum (Carcinoma peritonei) Pathology

Primary
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- Mesothelioma Secondary from carcinoma of - Stomach, - Colon, - Ovary - Breast and bronchus.
Mesothelioma
It is a highly malignant tumour. Aetiology: asbestosis Treatment - Alkylating agents
Secondaries peritoneum
Pathology
The peritoneum is studded with Discrete nodules Plaques or
Diffuse adhesions giving rise to frozen pelvis. The peritoneal cavity is filled with clear, straw-coloured or blood-stained ascitic fluid.
DD nodules on peritoneum
Secondary deposits Tuberculosis (tubercles are greyish and translucent) Fat necrosis (opaque nodules) Peritoneal hydatids Other rare causes talc granuloma, splenosis, actinomycosis,encapsulated foreign bodies
Treatment
Systemic chemotherapy Intraperitoneal chemotherapy with cisplatin, mitomycin C or methotrexate after drainage of ascites Tamoxifen for breast cancer secondaries
Pseudomyxoma Peritonei
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Rare Sex: frequently in females. The abdomen is filled with a yellow jelly It is locally malignant but does not give rise to extraperitoneal metastases.
Aetiology
Mucinous cystic tumours of the ovary, mucocele of appendix and colloid carcinoma of rectum
Clinical features
Painless abdominal distension with out shifting dullness.
Investigations
Ultrasound and CT scanning.
Treatment
Laparotomy and masses of jelly are scooped out. The appendix / ovarian tumour is excised In recurrence cases - Radioactive isotopes or intraperitoneal chemotherapy
THE GREATER OMENTUM Functions

Rutherford Morison called the greater omentum as `the abdominal policeman'. To limit intraperitoneal infective and other noxious processes - E.g., acute appendicitis forming appendicular mass.
Torsion of the omentum.

It is rare
Aetiology
Primary Secondary - to an adhesion of the omentum to an old focus of infection, or to a hernia.
Clinical features
Obese males are commonly affected They present with acute abdominal pain, mistaken for acute apendicitis
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On examination - Tender lump in upper abdomen - Features of bacterial peritonitis in cases of gangrenous omentum.
Treatment
Laparotomy and excision of the mass.
Cysts of greater omentum (omental cyst).

Causes
Lymphatic cysts. Pseudo pancreatic cyst Hydatid cyst.
Other diseases of greater omentum

Greater omentum is affected by any disease affecting the peritoneum, but mostly affected in tuberculosis and malignancy, when the omentum is scrolled like a cake.
Surgical applications of greater omentum

Sealing the perforation. (omental plugs) Filling of cavities - e.g., after excision of large hydatid cyst of liver Repair of VVF & high level recto vaginal fistula by interposing it between the two viscera Arrest of bleeding as a haemostatic plug especially in the tears of liver To cover raw surfaces in the abdominal cavity Extra-abdominal uses - Perfusion of ischemic limbs, e.g., in TAO, omentum is brought subcutaneously to lower limbs through femoral canal after pediculation
THE MESENTERY Anatomy

The mesentery of small bowel stretches from duodeno-jejunal junction to ileo-caecal junction. It contains the jejunal branches of superior mesenteric artery and vein, the lacteals from the bowel and mesenteric lymph nodes.
Injuries
Causes
Penetrating injury of abdomen Dr. Yogirams lectures on surgery
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Blunt abdominal trauma - Seat-belt syndrome If a car accident occurs when a seat belt is worn, sudden de-acceleration can result in a torn mesentery leading to haemoperitoneum. Usually, it is associated with rupture of the intestine.
Investigations
Xray abdomen erect US scan abdomen Diagnostic peritoneal lavage - A subumbilical catheter is passed into the peritoneal cavity. One litre of normal saline is run into the peritoneum and then drained off by placing the bag and tubing below the patient's abdomen. The presence of blood (> 100 000 RBC/mm3), bile or intestinal contents is an indication for laparotomy.
Treatment
Small wounds and wounds in the long axis are sutured. Large and transverse, tears where the blood supply to the neighbouring intestine is cut off, resection of affected gut is done.
Swellings of mesentery
Classification
Cystic - Mesenteric cyst - Cysts of wolffian & Mullerian remnants - Dermoid cysts - Sero sanguinous cyst of mesentery - Hydatid cyst - Cold abscess of mesentery Solid - Lymph node masses Inflammatory v Non specific v Tuberculous Neoplastic
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v Primary v Secondary - Mesenchymal tumours Lipoma, Fibroma Sarcoma
Clinical features of mesenteric mass

Swellings move perpendicular to the line of mesentery. Restricted mobility in the line of mesentery. Resonance around the mass with a band of resonance across the mass.
Acute nonspecific mesenteric adenitis

Aetiology
? Yersinia infection of the ileum. ? Virus infection
Clinical features
Incidence: - Children, (unusual after puberty) Central abdominal pain associated with vomiting It mimics acute appendicitis in children (If vomiting is absent, it is more likely to be a case of mesenteric adenitis than appendicitis) There may be past history of recurrent attacks of the similar problem On examination, - Pyrexia (rarely, it exceeds 38.3C) - Tenderness is along the line of the mesentery. - Shifting tenderness (differentiates from appendicitis) After laying the patient on the left side for a few minutes, the maximum tenderness moves to the left )
Brucellosis should be suspected if there is associated enlargement of cervical, axillary and inguinal nodes
Investigations
Leucocyte count: 10,000 12,000/mm3 on the first day of the attack, and falls on the second day.
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US scan
Treatment
When the diagnosis can be made with certainty - Bed rest. If acute appendicitis cannot be excluded - Laparoscopy or appendicectomy
Tuberculosis of the mesenteric lymph nodes

Pathology Source of infection
Peyer's patches.
Clinical presentation
1) Demonstrated radiologically due to calcified nodes: - To be distinguished from other calcified lesions, e.g. renal or ureteric stones 2) As general disturbance: - Loss of appetite - Loss of weight - Evening pyrexia 3) Non-specific abdominal pain 4) Features resembling acute appendicitis 5) As intestinal obstruction, due to kinking of small intestine adhered to a caseating node 6) As pseudomesenteric cyst, due to cold abscess in the mesentery. 7) As ileocaecal lymph nodal mass
Investigations
US /CT scan
Treatment
ATT In cold abscess, the tuberculous pus should be aspirated without soiling the peritoneal cavity
Mesenteric cysts
Classification
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Chylolymphatic cysts Enterogenous cysts Cysts of urogenital remnant Dermoid (teratomatous cyst)
Chylolymphatic cyst
It is the commonest of mesenteric cysts
Aetiology
Probably from congenitally misplaced lymphatic tissue that has no communication with the lymphatic system
Pathology
Site: Mesentery of the ileum It is filled with clear lymph or chyle Usually unilocular and solitary Occasionally, the cyst attains a large size It has an independent blood supply, thereby enucleation is possible without the necessity of resection of gut
Enterogenous cyst Pathology

Aetiology A diverticulum or a sequestrated congenital duplication of the intestine becomes cyst It has a thicker wall than a chylolymphatic cyst, and lined by mucous membrane It contains colourless or yellowish-brown mucinous fluid It has a common blood supply with intestine; hence, removal of the cyst needs resection of the related portion of intestine
Clinical features of a mesenteric cyst

Age: - 10 20 yrs (rarely between 1-10 yrs) Modes of clinical presentation As a painless abdominal swelling with features of mesenteric swelling As recurrent attacks of abdominal pain with or without vomiting - Due to angulation of the bowel over the cyst, or due to torsion of the mesentery
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As acute abdominal pain due to - torsion - rupture of the cyst - haemorrhage into the cyst or - infection
Investigations
Barium meal follow-through or enteroclysis: - The bowel is displaced around the cyst or the lumen of the bowel may be narrowed US scan: - Cystic mass IVP Cystogram
Treatment
Chylolymphatic cysts: enucleated in toto Enterogenous cyst: - Enucleation must not be attempted - If short segment of the intestine is involved Resection of the cyst with the adherent portion of the intestine, followed by intestinal anastomosis Cystoenterostomy
- If a large segment of intestine is involved - Marsupialisation is not advised because of fear of a fistula or recurrence
Cysts arising from a urogenital remnant

Usually, they are retroperitoneal but may project forward into the mesentery and present as mesenteric cyst
Differential diagnosis of mesenteric cysts

Serosanguineous cyst Tuberculous abscess of the mesentery Hydatid cyst of the mesentery
Neoplasms of the mesentery
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Classification
Benign - Lipoma - Fibroma - Fibromyxoma Malignant: - Lymphoma - Secondary carcinoma
Treatment
Resection with the adjacent intestine. In inoperable cases, radiotherapy
THE RETROPERITONEAL SPACE Retroperitoneal haematoma

Causes
Acute pancreatitis Bleeding from RP organs - Fracture spine - Leaking abdominal aneurysm - Ruptured kidney
Abscess
Causes:
Infected haematoma Infections of kidney or spine - Tuberculosis - Non-specific
Retroperitoneal cysts
Causes:
Cysts of urogenital remnant Teratoma or dermoid cysts
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Clinical features:
A large cyst in the abdomen
Hydronephrosis
Investigations
US / CT scanning IVP
Treatment:
Excision through a trans-peritoneal incision
Idiopathic retroperitoneal fibrosis Discussed in the chapter on kidney Primary retroperitoneal neoplasms
Mesenchymal tumours - Lipoma - Sarcoma
Retroperitoneal lipoma
Sex - Commonly females
Pathology
Sometimes, it is very big Can undergo myxomatous degeneration, (seen only in retroperitoneal lipoma) It is often malignant (liposarcoma) and may increase rapidly in size
Retroperitoneal sarcoma
It presents signs similar to a retroperitoneal lipoma
Clinical features of Retro peritoneal tumours

Swelling abdomen with or with out pain - Fixed, does not fall on knee-chest position, does not move on respiration, tympanitic Features due to obstruction - Subacute intestinal obstruction or hydronephrosis
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Neoplasm of the kidney Hydronephrosis
Investigations
US/CT scan IVP
Treatment
Laparotomy and excision If complete removal is not possible, debulking is done followed by radiotherapy
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DISEASES OF SPLEEN
Anatomy
It measures 1x 3x 5 inches (2.5x7.5x12.5 cms) (size of a clenched fist). It weighs 200G (7 ounces). It lies between 9th and 11th ribs on left side. Its long axis lies along the line of 10th rib. It is developed from the dorsal mesogastrium. It has red and white pulp. The red pulp filters abnormal red cells and white pulp has an immune function.
Functions of spleen
Earlier it was considered dispensable as it was considered not essential for life. But, it performs some of the most important functions in the body, namely Immune function: - Major site of immunoglobulin M (IgM) production - Produces non-specific opsonins tuftin and properdin (B and T cell antibodies), which sensitises bacteria and fungi for phagocytosis Filtration of cellular and non-cellular material from blood. Removal of old RBC and platelets (culling) Pitting: Removal of particulate inclusions (e.g., malarial parasite, nuclei) from RBC and returning the repaired RBC to the circulation. Re-utilisation of iron removed from the haem of destroyed RBC. Pooling of platelets and blood: The pooled blood is pumped into circulation during shock to replace lost blood volume. This volume contibuted by spleen in humans is small (around 30ml), but is large in lower animals. Haematopoiesis in intra uterine life up to 5th month.
Investigations
US scan CT scan Radio- isotope scans with technetium 99m (99mTc) Haematological investigations to study associated haematological disorders LFT
Congenital diseases
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Splenunculi
They are present in 20% of people. They are hamartomata. Spleninculi are single or multiple accessory spleens found near hilum, behind the tail of pancreas, ligaments of spleen and in the mesocolon. They become hyperplastic after splenectomy and takes the function of spleen. They are found at autopsy or at CT scanning.
Cysts
Pathology
They are rare and they are formed from embryonal rests. Types: dermoids, mesenchymal inclusion cysts
False cysts following organisation of post traumatic clots Hydatid cyst
Investigations
US scan
Treatment
Guided aspiration and sclerosant injection
Rupture of the spleen Causes

Blunt trauma to upper abdomen and left side of lower chest Fall from a height without direct trauma to the abdomen in diseased spleens, e.g.; tropical splenomegaly Penetrating injuries of abdomen or lower chest
Types of clinical presentation

The clinical presentation depends upon the tear and the speed of bleeding. The types of presentation are 1) Severe initial shock with immediate fatality 2) Shock with features of haemoperitoneum 3) Delayed shock and haemoperitoneum
1) Severe initial shock with immediate fatality.

This occurs usually due to avulsion of splenic pedicle
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2) Shock with features of haemoperitoneum General features of shock

Increasing pallor, rising pulse rate, falling blood pressure, cold clammy skin, deep sighing respiration, restlessness and oliguria. Localised bruising over left upper quadrant
Local features of haemo-peritoneum

Tenderness and guarding in the left upper quadrant Pain radiating to left shoulder due to irritation of left dome of diaphragm by blood. Distension of abdomen usually 2-3 hours after the accident due to reflex paralytic ileus and collection of intra peritoneal blood Shifting dullness in 25% of cases Ballances sign: shifting dullness can be elicited in right flank and not elicited in left flank due to presence of clotted blood in the left flank.
3) Delayed shock and haemoperitoneum:

Due to reactionary or secondary haemorrhage or due to rupture of a subcapsular haematoma
Investigations
Plain X ray abdomen: The signs of splenic tear are - Obliteration of psoas shadow (Lt) - Fracture of lower left ribs - Indentation of fundic gas bubble - Obliteration of splenic outline US scan of abdomen Diagnostic peritoneal lavage C.T.Scan Angiography
Treatment:
Resuscitation and assessment of associated injuries Surgery - Laparotomy - Assessment of injury to spleen and other organs
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- Collection of blood from peritoneal cavity for auto transfusion if there is no associated injury to hollow viscus or liver (because the blood gets contaminated with bile or intestinal juices in associated injuries) Splenectomy Splenorraphy (repair of splenic tears in children) depending upon the size of the tear - Suturing - Suturing on greater omentum - Excision of one pole of the spleen - For multiple tears, enclosure in an absorbable mesh bag
Rupture of malarial splenomegaly

Trivial trauma can cause splenic rupture. Identification of subcapsular haematoma and splenectomy saves grave complications. Splenectomy is difficult because of adhesions between spleen and diaphragm.
Splenectomy Indications
Trauma - Following an accident or - during a surgical operation, for example when mobilizing the splenic flexure of the colon Removal en bloc with other surgeries - As a part of a radical gastrectomy As part of staging laparotomy for Hodgkins lymphoma (now, not done) To reduce anaemia or thrombocytopenia in - Spherocytosis - ITP - Hypersplenism In association with shunt surgery for portal hypertension.
Procedure
Open technique - Abdominal - Abdomino-thoracic Laparoscopic
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Open splenectomy Incision

Left paramedian/upper midline Thoraco-abdominal incision through 8th or 9th space - Done in massive splenomegaly cases with dense adhesions
Proceedure
After laparotomy, the anterior layer of gastrosplenic ligament is opened, short gastric vessels ligated and cut. Care taken to avoid injury of greater curvature of stomach during this proceedure. The anterior layer of lieno-renal ligament opened. Splenic artery and vein ligated and cut after separating the pancreas tail from the hilum of the spleen. Spleen removed after incising the posterior layer of lieno-renal ligament.
Postoperative complications
Haemorrhage, if a ligature slips off the splenic artery. Gastric dilatation Haematemesis due to mucosal damage to the stomach while ligating the short gastric vessels. Left basal atelectasis, sometimes with pleural effusion - Due to damage or to irritation of the left hemidiaphragm by a subphrenic abscess (this may be accompanied by persistent hiccough) Pancreatitis Damage to the tail of the pancreas during mobilization of the splenic pedicle.
Pancreatic fistula.
Left pleural effusion, peritoneal effusion or abdominal wall dehiscence. Gastric fistula due to damage of the greater curvature of the stomach when ligating the short gastric vessels. Paralytic ileus
Post splenectomy sequelae

1) Haematology
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- Rise in the white cell and platelet count There may be a risk of thrombosis if the platelet count rises above 1000 X 109 /L and it is essential to anticoagulate prophylactically
2) Septicaemia - It is due to absence of the following functions of spleen Phagocytosis of bacteria, particularly encapsulated bacteria. Reduced antibody production (deficient in tuftsin, IgM and properdin levels )
- Causative bacteria: streptococcus pneumoniae, pneumococus, neisseria meningitides, haemophilus influenza, e.coli and Babesia microti. - Clinical features: opportunistic infections of lungs, brain, malarial fever (OPSI)
Opportunistic post-splenectomy infection (OPSI)

Preventive vaccination against Pneumococcus, H. influenza, meningococcus Patients living in malaria endemic areas should receive antimalarial prophylaxis. Antibiotics (amoxycillin) for 2 years in adults and upto the age of 15 yrs in children. To prescribe antibiotics for all infections.
Trauma to abdomen Causes

Blunt abdominal trauma - Automobile accidents - Human or animal assaults - Fall from heights Blunt trauma to lower chest Penetrating injuries - Stab injuries - Gun shot injuries
Organs injured
Abdominal wall Liver Spleen Bowel and stomach Mesentery
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Kidneys and urinary bladder Great vessels
Clnical presentation
It depends upon the severity of the injury and the organ involved. The types of presentations are Immediate fatality due to rupture of great vessels or avulsion of the pedicles of the organs like spleen Features of haemoperitoneum - Features of shock - Tenderness, guarding and distension are present depending upon the amount of bleeding or intestinal contents leak into the peritoneal cavity Delayed features of haemoperitoneum and shock
Investigations
Plain X ray abdomen: - Pneumo peritoneum in perforations of the bowels - Frature of lower ribs in liver and splenic injuries - Fracture of transverse process in renal injuries US scan of abdomen Diagnostic peritoneal lavage C.T.Scan - Useful to evaluate injuries of liver, spleen, duodenum, pancreas, kidneys and major vessels Angiography in suspected vascular injuries Laparoscopy
Treatment
Resuscitation
ABCD Naso gastric aspirations IV fluids/ blood transfusion Antibiotics Monitoring vital data
Laparotomy
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Indications
Evidence of injury to any intra abdominal organ
Procedure
Auto transfusion of blood collected in the peritoneal cavity, if there is no injury to bowel or if there is no bile or intestinal leak into the peritoneal cavity The injured organ is dealt with by appropriate meeasures
Idiopathic thrombocytopenic purpura

Purpura = prophyra (Greek) = purple.
Definition
Purpura is defined as local haemorrhage into the skin.
Causes of Purpura
1) Incresed capillary fragility, e.g., in steroid induced or Henoch Schonlein purpura. 2) Defective platelets (thrombocytopathies), e.g., after taking aspirin which inhibitis thromboxane and prostaglandin, reducing the adhesiveness of platelets. 3) Reduced number of normal platelets (thrombocytopenia). - Decreased production by marrow megakaryocytes - Marrow suppression by cytotoxic chemotherapy - Aplastic anaemia. 4) Increased platelet consumption - Disseminated intravascular coagulation - Large haemangioma in which platelets adhere to the abnormal endothelium 5) Increased platelet destruction by the spleen. - Autoimmune disease (e.g. systemic lupus erythematosus) - Drug reactions, e.g., Quinine - Infections (e.g. mononucleosis). - Increased splenic sequestration 6) ITP (the platelet destruction may not be associated with any other condition.) (Splenectomy may sometimes be helpful in purpura associated with splenic destruction or sequestration. It is most useful in the management of ITP).
Idiopathic Thrombocytopenic Purpura
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Aetiology
Development of auto-antibodies to platelets (the normal blood platelet count is 250 X 109 400 X 109 /liter). The children born to mothers with ITP may have temporary maternal antibody induced thrombocytopenia after birth.
Clinical Features
Purpuric patches (ecchymoses) in the skin and mucous membrane - more prominent in dependent areas because of a gravity aided intravascular pressure. Spontaneous bleeding from mucous membrane (e.g. epistaxis and menorrhagia in women), and prolonged bleeding of minor wounds. Urinary and gastrointestinal haemorrhage and haemarthrosis (rare) Intracranial haemorrhage is also rare, but is the most frequent cause of death. Tourniquet test is positive. The spleen is palpable in only 25% of cases, and gross splenic enlargement suggests that the diagnosis is not ITP.
DD of purpuric rash
Peticheal rash Scurvey
Investigations
BT prolonged, but the CT and PTT are normal. The platelet count: reduced (usually less than 60 X 109 /litre). Bone marrow biopsy: increased number of megakaryocytes
Treatment In children
As the disease regresses spontaneously after first attack, medical treatment is advised Steroids and azathioprine are given for short periods Splenectomy for severe relapsed cases and for girls approaching menarche
In adults,
The initial attack is less severe than in children, but the disease relapses and becomes more severe. Medical treatment
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- Steroids, blood or platelet transfusions to control thrombocytopaenia Surgery - Splenectomy is indicated where the ITP has persisted for more than 6-9 months.
Prognosis
About 15% does not derive benefit from the splenectomy. Usually, a response to steroids predicts a good response to splenectomy.
The Haemolytic Anaemia Introduction

The haemolytic anaemias amenable to splenectomy are Hereditary spherocytosis. Acquired autoimmune haemolytic anaemia. Thalassaemia Hereditary elliptocytosis. Pyruvate kinase deficiency.
Hereditary spherocytosis
Pathology Cause
Congenital defect in the red cell membrane, with increased permeability to sodium. Genetic: Mendelian autosomal dominant.
Incidence:
Males and females are equally affected.
Pathogenesis
Increase in permeability of the red cell membrane to sodium osmotic pressure in the red cell rises RBC swells and becomes more spherical To keep the sodium out, the sodium pump has to work harder causing increase in the energy and the oxygen requirements of the RBC Weakening of the cell membrane fragility of cell membrane. The energy and oxygen requirements are particularly difficult to satisfy in the spleen, where there is deficiency of both glucose and oxygen destruction of large number of red cells in the spleen (Splenectomy reduces this cell destruction. It does not cure the congenital red cell membrane defect, but it lessens the anaemia and makes the red cell survival time normal) Increased red cell destruction Increased levels of unconjugated bilirubin (Acholuric jaundice) Liver conjugates and excretes the excess bilirubin in the bile (Hence, the Dr. Yogirams lectures on surgery
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levels of serum bilirubin is low inspite of increased production of bilirubin) Formation of pigment stones in the gall bladder
Clinical features
Anaemia Jaundice - Mild and may not appear until adolescence or even adult life. - Sometimes the patient is born jaundiced Biliary colic due to pigment stones in CBD Every child with gall stones should be investigated for heredity spherocytosis and family history should be enquired Spleen is enlarged. Sometimes the liver is also palpable. Chronic leg ulcers
Haemolytic crisis
Sometimes, severe crisis of red blood cell destruction, precipitated by acute infection, leading to death occurs in infancy or childhood. During a crisis, an erythrocyte count may fall from 4.5 millions to 1.5 millions in less than a week. Such crises are characterized by the onset of pyrexia, pallor, and jaundice
Investigations
Blood film examination The fragility test: - Increased fragility of erythrocyte (Normal RBC haemolyse in 0.47% saline solution. In this condition haemolysis occurs in 0.6% or in even stronger solutions) The reticulocyte count: increased Faecal stercobilinogen: increased Radioactive chromium: shows the degree of red cell sequestration by the spleen. US Scan: - To estimate the size of spleen and to see for any gall stones.
Treatment
Splenectomy. - In juvenile cases, it is done at 7years Surgery at earlier age may make the child vulnerable to infections Dr. Yogirams lectures on surgery
64
Surgery at later age may cause gall stones
Acquired Autoimmune Haemolytic Anaemia

Pathology
Because of autoimmune reaction to red cell membrane, red cell survival is reduced
Aetiology
Idiopathic Drug reaction (e.g. to - methyldopa), Associated with SLE
Clinical features
Age: 50 years Sex: in women. Splenomegaly Pigment gallstones (20% of cases)
Investigations
Blood - Anaemia with spherocytosis - Coombs test is usually positive.
Treatment
Usually, the disease has an acute, self- limiting course, and no treatment is necessary Corticosteroids
Indications for surgery (splenectomy):

Failure of steroids or where steroids are contraindicated
Tropical splenomegaly Causes

Massive enlargement of the spleen occurs frequently in the tropics due to Malaria (especially in children), Kalaazar and Schistosomiasis ? Abnormal immune response to malaria or unusual species of plasmodia. Malnutrition
65
Pathology
The spleen is grossly enlarged (2000-4000g). The enlarged spleen causes sequestration of RBC and platelets
Treatment:
Splenectomy Indications
Anaemia Pain or discomfort by the weight of an enormous spleen.
Post splenectomy precautions:

Antimalarial chemotherapy (e.g. proguanil) for life.
Hypersplenism due to portal hypertension

Splenomegaly accompanies portal hypertension. Associated with thrombocytopenia (due to splenic sequestration of platelets) and granulocytopenia. These are permanently relieved when splenectomy accompanies the relief of portal hypertension. Shunt surgery alone does not have the same effect.
Causes of splenomegaly
(Spleen should enlarge 2 3 times its normal size for becoming palpable clinically)
A) Mild (tip of spleen is palpable)

Acute infections - Viral hepatitis - Glandular fever - Typhoid Chronic infections - Bacterial endocarditis - Brucellosis - Tuberculosis Haematological - Megaloblastic and iron deficiency anaemia
66
- Polycythaemia - Myeloma - Idiopathic thrombocytopaenic purpura Collagen diseases - Rheumatoid arthritis - Lupus erythematosis Infiltration - Amyloidosis - Sarcoidosis Cysts
B) Moderate (upto umbilicus)

Portal hypertension Haemolytic anaemia Leukaemia Lymphoma Cyst
C) Massive (upto right iliac fossa)

Myeloid leukaemia Myelofibrosis Gauchers disease Tropical splenomegaly - Malaria - Kalazar Hydatid cyst
67
ANAESTHESIA
Introduction
A surgical patient during surgery undergoes Metabolic response to trauma Effects of anaesthesia on metabolism, CVS and CNS
Surgical trauma with resultant blood, fluid and electrolyte loss; tissue access to microbes Hence, every patient undergoing surgery should have preoperative evaluation for fitness to withstand these challenges, and should have monitoring of the vital systems during surgery and post-operative period.
Pre operative examination

To assess the fitness of the patient for anaesthesia and surgery Haemodynamic system BP., PR, HB% Cardio-respiratory systems - Clinical examination - In selected cases, X ray chest, ECG, echocardiogram and TMT Renal system - Blood urea or creatinine Bleeding diathesis - BT, CT, PTT Metabolic system diabetes mellitus Neurological diseases, jaundice, sepsis
HIV and HBsAg

Universal precautions should be taken in every case to prevent cross infection to the medical personnel
Preparation of the patient

NBM 8 hrs before surgery Bowel evacuation - By a mild laxative night before the surgery or by s/w enema Sedation
68
- Nitrazepam or diazepam or phenobarbitone the night before surgery to allay anxiety and apprehension Consent - The proceedure to be done, its sequelae and alteranate treatments for the disease should be explained to the patient and the close attendants and a written consent has to be taken - If any part of the body has to be removed, a consent to that effect must also be taken in writing
PREPARATION OF PATIENTS SKIN (OPERATING AREA)

The area of operation requires much greater attention than the hands of the surgical team. It is of no use to apply antimicrobials to a dirty and unclean area, however strong and broad-spectrum they may be. In the ward

Shaving Cleansing with detergent Painting with antiseptics Painting with antiseptics.
In the operation theatre
Procedure in the ward

1) Shaving
Shaving of the proposed operation site and the adjacent area is not only aesthetic but also is helpful by not obscuring the operating field, especially, the scalp, pubic and perineal areas. However, it causes minor cuts on the skin that permits bacterial growth. Shaving the operating area one day before surgery significantly increases the risk of wound infection. Hence, shaving should be performed as close to the time of operation as possible and the interval between the shaving and the operation should not exceed six hours.
2) Cleansing with detergent

After shaving, the area to be operated upon should be cleansed thoroughly with detergent to free the soil, dirt and the microbial flora. Special attention has to be paid to creases and crevices like umbilicus, groin, axilla, etc. A special care should be taken for ostomy openings and around them. If exudative or infective lesions are present in the area or adjacent area to operation, the surgery (if elective) has to be postponed. After cleaning, the area should be dried with a clean and dry towel. (Moist areas attract bacterial colonisation.)
3) Anti-microbial painting
69
Any of the antimicrobials may be used to paint the area, after cleaning with the detergent. The area is covered with a sterile or clean towel.
Properties of few routinely used anti-microbial agents*

A) Alcohols (ethyl, n-propyl, and isopropyl): They are effective in concentrations of 50%-70%. Drying for ten seconds after application increases their effectiveness. They are highly effective and act rapidly with broad-spectrum activity except against spores. The organic matter can inactivate them, and alcohol can irritate the mucous membranes and cause dryness of the skin. B) Chlorhexidine gluconate (0.25-0.5%): It has potent broad-spectrum activity except against myco-bacterium tuberculosis. It should be swabbed for at least two minutes and should be repeated second time for two minutes for efficient action. It has marked and persistent action for 4-6 hours. It should be kept out of eyes* , meninges and mucous membranes of some organs like middle ear and oral cavity. It is also used as 0.5% solution in 70% alcohol. C) Iodine/iodophors (povidone iodine): They are highly effective and possess broadspectrum activity. Iodophors require contact time of two minutes to release free iodine. They can be used on mucous membranes. They have minimal residual activity and their effectiveness is reduced by organic matter, irritates skin when pooled on it and causes allergy in a few people. (*Nomenclature of antimicrobial techniques: Asepsis: Prevention of entry of micro-organisms into the body. Antisepsis: Prevention of infection by killing/inhibiting the microbes on skin and other body tissues. Disinfection: Eliminating most but not all disease causing micro-organisms from inanimate objects. Sterilisation: Eliminating all disease causing micro-organisms including spores from inanimate objects)
Procedure in the operation theatre

Preparation of the site of operation
The skin well beyond the site of operation (a minimum of 20 centimetres around the proposed area of operation) has to be prepared. A sterile sponge held in long sterile sponge holding forceps is taken. It is wrung in antiseptic lotion of choice and the antimicrobial lotion is applied to the proposed area. It is worked from the area of proposed incision outwards in concentric circles. The crevices, folds and unclean areas should be painted to the last. Open wounds and stomata should also be attended to the last. The sponge used to prepare the outer unclean area should not be reused to paint the central area. The preparation should last for 3-5 minutes for the optimum action of antimicrobials. If the area is unclean or soiled, or surgery is planned for artificial implants, two or three sponges may be used. Each time the sponge is discarded and a new sponge impregnated with antiseptic is held with the forceps. While the new sponge is handed over to the tips
70
of the sponge- holding forceps, sufficient precaution should be taken not to touch the tips of the forceps with the gloved hand. Finally, 60-70% alcohol is painted over the area and allowed to dry for 10 seconds to have complete or total bactericidal action of alcohol. A thorough cleansing of the skin, free from dirt, grease and soil is an essential prerequisite in skin preparation. Antimicrobial application is only a supplement and not a substitute.
Anaesthesia Pre medication

These drugs are given before any form of anaesthesia To counter the harmful effects of anaesthetic drugs To induce sleep and reduce the dose of anaesthetic agents Atropine: it is given before general anaesthesia - To dry the secretions and to prevent the bradycardia and hypotension - Dose: 0.01mg/Kg body wt Hypnotics: morphine, pethidine, pentozocaine, diazepam - To allay the fear and anxiety of surgery
Drugs
Types of anaesthesia
General Regional - Spinal - Local
General anaesthesia drugs

The drugs used to administer general anaesthesia are Basal narcotics Muscle relaxants Inhalational agents Gases
Basal narcosis or induction

These are rapidly acting drugs to produce anaesthetic state consisting of profound analgesia, normal pharyngo- laryngeal reflexes and sedation with normal muscle tone
Drugs
71
2.5% thiopentone sodium intravenously (10-20ml) Ketamine (2mg/Kg IV or 10mg/Kg IM) Propofol
Muscle relaxants
Uses:
Complete relaxation of muscles aids surgery, especially abdominal, and chest surgery Gives control over the respiratory system Hence, controlled respiratory assistance should be provided during their administration
Types of muscle relaxants

Two types Depolarising and Non-depolarising
Depolarising relaxants - E.g.,: Suxamethonium (50-100mg) /IV

They act like acetyl choline with persistent action causing spread of depolarisation to the adjacent muscle making it unresponsive to stimulus. These drugs are hydrolysed by serum cholinesterase. They produce twitchings followed by profound muscle relaxation for 4-5mts. Congenital absence or impaired production of cholinesterase due to liver disease can cause prolonged muscle relaxation till the cholinesterase is infused by fresh blood transfusion. Use: for endotracheal intubation and for ultra short procedures
Non-depolarising relaxants
These drugs prevent adsorption of acetyl choline to the cholinergic receptors and prevents depolarisation in the endplate which causes muscular tone and contraction. There are no fasiculations. They have longer duration of action (20-45mts). Their action is reversed by neostigmine (anticholinesterase), which increases the concentration of acetyl choline at the motor end plates. Drugs Tubocurarine chloride, gallamine, pancuronium (pavulon) Vecuronium, atracurium, cisatracurium (recent ones)
Inhalational agents
Ether Trilene Chloroform Dr. Yogirams lectures on surgery
72
Halothane, enflurane, and sevoflurane (recent ones)
Gaseous agents
Nitrous oxide Cyclopropane
Procedure of general anaesthesia

The steps of general anaesthesia are Premedication: hypnotics and atropine is given Induction with thiopentone: intravenous administration of thiopentone ( an ultra short ating barbiturates induces sleep Scuccynyl choline is given, once the patient gets into sleep to paralyse the vocal cords Endotracheal intubation: after giving succynyl choline, the patient gets twitchings followed by complete and profound paralysis of all skeletal muscles. Then, endotracheal intubation is done Maintenance and monitoring: the patients is maintained in general anaesthetic state with the following drugs and gases as long as surgery takes place. - General anaesthetic drugs Volatile: Ether or halothane with nitrous oxide gas and with Oxygen - Long acting muscle relaxants are given and the patient is ventillated Reversal of anaesthesia is done when surgery is completed by discontinuing the nitrous oxide and halothane and patient is ventillated with 100% oxygen till the muscle relaxant effect wanes. Then, neostigmine and atropine are given. Extubation is done after complete recovery of the reflexes, especially gag reflex Postop analgesia is administered with morphine, pethidine, pentozocine, or tramadol.
Complications
Shock Respiratory failure Cardiac failure
Regional anaesthesia Drugs

Lignocaine (0.5% to 1% solution)
Duration of action: 1-2 hrs Max dose: 3mg/Kg, 7mg/Kg if mixed with adrenaline (1:250 000) Dr. Yogirams lectures on surgery
73
Adrenaline retards absorption and prolongs the anaesthetic effect - It should not be given for finger block, penile block and for ear lobule
Side effects: cardiac depression, drowsiness, convulsions and unconsciousness
Bupivicaine (0.25 0.5% solution)

Duration of action: 5-8 hrs Max dose: 2mg/Kg
Ropivacaine
Spinal anaesthesia Methods

Intrathecal (sub arachnoid) anaesthesia: Injection of local anaethetic, e.g., lignocaine or bupivicaine into subarachnoid space Epidural (extra dural) anaesthesia: Injection of local anaethetic, e.g., lignocaine or bupivicaine into epidural space
Sub-arachnoid anaesthesia
Procedure
Hyperbaric local anaesthetic agent is injected below the conus medullaris (below L1) into the subarachnoid space by lumbar puncture The lumbar puncture needle is passed through supraspinous, interspinous ligaments, ligamentum flavum and dura matter
Types
Low spinal (L4/5 space in sitting posture) - Block of S2 S5 Mid spinal (L3/4 space with 50 Trendlenbergs tilt) - Block of T7 L4 High spinal (L2/3 space with 50 Trendlenbergs tilt) - Block of T3 L5
Indications
Lower abdominal surgeries, e.g, hernia, hydrocele, anal surgery, hysterectomy and other pelvic procedures
Spinal anaesthesia - Complications

Hypotension due to paresis of spinal sympathetic out flow - If the block is above T10 level, the fall of BP is profound and dangerous (hence, Dr. Yogirams lectures on surgery
74
spinal block is made between T10 L4 segments) - It is usually associated with bradycardia - Prevention: Preop fluid loading with one L of RL - Treatment: parenteral inj of vasopressor agents, e.g. mephenteramine Respiratory depression - Due to hypoxia of respiratory centre due to severe hypotension - Due to paralysis of respiratory muscles Nausea Post operative headache, retention of urine, meningitis, abducent palsy
Risk factors for spinal anaesthesia

Resting PR < 60 Age >50 yrs ECG : prolonged PR interval Use of beta blockers
Sensory block above T6 Presence of two or more factors indicate high risk
Extra dural anaesthesia

Method:
Inj of 10 15 ml of lignocaine (1-2%) or bupivacaine (0.5%) into epidural space
Advantages
Less danger of meningitis and neurological sequelae Absence of PO headache Prolonged PO analgesia Repeated inj can be made into the space by inserting a cannula in to the space. E.g, obstetric analgesia, following chest trauma, pain relief in acute pancreatitis, chronic pain due to cancer The incidence of bradycardia and circulatory collapse is much lower than spinal anaesthesia due to slower onset of sympathetic blockade allowing more time for the compensatory changes to develop above the level of blockade
Disadvantages
Danger of sub arachnoid injection with total spinal paralysis
Local anaesthesia
75
Methods
Surface anaesthesia, eg., mucosal anaesthesia of urethra, eye, throat etc Infiltration anaesthesia Field block - e.g., hernia block, breast block, Nerve block, eg, brachial plexus, cervical plexus block, intercostal block, ring block
76
BASIC SKILLS IN SURGERY

Dissection, Suturing, Retraction and Assisting at operations.
Dissection
1. Possession of a thorough knowledge of local and regional anatomy. 2. An adequate incision. 3. Identification and dissection in the anatomical planes of cleavage. 4. Haemostasis. 5. Gentle handling of tissues and appropriate exposure of tissues. 6. Safety to the neighbouring structures
Suture materials Types of suture materials

Sutures are broadly classified into two groups absorbable and non-absorbable. Each is again classified into natural and synthetic.
Absorbable
-
Natural
Catgut (surgical gut)

v Plain v Chromic
Synthetic

Polyglycolic acid, polyglecaprone 25 Polyglactin 910 Polydioxanone (pds)
Non- absorbable
-
Natural

Cotton Linen Silk Polyamide (nylon)
Synthetic
77
Polypropylene Polyester Stainless steel
Absorbable sutures
Natural absorbable sutures Surgical Gut (catgut):
It is derived from the sub mucosa of a sheeps intestine (not from the cats gut). These threads resemble the strings of some musical instruments like Kit (a small fiddle used by dancers). Hence they were called as Kitguts and later as catguts (young cats are called kitten). As catgut is a pure collagen, which is a foreign protein, it produces intense tissue reaction. Catgut is of two types plain catgut and chromic catgut. Plain Catgut: It loses its complete tensile strength in fifteen days and absorbed in forty to sixty days depending upon its size. It elicits an early and intense tissue reaction. Because of the early loss of its tensile strength when the support of the wound is crucial and due to its intense tissue reaction, it is not used routinely. Chromic Catgut: It is manufactured by coating the plain catgut with salts of chromic acid. (Lord Joseph Lister borrowed the idea of tanning of leather by chromic acid, to make chromic catgut). Because of coating with chromic salts, the tissue reaction becomes slow and less intensive and so absorption is delayed. Chromic catgut loses all its tensile strength in thirty days and disappears in sixty to one hundred and twenty days, depending upon its size and the tissues where it is used. These sutures are absorbed by enzymatic digestion from enzymes liberated from cellular response. They are monofilament and can be handled easily with a secure knot at second throw. Catgut is used mainly for subcutaneous sutures, ligating small vessels and intestinal anastomosis. Because of the tissue reaction and unpredictable absorption, synthetic absorbable sutures are fast replacing catgut sutures.
Synthetic absorbable sutures

Polyglycolic acid (Dexon), polyglactin 910 (Vicryl), polyglecaprone25 and polydiaxonone (PDS) are the commonly used synthetic absorbable sutures. They evoke little tissue reaction and are absorbed by hydrolysis in the presence of the tissue fluids. Polyglycolic acid and polyglactin 910 lose their tensile strength in 30 days and absorbed in 90 days. Polydiaxonone takes 50 days to lose its tensile strength and 180 days to get absorbed. Because of longer tensile strength retention, it is used safely in some slow healing tissues where hitherto non-absorbable suture material was indicated. These sutures are less pliable and needs a special knotting technique. Two throws in the first hitch and one in the second and third (surgeons knot) (Fig. 5-23). These are available as braided and monofilament strands.
Non-absorbable sutures
Natural non-absorbable sutures
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Silk: It is derived from cocoon of silk worm. As it is a protein, it produces intense tissue reaction. Unlike catgut, it is not absorbed and produces granulomata or sinus till it is extruded, especially, when used nearer to the skin. Encapsulation with fibrous capsule usually occurs in 14-21 days and is delayed if infection supervenes. It has high tensile strength for two years. It has excellent handling properties and is considered as a benchmark for sutures. It can be tied easily and securely. Linen: It is made from a plant called flax (Linum usitatissimum), cultivated for its textile fibre. It has properties similar to silk. It gains strength when becomes wet. So, it is extensively used for ligating pedicles. Cotton: It is derived from the hair of cotton seed. It is weaker than linen and handling is inferior to silk. Because of their tissue reaction, these natural sutures are replaced by synthetic nonabsorbable sutures.
Synthetic non-absorbable sutures

Polyesters (Terylene, Dacron): They have high tensile strength and retain indefinitely with low tissue reactivity. They have a tendency to cut through the tissues and so they are coated with PTFE or Teflon or Polybutylate. Their handling properties are excellent. Polyamide (Nylon): It has low tissue reaction and loses 25% of its tensile strength after two years. It has a property called memory (a tendency to return to the shape set during manufacturing process or packaging). So, it tries to untie the knot spontaneously. Hence, it needs three or four throws in the knot. Handling is not good as the strand is stiff. Polypropylene (Prolene): It has extremely low tissue reactivity and retains its tensile strength indefinitely. Handling is good and knots well as it deforms on knotting and beds down on itself. It also needs three or four throws for secure knotting. It can stretch to 30% without loss of tensile strength. Hence it is very useful where some swelling of tissues is expected in the postoperative period, as the swollen tissues in the suture are not strangulated because of its capability to stretch. Stainless steel: It has excellent strength and low tissue reaction (inert). It has poor handling characters. It kinks on knotting which makes it weak and hence, proper knotting technique has to be used. Barbs on the ends of the sutures can traumatise the tissues. Synthetic non-absorbable suture materials also need the same knotting technique as that of the synthetic absorbable sutures, i.e., surgeons knot.
79
Loss of tensile strength

50% loss (days) 100% loss (days)
Absorption (days)
Absorption mode *
Tissue reaction
Plain catgut
15
60-120
Enzyme digestion Enzyme digestion Hydrolysis
High
Chromic catgut
6-10
30
60-120
Mild to moderate Low
Polyglycolic acid and polyglactin PDS Silk, linen & cotton
17
30
90
35 ---
50 >2yrs
180 Nil
Hydrolysis ---
Low High
Polyester & polypropylene Nylon (polyamide) Stainless steel
---
Indefinite
Nil
---
Low
---
25% loss after 2 yrs Indefinite
Nil
---
Low
---
Nil
---
Low
(*Enzyme digestion more tissue reaction; hydrolysis less tissue reaction)

Lecture Notes On Surgery - Part II - Dr. Yogiram Bolisetty

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Lecture notes on surgery Part II Dr.

DISEASES OF VERMIFORM APPENDIX

Position of appendix in relation to caecum

Inflammatory disorders Acute appendicitis

Dr. Yogirams lectures on surgery

Factors for spreading of infection

Obstructive appendicitis - Pathology

Dr. Yogirams lectures on surgery

Sequelae of acute appendicitis Catarrhal appendicitis

Dr. Yogirams lectures on surgery

Age of the patient and Associated conditions like pregnancy

Clinical presentation of catarrhal appendicitis General features:

Dr. Yogirams lectures on surgery

Clinical features of obstructive appendicitis

Atypical clinical presentation

Clinical presentation according to position Retrocaecal acute appendicitis

Pelvic acute appendicitis

Pre ileal or post ileal acute appendicitis

Variations in clinical presentation due to age

Dr. Yogirams lectures on surgery

Infants and children

Clinical presentation according to associated conditions Pregnancy

Clinical features of acute appendicitis with general peritonitis

Differential diagnosis of acute appendicitis

Dr. Yogirams lectures on surgery

Upper abdomen diseases Perforated peptic ulcer

Dr. Yogirams lectures on surgery

Rectus sheath haematoma

Diseases of Pelvis Salpingitis

Dr. Yogirams lectures on surgery

Features of haemoperitoneum (shoulder tip pain, local guarding) may be seen

Twisted ovarian cyst

Mittelschmerz (Ruptured Ovarian follicle)

Diseases of retroperitoneum Ureteric colic

Right testicular torsion

Neurological Pre herpetic neuralgia of T10 and T11 dermatomes

Dr. Yogirams lectures on surgery

Differential diagnosis depending upon the age In infants and children

Dr. Yogirams lectures on surgery

Contra indications for emergency surgery

APPENDICULAR MASS Pathology

Dr. Yogirams lectures on surgery

Dr. Yogirams lectures on surgery

Ochsner Sherren regimen

Contra indications for Ochsner Sherrens regime

Indications for surgery during the course of conservative treatment

Dr. Yogirams lectures on surgery

Appendicitis complicating Crohns disease Treatment

Tumours of appendix Pathology

Carcinoid tumour (argentaffinoma)

Dr. Yogirams lectures on surgery

Mucocele of appendix Pathology

Dr. Yogirams lectures on surgery

Appendicectomy Procedure of appendicectomy

Alterations in the procedure

Complications of appendicitis and appendicectomy Complications of appendicitis

Dr. Yogirams lectures on surgery

Retention of urine Chest complications - Bronchial pneumonia - Atelectasis - Empyema

Dr. Yogirams lectures on surgery

THE PERITONEUM, OMENTUM, MESENTERY AND RETRO -PERITONEAL SPACE

Functions of the peritoneum

Dr. Yogirams lectures on surgery