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PROBLEMS OF WOMEN IN KARACHI PAKISTAN Depression Symptoms, Depression causes, Depression treatment, Antidepressants, Medical help, Some do's and don'ts when you are depressed --- Medical information of depression, Diagnostic criteria for major depression, Depression/: differences in Men and women, Depression and suicide, High risk factors for depression, Treatment principles for depression, Depression and the life time reproductive cycle, Pre menstrual depression,  Depression during pregnancy, Depression during post partum period, depression during peri menopausal period , Depression associated with Infertility Miscarriage or perinatal loss

SURGERY

Surgery Text Book by Dr Taj Uddin

SURGICAL WEBSITES             KIDNEY SURGERY         POSTGRADUATE SURGERY LINKS 

BREAST DISEASE     Breast cancer Breast lump Breast awareness Breast calcifications  Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis                                                                                                                                                 

LIVER ABSCESS      Anatomy of liver Physiology of liver Method of examination of liver Haematology of liver disease. Amoebic liver abscess .Pyogenic liver abscess. Percutaneous needle aspiration of liver abscess. Case study.  Result Result continued  Discussion                                                                 

CHOLECYSTECTOMY    Introduction   Historical Review  Anatomy of Gallbladder Physiology of Gallbladder Physiologic effects of pneumoperitoneum Pathology  of Gallbladder Investigations Pre- operative preparation of laparoscopic cholecystectomy Contraindications  Treatment modalities for gallstones.  Anaesthesia                                                                                                                       

INGUINAL HERNIA    HOW SURGICAL OPERATION IS DONE     THYROID EXAMINATION MANAGEMENT OF SEVERELY INJURED PATIENT      SEPSIS AND MULTIPLE ORGAN FAILURE CHEST TRAUMA     BRONCHOGENIC CARCINOMA     TETANUS AND ANAEROBIC INFECTIONS 

SURGERY WEB PAGE BY DR TAJ UDDIN   Breast awareness Breast calcifications Breast cysts Breast pain Duct ectasia Fat necrosis Fibroadenoma Hyperplasia Intraductal papilloma Phyllodes tumour Sclerosing adenosis Breast cancer HOW SURGICAL OPERATION IS DONE THYROID EXAMINATION INGUINAL HERNIA Cholecystectomy LIVER ABSCESS CHOLECYSTECTOMY POSTGRADUATE SURGERY TETANUS AND ANAEROBIC INFECTIONS BRONCHOGENIC CARCINOMA  CHEST TRAUMA KIDNEY SURGERY SEVERELY INJURED PATIENT SEPSIS BLOOD TRANSFUSION SUTURES AND DRAINS     INGUINAL HERNIA Site hosted by Dr Taj Uddin Qadri  FCPS FRCS Assistant Professor of Surgery Baqai Medical University Karachi Pakistan INGUINAL HERNIA REPAIR IN CHILDREN 1. More common in boys 2. Always indirect Principles 1. Often bilateral (incidence of right:left is 2:1) 2. Often associated with abnormalities of descent (undescended and ectopic testis) 3. Often contains the ovary in girls under 2 years' old 4. High incidence of strangulation in the first few months of life 5. Operation at any age is now safe with modern anaesthesia Preoperative management 1. Examine both sides and mark the appropriate side 2. If for strangulation, then sedate and place in gallows traction or over a pillow for one hour, if reduction then does not occur,proceed to surgery Pre-incision 1. General anaesthesia with optional endotracheal intubation 2. Position - supine 3. Skin preparation of lower abdomen and groins Incision Groin skin crease incision above and parallel to medial inguinal ligament Procedure (inguinal herniotomy) 1. Divide superficial fascia 2. Ligate and divide the superficial epigastric vein 3. Locate the hernial sac at the external inguinal ring lying lateral to the cord/round ligament (the external ring overlies the deep ring in infancy) 4. In an older child it may be necessary to open the inguinal canal by dividing the external oblique aponeurosis lateral to the external ring to gain access to the sac 5. Very carefully dissect the covering layers of spermatic fascia and cremaster off the sac and gently separate the sac from the cord/round ligament 6. The hernial sac may be completely into the scrotum and therefore contain the testis; if so, then carefully divide the sac at the top of the scrotum and pick up its proximal margins in forceps; otherwise open the apex of the sac. In both cases examine and reduce its contents to the abdomen 7. In a strangulating hernia this should be done very gently as the mesentery of the small bowel and testicular vessels are easily damaged 8. Transfix and ligate the neck of the empty sac with an absorbable suture. Excise any redundant sac 9. Closure a. Close the external oblique aponeurosis if opened b. Close the superficial fascia as a separate layer c. Close the skin with a subcuticular absorbable suture  Structures of cord or round ligament Anatomy of indirect inguinal hernia. Postoperative management 1. Elective cases may be done as day-cases and sent home the same evening 2. Emergency cases - await the return of normal bowel function Complications 1. Testicular infarction - due to cord compression in strangulated hernias 2. Recurrence - due to incomplete excision of the sac     IN ADULTS Principles 1. More common in males (10:1 males:females) 2. 90% indirect, 10% direct 3. Operating for the second time in a male then it is wise to obtain consent for orchidectomy; such circumstances are usually exceptional 4. Exclude any predisposing factors a. Chronic obstructive airways disease b. Bladder outflow obstruction 5. Many operations and modifications have been described for this procedure, probably as testament to the fact that recurrence occurs with all, usually with an incidence of 5%. Preoperative management 1. Examine both sides and mark the appropriate side 2. Chronic obstructive airways disease may well need preoperative chest physiotherapy (or consider local anaesthetic) 3. If strangulating, then needs resuscitation a. Cross-match 2 units of blood b. Broad spectrum and metronidazole antibiotic prophylaxis c. Nasogastric aspiration d. Catheterise Pre-incision 1. General anaesthesia with or without endotracheal intubation (essential in strangulation) or local anaesthetic infiltration (60 ml of 0.5% Marcaine) 2. Position - supine 3. Skin preparation - groin (if obstructed, then prep whole of abdomen since a laparotomy may be necessary) Incision Groin incision 3 cm above and parallel to the medial two-thirds of the inguinal ligament Procedure 1. Ligate and divide the superficial epigastric vein 2. Locate the spermatic cord/round ligament as it emerges at the external ring, divide the external oblique aponeurosis laterally from the external ring in the line of its fibres to expose the inguinal canal 3. Indirect hernia - lies in front of the cord a. Dissect the cremaster off the sac and dissect the sac and cord b. Open the apex of the sac, inspect and reduce the contents c. Transfix the sac at the deep ring and excise the redundant sac 4. Direct hernia - lies behind the cord in Hasselbach's triangle • Reduce the sac en-masse, unless large, then open, reduce the contents, transfix the neck and excise the redundant sac Strangulating hernia 1. Almost always indirect 2. Open the sac and assess the viability of the contents 3. If the contents have reduced spontaneously to the abdomen, the constriction was probably minimal and they are probably viable; therefore manage as an indirect hernia. Examine the patient regularly postoperatively for evidence of obstruction or peritonitis suggestive of necrotic bowel warranting a laparotomy 4. If the contents look potentially viable, then gently dilate the neck (agent of strangulation), increase the patient's oxygenation and wrap the bowel in warm saline soaked packs and reassess its viability after 10 minutes. If viable then return to the abdomen (good colour, pulsatile mesenteric vessels). If it is not viable or is of doubtful viability, then resect the segment reconstituting the bowel with an end-to-end anastomosis Herniorraphy In all cases perform a herniorraphy to reinforce the posterior wall of the inguinal canal. The guidelines of the Royal College of Surgeons of England recommend either the Shouldice Repair or the Lichtenstein Repair. 1. Shouldice Repair (named after the Shouldice Clinic in Toronto) a. If not already opened, divide transversalis fascia b. Using either steel wire or monofilament nylon, reconstitute transversalis fascia, and internal oblique/conjoint tendon in layers using a double breasting suture technique 2. Lichtenstein Repair (named after the Lichtenstein Clinic in Los Angeles) a. Close any direct defect using a non-absorbable suture b. Perform the herniorrhaphy by suturing a polypropylene mesh prosthesis in place using a non-absorbable suture c. The prosthesis must extend from the pubic tubercle to lateral to the deep ring, with its two tails extending above and below the deep ring, inferiorly it must be sutured to the length of the inguinal ligament and superiorly above the conjoint tendon Closure 1. Re pair the external oblique aponeurosis with an absorbable suture 2. For a repeat repair in which the tissues may ooze then it may be wise to place a suction drain for 24 hours postoperatively 3. Close in layers Postoperative management 1. Mobilise early; if young and fit may be done as day-case surgery 2. If strangulated, then commence oral fluids once the nasogastric aspirate is minimal and flatus has been passed per rectum   Complications 1. Hernia recurrence - 5% 2. Strangulated hernia a. Wound infection b. Anastomosis • Leakage • Stricture c. Ileus