Thursday, September 25, 2014

Surgery Internship 101

Internship 101

I began my day anxiously wondering how will i cope in the department. I  had met the HOD previous day to report me joining into the surgery department. I was late 1 week from schedule due to self declared holiday. That week i thought i should spend my days with my baby sisters whom were in high school. Well, more of slept more-quality timeless-holiday. All because, i spent ALL my money during RAYA. By the end of first of raya, i am pennyless and helpless against my family needs and desires. No more shopping spree or going for a short break holiday at any beach or hotel etc... This time, i went only to my grandparents house in Puchong,Selangor and Pontian,Johor. If not because of our tradition of going convoys to relatives houses, i didn't even get a chance to spend my holiday going away from Segamat. 

Today, i got the money and yes, i have the mood to update the blog after so long." I need to plan my money properly." A resolution i made every time i received the money. 

Surgery Internship 101

My first day in surgery wasn't that bad. Just like a sponge, i had to absorb everything at once. It was splendid because we get to go home early after finishing our work. WORK!!! Finally, i'm a worker in society. I am no longer a full time student of exam but rather full time student of medicine, i hope. Everything was blurry at first but things began to take shape and form once you do it repeatedly. 

Today was my second day. I ran almost all the time. Yesterday, sir taught me about dressing and doing wound debridement of diabetic foot ulcer using different method step by step:
  1.  Prepare all items needed,making sure everything is kept sterile. 
  2. Use unsterilised glove and take savlon and pour it over the wound. Immerse cotton swab into savlon in cup and scrub the wound and surrounding area like washing with soap.
  3.  Add savlon with hydrogen peroxide in 3;2 ratio.Clean the wound properly. Finish with saline.
  4. Use sterilised gloves.Curette the wound. Remove all slough untill the wound surface became concave and all granulation tissue appearing like cauliflower growth is removed.The wound be filled with oozing blood and blood clots upon curretage. ( Do keep a change of clothes for this matter!Its blood splattering all over!!! Remember remove your pretty watch too! o_0)
  5. . Immerse cotton swab into betadine with hydrogen peroxide and apply generously to wound.The wound should appear pink or red with healthy granulation tissue on its  concave surface.
  6. Next, immerse cotton swab into betadine ,squeeze it thoroughly so that it wont stain the dressing in the outer layer.Keep the swab properly into the wound and add another white cotton swab over it to prevent soaking. 
  7. Take a roll gauze and big cotton pad to cover the wound properly.
  8. Tape the ends of bandage with micronized  pore cellotape. 

On the next patient, we learn to install a cost effective VAC unit to large foot ulcer in a diabetic patiet. The vacuum unit is kept for 3 days and by using this method and appliances, the total cost is reduced from staggering Rs5000 to only rs400 for ensuring the wound healing.This VAC unit helps to remove the dead tissues and pus from the wound for three days without a change of dressing. I wished we had some kind of hydraulic machine to hold the patient foot so both of us, the patient wont get leg cramp from lifting his leg far too long and the doctors in charge wont get back pain from supporting the leg and bending over the bed. Fuhh! 


Yesterday we went back by 1.30pm. Today, 3pm. If everyday like this, i should think of another hobby to fill up my empty day in the evening. Or, shall i driving lessons? Maybe i will. 

Pray for me. Wish me to be better in life and hereafter. 

Lesson of the day:
  • Arrange your priorities
  • Check your work.
  • Consult and ask if in doubt.
  • Smile even if tired.
  • Focus to seniors/staffs instructions
  • Know when to say no .
  • Do discharge previous day, so you can give it to staff for corrections.
  • Again, always check your work with co intern and staffs.

Future me, be strong! Don't loose faith and hope!!! 


Saturday, July 12, 2014

Bertatih

Hello world. Mungkin apa yang kita hendakkan tak dapat dibandingkan dengan nikmat kurniaan Allah.


Friday, April 25, 2014

Excision of swellings

A.LIPOMA

Indication

  • Large size (cosmesis/patients wish)
  • Recent rapid increase in size (sarcomatous change) 
  • Symptomatic naevo/neurolipomas
  • causing pressure symptoms based on site.
Surgical procedures
  • Incision: A linear incision over the summit of the swelling is placed and flaps raised on both sides of the incision.
  • Layers opened: skin and some part of the subcutaneous tissue till the capsule of the swelling is encountered.
  • Dissection : using an artery forceps or a moquito forceps( if a small swelling) , a plane is created between the raised flaps and the capsule of the swelling.Pressure is given at the base of the swelling to deliver out of lipoma.A small vessel may be encountered as the base is being dissected that should be identified and cauterised or ligated.The specimen should be sent for hisptopathological evaluation.
Closure
  • The cavity left after the excision can be closed by few interrupted vicryl sutures to close the subcutaneous layer. The excess skin is removed. The skin is closed with 2.0 ethilon vertical mattress suture. Sometimes a drain may have to be kept to drain the cavity.Remove suture after 7-10days.
B.SEBACEOUS CYST

Indication : Infection , cosmesis

Surgical procedure: 
  • Elliptical incision around the summit of the swelling encircling the punctum.
  • Layers opened:
  1. Incision should be superficial. Care should be taken not to cut open the cyst wall.
  2. The principle is to completely excise the cyst with its wall and the overlying punctum and a bit of the surrounding skin around the punctum.
  • Dissection 
  1. A plane is created between the skin and the cyst, carefully, preventing opening of the cyst wall.
  2. An Allis forceps may be applied to the punctum and the elliptical skin to get a traction. Flaps need to be raised gradually on either sides of the incision and then deliver the cyst in toto.(huh?)
  3. If the cyst wall opens up, the sebum is removed completely and an effort to remove all the cyst wall in piece meal is made.
Closure: Single layer closure of the skin. suture removed after 7-10 days.

Hernia (Angin Pasang)

Hernia (Angin Pasang):

Pengenalan
Hernia berlaku apabila kandungan dalam satu-satu ruang badan (biasanya abdomen) membonjol keluar daripada kawasan yang biasa mereka berada. Kandungan ini biasanya adalah sebahagian usus atau tisu lemak abdomen yang dilapisi oleh lapisan nipis (membran) yang juga akan membentuk kantung hernia/hernia sac. Ia dikenali dengan angin pasang surut kerana sifat bonjolan itu dapat dilihat dan ada masa tidak. Sifat ini dalam bahasa perubatan dikenali sebagai 'reducible'.


Jenis-jenis Hernia (Angin Pasang)
  1. Inguinal hernia: Berlaku di bahagian kelangkang. Tujuh puluh lima peratus hernia adalah dari jenis ini. Ia 25 kali lebih kerap berlaku kepada lelaki berbanding wanita. Hernia jenis ini boleh dibahagikan kepada 2 jenis iaitu langsung dan tidak langsung. Keduanya dibezakan melalui sedikit perbezaan berdasarkan kepada punca kejadian mereka. Kedua-duanya boleh kelihatan serupa semasa membonjol di kawasan kelangkang. Membezakan antara keduanya adalah amat penting semasa membuat diagnosa klinikal.
    • Angin Pasang tidak langsung: Hernia akibat bonjolan bila mana kandungan bonjolan terkeluar melalui jalan yang pernah dilalui oleh testes (buah pelir) semasa perkembangan di peringkat janin dahulu. (Ketika peringkat awal janin, buah pelir berada di dalam abdomen dan semasa perkembangan, ia turun ke bawah sehingga masuk ke dalam buah zakar). Jalan ini biasanya tertutup sebelum bayi lahir tetapi boleh menjadi tempat berlakunya hernia kemudian hari. Hernia ini boleh berlaku di semua peringkat umur. Kadangkala kantung hernia boleh membonjol sehingga ke dalam buah zakar.
    • Angin Pasang langsung: Hernia ini berlaku pada kawasan di mana dinding abdomen agak kurang tebal. Ia biasanya tidak menonjol ke dalam skrotum. Tidak seperti hernia tidak langsung yang boleh berlaku di semua peringkat umur, Hernia langsung ini cenderung berlaku  kepada mereka yang berada di peringkat pertengahan umur dan orang tua disebabkan dinding abdomen menjadi semakin lemah bila umur meningkat.
  2. Hernia femoral: Saluran femoral adalah jalan di mana salur darah arteri, vena dan saraf femoral keluar daripada abdomen untuk memasuki kawasan peha. Biasanya saluran ini ketat dan padat, tetapi kadangkala ia menjadi besar untuk membolehkan kandungan abdomen menonjol ke dalam saluran tersebut. Hernia femoral menyebabkan bonjolan di bahagian bawah lipatan kelangkang, di kawasan tengah peha. Biasanya berlaku kepada wanita dan lebih berisiko untuk tidak bersifat pasang surut/irreducible dimana ia tidak boleh ditolak masuk.
  3. Hernia hirisan: Pembedahan abdomen boleh mengakibatkan dinding abdomen berubah dari segi struktur terutama di bahagian yang dihiris. Ia  menyebabkan kawasan bekas hirisan ini menjadi lemah. Hernia boleh terjadi pada bahagian yang lemah ini. Ia berlaku dalam 2%-10% pembedahan abdomen.
Penyebab Hernia (Angin Pasang)
Hernia yang berlaku di kalangan warga tua samada disebabkan oleh adanya jalan yang terbentuk semasa perkembangan fetus, bukaan sedia ada di dalam ruang abdomen atau kawasan dinding abdomen lemah oleh sebab sesuatu keadaan.
Apa jua keadaan yang menyebabkan peningkatan tekanan dalam ruang abdomen boleh menyumbang kepada pembentukan hernia atau menerukkan lagi hernia. Contoh termasuk:
  • Obesiti,
  • Mengangkat objek berat,
  • Batuk,
  • Meneran semasa buang air besar atau kecil
  • Penyakit paru-paru kronik dan,
  • Ada cecair di dalam ruang abdomen.
Gejala, tanda-tanda dan komplikasi hernia(angin pasang)
Gejala dan tanda-tanda hernia adalah berbagai-bagai. Ia boleh jadi ringan iaitu seseorang mengadu menghidapi bonjolan yang tidak sakit yang timbul apabila berdiri atau batuk atau meneran dan masuk balik bila berbaring atau ditolak masuk dengan tangan.
Ada yang datang dengan gejala dan tanda-tanda yang teruk seperti bonjolan yang sakit, tidak boleh disentuh apa lagi ditekan masuk balik ke dalam ruang abdomen, kulit luar mungkin kelihatan merah kehitaman dan pesakit mungkin demam. Ini adalah akibat kandungan bonjolan seperti usus telah mengalami kekurangan bekalan darah akibat himpitan (jerutan) salur darah biasanya di lubang bukaan hernia. Ia dikenali sebagai angin pasang terbelit (strangulated hernia).
  • Angin pasang surut
    • Ia boleh muncul sebagai bonjolan baru di bahagian kelangkang atau kawasan abdomen lain.
    • Seorang boleh rasa sakit/senak sedikit tetapi biasanya sentuhan pada bonjolan tidak menyebabkan rasa sakit.
    • Bonjolan akan timbul atau bertambah saiz bila berdiri atau bila tekanan dalam abdomen bertambah (seperti batuk).
    • Ia boleh ditolak masuk semula ke dalam abdomen (reducible).
  • Angin pasang tidak surut
    • Ia boleh merupakan bonjolan besar yang mungkin sakit yang sebelum ini ada pasang surut, kemudiannya menjadi tidak boleh masuk semula ke dalam abdomen dengan sendiri atau bila ditolak masuk dengan tangan.
    • Sebahagiannya mungkin kronik iaitu telah berlaku untuk satu jangkamasa yang lama tetapi oleh kerana tidak sakit pesakit tidak mendapatkan rawatan.
    • Ia boleh menjadi strangulated hernia.
  • Angin pasang terbelit
    • Hernia ini biasanya bermula sebagai hernia tidak surut yang kemudiannya mengalami belitan pada bukaan hernia menyebabkan himpitan pada salur darah seterusnya mengakibatkan usus yang terperangkap dalam bonjolan tidak mendapat bekalan darah.
    • Biasanya pesakit mengadu sakit terutama apabila bonjolan ditekan. Boleh ada tanda-tanda usus tersumbat seperti loya, muntah dan perut menjadi kembung.
    • Pesakit boleh ada demam dan biasanya kelihatan tenat.
    • Rawatan kecemasan dan pembedahan segera perlu dilakukan.
Rawatan
Penjagaan di Rumah
Secara umum semua jenis angina pasang perlu dibedah kecuali seseorang pesakit tidak boleh menjalani pembedahan atas sebab-sebab kesihatan yang lain.
Elakkan aktiviti-aktiviti yang boleh meningkatkan tekanan dalam abdomen seperti batuk, angkat objek berat atau meneran yang boleh menyebabkan angina pasang menjadi lebih besar. Seseorang yang batuk perlu mendapatkan rawatan.
Seseorang yang meneran semasa buang air besar atau kecil perlu menjalani pemeriksaan doktor untuk mengetahui puncanya. Ia mungkin disebabkan masalah sembelit atau masalah kelenjar prostat besar (benign prostatic hyperplasia) yang perlu dirawat.
Rawatan Perubatan
Bergantung kepada samada ia boleh surut atau tidak boleh surut dan kemungkinan terbelit.
  • Angin pasang boleh surut
    • Secara umum, semua angin pasang perlu dibedah untuk mengelakkan kemungkinan komplikasi terbelit.
    • Jika pembedahan tidak boleh dilakukan atas sebab kesihatan yang lain, doktor akan selalu membuat pemeriksaan secara berkala.
    • Keadaan di mana doktor tidak melakukan pembedahan
      • Ada hernia yang mempunyai bukaan hernia yang besar di mana risiko untuk terjerut adalah sangat rendah dan pembedahan untuk menutup bukaan besar ini adalah rumit.
    • Rawatan setiap hernia adalah berbeza dan doktor akan berbincang dengan pesakit kaedah rawatan termasuk risiko dan faedah jika dibedah atau tidak.
  • Angin pasang tidak surut
    • Semua angin pasang tidak surut memerlukan rawatan kecemasan kerana risiko komplikasi terbelit.
    • Cubaan untuk surutkan atau masukkan semula angin pasang boleh dilakukan biasanya dengan bantuan ubat tahan sakit dan ubat peregang otot (muscle relaxant).
    • Jika cubaan gagal, pembedahan kecemasan perlu dilakukan.
    • Jika cubaan berjaya, rawatan seterusnya bergantung kepada jangkamasa angin pasang ini berada dalam keadaan tidak surut (irreducible).
      • Jika kandungan angin pasang adalah usus dan kemungkinan berlaku belitan dan bekalan darah ke usus yang terperangkap itu terhenti, tisu usus tersebut akan mati atau rosak ( gangrenous) dalam masa 6 jam.
      • Dalam kes angin pasang terbelit melebihi masa di atas, pembedahan dilakukan untuk melihat kerosakan tisu usus dan membaiki angin pasang .
      • Jika masa tidak surut adalah pendek dan diyakini tidak berlaku belitan dan tisu usus tidak rosak, pesakit boleh keluar wad selepas disurutkan.
    • Disebabkan angin pasang ini berisiko untuk berulang menjadi tidak surut, adalah lebih  baik pembedahan dilakukan lebih awal daripada biasa.
Kadangkala, angin pasang tidak surut ini telah berlangsung begitu lama dan menjadi kronik di mana pesakit tidak merasa sakit dan tiada tanda-tanda sumbatan usus, bagi kes seperti ini pembedahan boleh dilakukan secara elektif (mengikut jadual seperti biasa.

'via Blog this'

Appendicectomy


Indications: Acute appendicitis, recurrent appendicitis

Procedure:

Incision

  • McBurney's grid incision is the most popular incision. it is right angles to the spino-umbilical line placed at Mcburney's point.It is about 6-8cm in length.
  • Lanz incision are cosmetically better than McBurney's.
  • Right paramedian incision is made when diagnosis is in doubt as a part of exploratomy laparotomy.


Layers opened:
  • skin
  • two layers of subcutaneous tissue: Camper's, Scampa's..
  • external oblique aponeurosis running downwards and medially.it is incised in the direction of the fibres
  • Internal and transverse abdominal muscles are split
  • Peritoneum.
Surgical procedure
  • Appendix is gently held at mesoappendix by using Babcock's forceps and blood vessels in the mesoappendix are divided.These include appendicular artery, branch of ileocolic artery.Once the appendix is freed upto the base (caecum), a purse string suture is applied all round appendix, taking bites from caecum , using 2-0 atraumatic silk.
  • Appendix is crushed at the base and is held 1cm above the crush. A tight silk ligature is applied at the crushed site and appendix is cut in between.Stump is cleaned with spirit.invaginated and purse string is tightened.This is called burial of the stump.Perfect haemostasis is obtained.
Closure
  • Peritoneum -continous 2-0 catgut/vicryl
  • Split muscles -sutured together by a few interrupted suteres using chromic catgut/vicryl
  • External oblique is sutured with silk
  • Subcutaneous fat is sutured with vicryl 
  • Skin with interrupted silk .Instead of catgut, 2-0 silk , 2-0 vicryl is being used more often nowadays.
  • Corrugated red rubber drain is not kept routinely unless there is gangrenous appendicitis or a lot of pus in the peritoneal cavity.

Monday, April 21, 2014

Hyperemesis Gravidarum

Defnition  : It is a severe type of vomiting in pregnancy which has got deleterious effect on the health of the mother and/or limits her in day to day activities. 

- D.C.Dutta-

Management

  • Hospitalisation 
  • Fluids - Calculate the amount of fluid given  approximate 3 litres  50:50 5% Dxtrose: Ringer Lactate+ extra amount of 5% dextrose equal to the amount of vomitus and urine in 24 hours. 
  • Drugs- Antiemetic (Promethazine 25mg,prochlorperazine 5mg,trifluoropromazine 10mg,metoclopramide.


Friday, April 18, 2014

Pelvic Organ Prolapse


Have no idea what it is called in Malay. I wished i had a dictionary specialised in medical terms in Malay. It would help a lot of  medical students and young doctors in Malaysia. What a horror for me to describe inflammation to malay and arguing wether its correct or not. I wished we could just teach laymen the proper medical terms instead of laymens term.

Ha, mungkin namanya rahim jatuh atau peranakan jatuh. Erm, betul kot...
























Classification of prolapse

Anterior vaginal wall-upper one third :cyctocoele
Posterior vaginal wall-Lower one third :Urethrocele
Posterior vaginal wall
Upper one third - Enterocele
Lower one third -Rectocele

Uterine descent
-Descent of cervix into vagina
-Descent of the cervix upto the introitus
-Descent of the cervix outside the introitus
-Procedentia:All Uterus outside the introitus

Management
It is divided into  >Preventive>conservative>surgery
Preventive care
  • Adequate antenatal anda intranatal care
  • Adequate postnatal care
  • General measures -avoid strenuous activities,chronic cough,constipation and heavy weight lifting,avoid too many and too soon pregnancies
Conservative
  • Improve general measures above
  • Oestrogen therapy replacement
  • Pelvic floor exercise : Kegel exercise
Pessary treatment
Pessary treatment does not cure uterine prolapse. It relieves the symptoms by steching the hiatus urogenitalis thus preventing vaginal and uterine descent.
It is used in patients with
  • Early pregnancy:placed upto 18 weeks when the uterus is sufficiently enlarge to sit on the brim of pelvis.
  • Puerperium: to facilitate involution.
  • Unfit for surgery
  • Unwillingness for surgery
  • While waiting for operation

Surgical Management of prolapse
-It is indicated when the conservative treatment has failed or not indicated.
-There is no single procedure for all types of prolapse.It depends on anatomical alteration of structures and the degree of prolapse.
-Age,reproductive abiliity and sexual functions should be considered before any specific surgery.

Types of operation



Anterior colporhaphy
  •    To correct cycstocele and urethrocele.
  • Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant.
  • Metal catheter is introduced to know the lower limit of bladder.
  • Inverted T incision made to anterior vaginal wall.Horizontal incision is made below the bladder and the vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below the external urethral meatus.
  • The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection.
  • The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted  laterally.
  • The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.
  • The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side.
  • The cut margins of the vagina are apposed by interrupted sutures with No 'O' chromic catgut using cutting needle.
  • The catheter is reintroduced once more to be sure that the bladder is not injured.
  • Toileting of the vagina is done.
  • Vagina is tight packed with  roller gauze smeared with antiseptic cream.
  • A self retaining catheter is introduced.
Paravaginal defect repair
Cyctocele is repaired by anterior colporrhaphy and plicating the endopelvic fascia in the midline under the bladder neck. but anterior vaginal prolapse may be due to the detachment of the endopelvic fascia from the lateral pelvic side wall.In the case repair should be done by reattaching the endopelvic fascia to the arcus tendineus fascia(white line) of the pelvis. This may be done retropubically through the space of Retziusor vaginally. This is indicated in cases with recurrent cyctocele following repair.







Perineorrhaphy/Colpoperineorrhaphy

Posterior vaginal wall prolapse is fixed by repairing
  • Relaxed perineum - The operation is extended to repair the torn perineal body.
  • Rectocele - The repair is extended to correct rectocele by tightening the pararectal fascia.
  • Enterocele - High perineorrhaphy is to be done right upto the cervicovaginal junction along with correction of enterocele.
*restoration of perineal body is essential with any form  of pelvic floor  repair. This maintains the normal vaginal  axis.

Step of operation
  • A pair of Allis tissue forceps is placed on each side at the lower end of labium minus and a third pair of  Allis is placed on the  posterior vaginal  wall in the midline  well above the rectocele bulge.
  • A horizontal incision is made on the mucocutaneous junction joining the two allis tissue  forceps.
  • Through the incision , with the help of perineorrhaphy scissors, the posterior vaginal wall is dissected off from the perineal body and rectum  upto third Allis forceps placed on the posterior vaginal wall.
  • A vertical incision is made from the apex to the  middle of the horizontal incision (inverted T shaped incision)
  • The two triangular flaps are now  dissected laterally to expose the rectum and musculofascial structures levators ani muscle.
  • Lax vaginal flaps are excised.
  • The rectocele is corrected by suturing the pararectal fascia with interupted sutures.
  • Two or three interrupted sutures are placed through  the levator ani  and fibro muscular  tissues  of the  perineal body  using No I catgut. The rectum should be  pressed back by finger while the sutures are placed.
  • The knots to be placed  at later stage.
  • The cut margins of the posterior vaginal wall are approximated ,starting  from the apex using  No 'O' catgut untill it reaches upto the perineal body.
  • The knots are now placed to the sutures passed through the perineal body.
  • The rest of the posterior vaginal wall and the skin margins are apposed by interrupted catgut sutures.
  • Toiletetting of the vagina is done.
  • tight vaginal pack is optional.



Repair of enterocele and vault prolapse
Enterocele is corrected transvaginally. The principles of correction are to obliterate the neck of the enterocele sac as high as possible by purse string suture, to  excise the excess peritoneal sac and approximation of the uterosacral ligaments.
step by step procedure.
  • An inverted T shaped incision is made with the vertical arm of the T extending up to the apex of the vaginal vault and the horizontal arm, along the mucocutaneous border.
  • Dissection is carried out to expose the enterocele sac.
  • The sac is opened the contents (bowel and omentum ) is pushed away.
  • The peritoneum of the posterior cul-de-sac is dissected off the anterior surface of the rectum and lower sigmoid and excised.
  • A purse string suture (2-0 vicryl)is placed high at the neck of the sac and tied. The excess peritoneum is resected off.
  • The cervix is pulled upwards. Two interupted sutures are now placed around the uterosacral ligaments. These sutures also pass through the posterior aspect of the cervix.These sutures are tied. rest of the steps are the same as that perineorrhaphy.
*AAbdominal repair of enterocele is done by obliterating the pouch of Douglas to prevent herniation of bowel. This is known as Moschowitz procedure. Generally three or four concentric sutures are placed incorporating the uterosacral ligaments and peritoneum over the rectosigmoid.

Pelvic Floor Repair (PFR)
PFR includes anterior colporrhaphy and colpoperineorrhaphy. It should be emphasized that the pelvic floor repair is not the operation for uterine descent. but as the uterine descent is most frequently associated with prolapse of the vaginal wall, pelvic floor repair has to be done along with operation for uterine descent.
Fothergill's or Manchester Operation
The operation is designed to correct uterine descent associated with cyctocele and rectocele where preservation of the uterus  is desireble.
The indications are :
  • Preservation of reproductive  functin
  • when the symptoms are due to vaginal prolapse associated with elongation of the (supravaginal) cervix.
Principles steps of the operation are:
  1. Preliminary dilatation and curretage
  2. Amputation of the cervix
  3. Plication of the mackenrodt's ligaments in front of the cervix.
  4. Anterior colporrhaphy
  5. Colpoperineorrhaphy
If family is completed vaginal sterilisation is to be done.
Steps of operation
  • D & C
  • Anterior colporrhaphy upto pushing the bladder
  • The posterior lip of the cervix is to be held with vulsellum and the cervix is drawn upwards.
  • A pair Allis forceps is placed in midpoint of the posterior cervicovaginal junction.
  • The anterior transverse incision is now extended posteriorly across the posterior cervicovaginal junction. The lateral and posterior vaginal wall is dissected off from the cervixby scissors and finger dissection.
  • The Mackenrodt's ligament with descending cervical artery of either side is clamped at higher level of amputation , cut and replaced by ligature(chromic catgut No 1)
  • The presence of enterocele should be searched for and if detected, to be repaired.
  • The cervix is now amputated at the calculated level.
  • Anterior lip of the amputated cervix is now held with single-toothed vulsellum.
  • The posterior lip of amputated cervix is covered by the vaginal flap using a Sturmdoff sutur or by Bonney's method.
  • The cut ends of Mackenrodt's ligament are sutured to the anterior surface of the cervix. alternatively, the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament->through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.
  • Pubocervical fascia is approximated as in anterior colporrhaphy.
  • Redundant portion of the vaginal mucosa is excised.
  • The cut margins of the vagina are apposed by interuppted sutures.
  • Posterior colpoperineorrhaphy is performed.
  • Toiletting the vagina is done.
  • Vaginal pack is given.
  • Self retaining catheter is introduced.

Vaginal Hysterectomy with Pelvic Floor Repair
-Also called as Ward Mayo's operation.
-Indications:
  • Uterovaginal prolapse in postmenopausal women.
  • Genital prolapse in perimenopausal age group along with the diseased uterus like DUB, unhealthy cervix or small submucuous fibroid requiring hysterectomy.
  • As alternative to Fothergill's operation where family is completed.
  • As an alternative to abdominal hysterectomyin undescended uterus either as a routine or in selected cases where abdominal approach is unsafe.PFR is not done in such cases.
  • As an alternative to laparoscopic assisted vaginal hysterectomy (LAVH)in selected cases of undescended uterus. Compared to LAVH vaginal hysterectomy is less expensive and the perioperative morbidity is no different.
Principles of the operation in prolapse
  • Removal of the uterus through vaginal route.
  • Correction of the enterocele, if any.
  • Approximation of the pedicles in the midline to have a good buttress.
  • Fixation of the uterosacral ligaments to the vault to prevent vault prolapse.
  • Bladder support is reconstituted utilising the broad ligaments and round ligaments as buttress.
  • Repair of cyctocele.
  • Reconstuction of the perineum.




Steps of operation for vaginal hysterectomy (indication -genital prolapse)


  • Anterior colporrhaphy procedure same, up till pushing the bladder.
  • The uterovesical peritoneum is  cut open.Landon's retractor is introduced and to be held by an assistant.
  • The posterior vaginal wall along the cervico vaginal  juncton is cut  as  in Fothergills operation.The vaginal wall is dissected down till the pouch of Douglas is reached. The peritoneum is cut open.
  • First clamp is placed which includes uterosacral ligament,Mackendrodt's ligament and descending cervical artery. The tissue are cut as close to the cervix and replaced by vicryl No 1 .Simmilar procedures the followed on the other side.
  • Second clamp includes uterine artery and base of the broad ligment. The structures are cut as close to the uterus and and replaced by ligature (vicryl No 1) .Same procedures are done other side.
  • The fundus is now brought out through the anterior pouch by a pair of Allis tissue forceps.
  • The third clamp includes round ligament , fallopian tube, mesosalphinx and ligament of the ovary.The structures are cut and replaced by transfixing suture (Vicryl No 1). Same done the other side.The uterus is removed.
  • Correction of enterocele is to be done at this stage.
  • Peritoneum is closed by purse string suture.
  • The sutures of the uppermost pedicles on either side are tied. The excess suturesof the uterien artery pedicle on each side are cut.The sutures of the pedicle containing the uterosacral and Mackenrodt's ligaments are passed throughthe vault crosswise and are to be held temporarily.
  • As in anterior colporrhaphy , the pubocervical fascia is approximated and fixed to thhe uppermost tied broad ligament pedicles to close the hiatus.
  • Redundant portions of the vaginal flaps are excised and the margins approximated by interupted sutures(Vicryl No 0)
  • Crosswise passed sutures of the lowermost pedicles are tied, thus fixing the ligaments with the vaults.
  • Perineorrhaphy is done.
  • Vaginal packing is optional.
  • Self retaining catheter is introduced.


Vault prolapse . Post hysterectomy (vaginal or abdominal )vault prolapse is usually accompanied by an enterocele ( 70%). However, cyctocele and or rectocele may be present. The vault prolapse in such cases may be effectively repaired transvaginally mantaining the same  principle of repair of enterocelealong with anterior colporrhaphy and colpoperineorrhaphy.

Conservative Rx: Pessary generally not recommended.

Surgical Rx: 

Transvaginal approach : 
  • Repair of enterocele along with pelvic floor repair.
  • Le fort operation
  • Colpocleisis (cases following hysterectoy)
  • Sacrospinious colpopexy.
Abdominal approach
  • Vault suspension (sacral colpopexy)
Le Fort operation
The procedur is almost obsolete. It may be done in old agevwith procidentioa he the patient is unfit for longer duration of surgery as vaginal hysterectomy with PFR. There should not be any uterine or pelvic pathology.Cervical cytology (pap smear) should be normal.The operation can be done under local anaesthesia.

Step b ystep
  • Denudation of rectangular vaginal flap from the anterior and posterior vaginal walls.
  • Apposition of the denuded anterior and posterior vaginal walls by chromic catgut. Two small channels are left in the vagina one on either side or drainage.
  • The comlications include -pyometra and urinary stress incontinence.
Colpocleisis (after hysterectomy)
Denudation of vaginal mucosa is done all around. Successive purse string absorbable sutures are placed from above downwards to appose the vagina walls.It is simple , safe and effective opertion for a woman who is no longer interested in coital function.

*sacrospinous colpopexy is done by fixing the vaginal vault to the sacrospinous ligamenton the right side. This procedure may cause damage to the bowel ,ureter or the pudendal vessels.It has higher failure rates.

Abdominal approach

Vault suspension (sacralcolpopexy):principle of the operation is to suspense the vaginal vault to be anterior longitudinal ligament in front of the 3rd sacral vertebra. Non absorbable suture material (Mersilene or Gore-tex mesh) is used.
Step by step
  • Abdomen is opened by vertical or transverse incision.
  • A verticle incision is made on the posterior peritoneum over the sacral hollow while the rectosigmoid is pulled up laterally.
  • Lateral angles of the vagina are identified and grasped with Allis tissue forceps.
  • Two strips or Mersilene or Gore-Tex mesh(1.5cm wide ) are fixed to the vaginal angles and are pulled up in the midline.The other ends are fixed to the anterior longitudinal ligament in front of 3rd sacral vertebra with proper tension.
  • Posterior peritoneum is sewn over the strips to make them retroperitoneal .
  • Complications: Stress urinary incontinene is important one.
*Laparoscopic sacrocolpopexy is found to be effective with similar result to open sacrocolpopexy.


Cervicopexy or Sling operation (Purandare's operation)

The operation is indicated in congenital or nulliparous prolapse without cyctocele where the cervix is pulled mechanically through abdominal route.Strips of rectus sheath of either side passed extraperitoneally are stiched to the anterior surface of the cervix by silk.

Step by step
  • A transverse abdominal incision is made through the skin and fat.
  • Two facial strips (retus sheath) of 1.5c wide are dissected off,keeping its lateral attachment at the lateral border of the rectus muscle intact.
  • The peritoneal cavity is opened in midline. Bladder peritoneum is dissected off and the uterine isthmus is exposed mobilising the bladder.
  • The medial ends of the facial strips are now brought down between the leaves of the broad ligament to this site of uterine isthmus.
  • The free edges of the facial strips are now fixed at the uterine isthmus  with a sturdy bite using silk. This is done after adjusting the correct position of the uterus.
  • Bladder peritoneum is repaired and abdomen is closed in layers. This operation may be combined with Moschowitz procedure.Instead of facial strips , currently non-absorbable(Marlex or Gore Tex) tape is used for this purpose.


Dysfunctional Uterine Bleeding

Im rewriting the answers for my sessional exams. Urgh, i know it was a disaster.
Definition of DUB : It is a state of abnormal uterine bleeding w/o clinically detectable organic,systemic pathology and iatrogenic causes.
It a diagnosis done by ruling  out :
  • pregnancy  related complications
  • tumours of uterus -Benign (Cervical polyp, endometrial polyp, fibroids)
  • Infections
  • foreign body- IUD
  • Systemic -Hepatic,Renal,
  • Blood disorders
  • idiopathic
  • endocrinal disorders
Types of DUB
  • Anovulatory (80%) -Threshold bleeding of puberty menorhagia,Metropathia Hemorhagica,Premenopausal DUB
  • Ovulatory(20%) - Irregular ripening,Irregular shedding, IUCD insertion,following sterilization operation.
Signs and symptoms
.Abnormal bleeding are associated with  or without ovulation and are grouped into:
  • Ovuular bleeding (polymenorrhea/polymenorhagia/oligomenorrhea/menorhagia of irregular shedding and ripening)
  • Anovular bleeding (usually excessive bleeding due to anovulation causing endometrium growth is under unopposed action of oestrogen in absence of progesterone).
Investigations of anovulatory DUB
  • Detailed history of menstruation ( no of pads used, passage of clots size & nomober, and duration of bleeding)
  • History of IUCD or  steroidal contraception
  • History of abnormal bleeding from gums, injury site, epistaxis.
  • Bimanual (per vagina, per rectal) examination done to exclude pelvic pathology.(  PV done  for all except virgins)
  • Blood haemoglobin estimation,platelet,PT,prothrombin time,
  • TSH,T3,T4 estimation done is suspected thyroid cases.
  • D&C ( Diagnostic uterine curretage)
  • USG and colour Doppler (endometrial hyperplasia : ET> 12mm,hyperechoic,and regular outline)
  • Hysteroscopy
  • Laparoscopy
  • Hysterography
Plan of investigations : Blood values->USG->D&C->Hysteroscopy/hysterography->laparoscopy

Management of anovulatory DUB
DUB treatment includes a general,medical and surgical treatment.
General treatment - Rest, correct anemia,
Medical treatment - Hormones,Prostaglandins synthethase inhibitors,Antifibrinolytics
Surgical treatment - Uterine curettage,endometrial ablation/resection,hysterectomy







Gynaecology terms

Menorrhagia : It is a cyclical bleeding occuring with excessive amount(80ml) or duration or both.
Polymenorrhea : It is  a cyclical menstrual bleeding that occurs less than 21 days .
Oligomenorrhea : It is a cyclical bleeding that occurs for more than 35 days.
Hypomenorrhea: It a scanty menstrual bleeding that occurs less than 2 days.
Metrorhagia:It is irregular and acyclical  uterine bleeding.
Menometrorhagia: It is irregular and excessive bleeding in which menstruation is difficult to be identified.

Monday, January 13, 2014

Surgery Practical Examination


Dear me. Please undo this mistakes. DO NOT REPEAT THEM !

Sincerely,

The idiot medic student.

I came to the department of a foreign hospital. I did not study here. Tapi, aku redha dengan apa yang akan terjadi. Sebab ini salah aku sendiri. Aku yang tak kuat untuk hadapi peperiksaan. Hari ni , aku kena hadapai semua yang kat depan mata dengan sendiri. Tak ada siapa yang akan tolong aku. Aku ibarat anak yatim. Tiada tempat nak bergantung. Tiada tempat nak mengadu. 

Malam tu, kepala agak serabut nak study yang mana satu dahulu.

Sepertimana nasihat kat sticker note aku,


" The key to success is not prioritizing your schedule, 
but rather scheduling your priorities"

Well said advice i think.

--------------------------------------------------------------------------------------------------------------------------

0700 am : Went to hospital early. 

0800 am: Start taking history of each cases.

1000am : Surgery viva session commenced.

1.30 pm: Lunch break.

200pm : Viva commenced. Ortho viva started.

500pm : Instruments surgery, specimens, X-rays for ortho, simple surgery procedures, 



Long case surgery

35 year old male, Jaya, came with swelling of the right mouth and chin  for the last ____month.
Also c/o wound and halitosis in the mouth.

GPE: 
- concious , cooperative
-well built, moderately nourished
- Pallour -ve, icterus -ve, clubbing -ve, cyanosis -ve, lymphadenopathy +ve, edema -ve.









Mouth and oral cavity examination:

Inspection and palpation:

  • Nose: Normal
  • Maxilla: Normal
  • Mandible (jaw) - Right angle 3 multiple swelling , border diffused in nature, surface irregular,extent 7x5cm extending from right angle of the lip and lateral border of mandible,part of swelling covered by hair, firm on palpation, fixed to the bone, skin over swelling not pinchable.
  • Lip: Normal
  • Oral cavity: 2 ulcer wound present on the right side of buccal mucosa extending to the inferolateral border of the tongue. wound size on buccal mucosa(4x1cm). Wound on tongue (4cmx2.5cm). Both wound no discharge, covered by pus and  slough unhealthy granulation tissue,beaded(?) elevated border(?) , blood tinged discharge, no bleeding on palpation, firm on palpation, involved teeth shaky mobile upon palpation, tenderness mildly present on palpation, 
  • Gingiva: swelling , oedematous, cyanosed, tobacco stained,firm on palpation, 
  • Tongue: An oval wound present over lateral margin of the right side of the tongue, induration present, border elevated, covered with pus and serous discharge.
  • Teeth: Poor dental hygine, carries present, mobile teeth, tobacco stained.
  • Uvula: Normal, no deviation.
  • Lymph node : multiple ipsilateral nodes but all less than 6cm N2B
DDx: Carcinoma of buccal Mucosa (  Viva : Squamous Cell Carcinoma) invading the right jaw and tongue. 

Stage 4: T4,N2B,M1 




Short surgery case


A 40 year old male from kerala presents with swelling behind his back.





Inspection:

  • A diffuse swelling present over the ________(lumbar vertebra/back?)
  • Puncta present over the swelling. 
  • No discharge present.
Palpation:
  • no local rise of temperature.
  • no tenderness.
  • Cystic in nature
  • margin well defined, border not indurated,
  • Skin over swelling; not pinchable
  • Center : indented
  • Mobility: Horizontal+ve, Vertical +ve,
  • Slip sign -ve
  • Fluctuation test +ve
  • Translumination test: -ve

DDx: Sebaceous cyst/ Lipoma/

Rx: Surface excision.(?)


Surgery short case

A 30 year old female with neck swelling c/o hoarseness of voice since 1 month.
C/o pain radiating the shoulder, aggravated on drinking, relieved on medication.
No h/o headache, no h/o deafness.

Inspection: 

  • One diffuse swelling, present over the middle of the neck.
  • Size 3cmx5cm, 
  • no redness or discharge.
Palpation:
  • No local rise of temperature
  • No tenderness
  • Mobility: non mobile(fixed?)
Ddx:
 -Papillary thyroid cancer invading recurrent laryngeal nerve.(Under 45 year,female,solitary nodule,deep cx LN involved,fixed LN,) 
-Tuberculous LN
-Secondaries in neck 


Orthopaedics Short Case

A 55 year old female, Mangala from Bankart came with trauma of the right hand two month back.

HOPI: 

H/o trauma suddenly and was treated by plaster cast for 25 days. When the trauma has not been cured, she was admitted to FMH for 5 days. Plaster cast was changed for 5 days.After 1 month of care , she was sent for operation when the trauma still not cured. She c/o pain since 2 month back , and not relieved  even after treatment. H/o of decreased movement range.
c/o pain and swelling of the right wrist.


Examination of the hand

  • Irregularity of the lower end of radius ( dinner fork deformity)
  • Th styloid process came to lie at the same level / higher than the ulnar styloid process.
  • Dorsal tilt present.
  • Tenderness present

DDx: Colle's fracture complicated by Sudecks osteodystrophy(pain,swelling,stiffnessof hand after removal of plaster) 

Rx: immobilise, below elbow plaster cast for six weeks



Orthopaedics Short Case

A 65 year old male came with a  left foot drop(?) since 15 years. 

HOPI: 

H/o foot drop for 15 years, h/o leprosy  for 45 years , on medication for 5 years,
 Right leg: No sensation from middle calf to ankle, heel normal, 
Left leg: foot drop for 40 years back, decreased sensation,
Both legs have skin desquamation,No pain on both legs.
Able to walk, gait normal, left foot touching the ground.
No h/o physiotheraphy.

Examination of left leg

  • Attitude: Patient sitting on the bed, both knees same level, adducted, heels touching the floor, normal dorsiflexion of the ankle, no shortening, no swelling, skin desquamation present,no tenderness, no local rise of temperature, sensation decreased, wasting of muscles present, 
  • movement active: inability to dorsiflex  left ankle ,  both knee extension and flexion normal,
  • Movement passive: no rigidity/spasticity on both legs. left ankle in plantar flexion upon elevation of left leg above ground.
DDx: Foot drop caused by common peroneal nerve palsy affected by leprosy.



p/s: In ortho no need to write case sheets , but they ask for the paper anyway. So, just write in the paper.

Man Ana ?

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