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

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
  • 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.


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.
  • 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, October 7, 2013

End Posting 9th term OBG

Erm, lambatnya update. 

Sorry, malas sungguh. Tapi, mengenangkan ini akan membantuku di kala nak dekat finals nanti, ku laratkan jugak. 

Kali ni dapat viva dengan cekgu old-school. The HOD. A very quiet male doctor. The only  old Beetle surrounded by Flowers in the OBG garden. Heheh. I wonder why they made him the Head of Department. Maybe he is guy? An d female can't take the post because they are too emotional and not as rational as the male colleagues when put under pressure? People keep saying that it is really distressing being in this specialty.

I got this  combination of worst case scenario during postings. A combination of many differential diagnosis and topics in both Gynaecology and Obstetrics. 

I think it is better to present the Obstetric case first as the questions are quite predictable.

Viva End Posting (Obstetrics)

Summary : 33 year old, G2P1L1  at 38 weeks 5 days of gestational age, with previous lower section caeserean section and overt diabetis melitus with single fetus, cephalic presentation and mobile head.

  • Urine pregnancy test. Other method of confirming pregnancy.
  • Folic Acid. Why it is given?
  • History of fever with rash. How Rubella is manifested?
  • Tetanus toxoid. Why it is given?
  • History of pedal oedema(pitting type). Differential diagnosis of oedema in pregnancy.
  • History of previous LSCS indicateed by Cephalo pelvic disproportion. Was started insulin after delivery. Stopped after 2 month. 
  • What is Lower section caesearean section? Describe the incision made. 
  • Past history of Diabetes melitus since 1 year.On Medication.
  • On Examination: thyroid enlarged
  • Inspection: overdistended abdomen, globular shape. Falnks full.Horizontal scar present 3cm above symphysis pubis measuring 13cm wide. No keloid, non tender scar.
  • Palpation:
            Fundal grip: Soft irregular, broad mass suggestive of breach.
            Lateral grip: Right- Continuos uniform resistance with smooth hard surface                                             suggestive of spine.
                                 Left: Small irregular Knob like structures, suggestive of limb                                          buds.
          1st Pelvic grip: Ballotable mass, non enggaged.
          2nd pelvic grip : Fingers converged, not enggaged.
  • Auscultation: Fetal  heart sound not heard. Why?

Viva End Posting(Gynaecology)

Summary: 53 year old(menopause) P3L3 with chronic cervicitis/vaginitis/endometrial polyp/adenomyosis/malignancy of cervix/endometrium

Chief complaints : History of passage of white discharge x 3 month
                              History of backache and abdominal pain x 1 month
                              H/o bleeding per vagina x 1 month 

  • DDx of discharge per vagina. Colour? 
  • What is clue cells?
  • DDx of painful lower abdomen.
  • DDx of mass in the lower abdomen.
  • DDx of bleeding per vagina in menopausal woman.
  • What is PID? Definition.

Lesson learnt: 

-Bring ALL books related. Even the note books. 
-Fight and dont give till the end. Open your mouth and speak clearly and loudly These people are getting old. Make their job easier. Dont say a word if you dont know anything. Just shake your head and ZIP your mouth.

Wednesday, September 18, 2013

End posting 8th term Medicine Unit 5

Segala puji bagi Allah yang memegang hati dan takdir manusia. Sesungguhnya, pencapaian dan pujian hari ini bukanlah milik mutlak bagi diri. Tetapi, milik Tuhan yang meminjamkan kekuatan untuk belajar.Yang menjadikan ujian itu setimpal dengan keupayaan diri. Saya mampu sebenarnya.

Tapi, hakikat manusia itu lemah dan tidak sempurna. Sesempurna manapun persiapan diri, masih ada kesilapan dan khilaf yang berlaku. Ye, saya juga manusia biasa. Buat silap dan tidaklah mahu berbangga dengan kesilapan itu... InsyaAllah, akan aku baiki diri dan tidak mengulangi kesalahan itu. Ya Allah, jauhkanlah aku daripada menzalimi diri sendiri dan pesakit-pesakitku kelak.

Jika aku jatuh dan berlemah hati, berilah aku kekuatan untuk kembali padaMu. Jadikan aku hamba yang bergantung harap sepenuhnya padaMu. Jadikan aku hamba yang bersangka baik dengan janjiMu.

Segala pujian di langit dan di bumi hanya padaMu.


Do not repeat this mistske.
B/p values never in odd number! Only 2mm calibration.
Dont forget history n sign of meningeal irritation.
Dont forget to write impression at the end of your case sheet.

p/s: Dr. S of unit 5 medicine said, "Good" at the end of case presentation.

Today is my first ever CNS examination.

Summary: Middle aged male pt came with h/o left sided weakness 5days back with history of inability to sit up from bed, drowsiness and past history of hypertension, smoking and alcohol consumption.

Impression: Cerebral thromboembolic stroke of left hemiplegia with lesion at level of internal capsule suggested by generalised motor deficit with sparing of facial nerve palsy.

Wednesday, August 21, 2013

2nd sessional Final Year Mbbs

I have to stay strong.

I have to.


Oh, you should.

Life is short.

Aim high dear,
Aim to shoot the moon,
At least,
When you fall,
You'll land among the stars...

Tuesday, August 13, 2013

Surgery Note

  • Herniotomy 
  • Herniorhaphy-approximate the inferior border inguinal ligament 
  • Hernioplasty 
  • Incisional hernia  
  • Children inguinal hernia-rx:herniotomy, coz no post wall 
  • Must know-anatomy of inguinal ligament. 
  • Pure tissue repair 
  • Mesh,sutures used 

Varicose vein  
  • Tests 
  • Hemorrhage  
  • Complications  
  • Investigation 
  • Treatments 

Carcinoma of stomach 

  • Left iliac fossa pain radiating to right aggravated on hip flexion n adduction 

Gall Bladder palpable  
  • Troisiers law, in jundiced pt, any palpable gallbladder is not due to stones. 

  • Obstructive jaundice 
  • Achylorius jaundice 
  • Typhoid Mary : enteric fever 
  • Back pressure 
  • Surgical jaundice 
  • Congenital hyperbilirubinemia 
  • Splenectomy 
  • ERCP 
  • Charcot's Law:  
  •  itching 
  • Parts of CHD : supra,retro.inferior,intra 

Umbilical hernia 
  • Infant: no surgery,self limiting 
  • Linea alba,  
  • Vertical vs transverse incision  
  • Induce hernia, child n adult. Cough n cry baby 

  • Choletectomy 
  • Choletotomy 
  • Valvulos colon 
  • Haustra 
  • Sigmoid colon,maize 
  • Congenital mega colon 
  • Hiershsprung disease,ganglia... 

Epigastric Hernia 
  • Many multiple defect 
  • Weakness over the fascia 
  • Linea alba is further defect 
  • Mesh sutured around,the defect 
  • Below or above the umbilicus 
  • Paraumbilical vs umbilical hernia 

Man Ana ?

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