N. Musan. San Francisco Art Institute.
If a proximal segment of the extrahepatic biliary system is patent order on line nizagara erectile dysfunction protocol does it work, choledochoduodenostomy buy generic nizagara 100mg on-line erectile dysfunction doctor houston, choledochojejunostomy or hepaticodocho-jejunostomy should be performed according to the circumstances 100 mg nizagara for sale impotent rage random encounter. When extrahepatic biliary system is not identified and the liver biopsy demonstrates presence of intrahepatic ducts order nizagara 100 mg on-line erectile dysfunction drug has least side effects, transhepatic drainage should be attempted at. Hepatic portoenterostomy with double Roux-en-Y anastomosis advocated by Kasai is a procedure worth trying. In this technique one loop of jejunum is taken out externally to prevent ascending cholangitis, which is a common complication after such type of operation. In cases where there is atresia of the intrahepatic duct, the only treatment left with is orthotopic total liver transplantation. This condition is restricted in one segment or even in one lobe, so segmental resection or lobectomy should cure this condition. Straight X-ray of the abdomen should always be performed in biliary tract disease This diagnoses radio-opaque stones in 15% of cases. Moreover faintly calcified stones, which may be rendered invisible if contrast radiography is advised in the beginning, can be diagnosed in first instance. Bile pigment calculi, which originate from haemolytic disorders, are usually non-radio-opaque. Similarly pure cholesterol stone is also not radio-opaque, but calcium carbonate stones are always radio-opaque. Gallstones which are formed with infection or inflamma tion are generally mixed stones. This investigation also shows rare cases of calcification of the gallbladder (porcelain gallbladder) and limy bile. Successful visualisation of the gallbladder depends on (i) blood flow to the liver, (ii) ability of the liver cells to excrete the dye into the bile, (iii) patency of hepatic and cystic duct sys tem and (iv) capability of the gallbladder to concentrate the excreted dye. Patient ingests 6 tablets of Telepaque one at a time with water, after dinner until bed time. On the following morning nothing is given by mouth to the patient till the radiological examinations are performed. After 2 or 3 films, the patient is given fatty food which will cause contraction of the gallbladder. Abnormal cholecystogram may demonstrate poor visualisation or non-visualisation of the gallbladder. Oral cholecystography with Telepaque is about 98% accurate based on surgical findings. Non-visualisation of the gallbladder may be caused by failure of absorption of oral contrast medium e. Oral cholecystography is probably the best method to demonstrate gallbladder disease and calculi within it (either by direct visualisation or by visualisation of filling defects). A few cases may show a normal gallbladder on oral chole cystography though the patient is suffering from pain in the gallbladder region. Oral cholecystography still remains the standard procedure for establishing the diagnosis of chronic cholecystitis and cholelithiasis in non-jaundiced patients. The technique is probably suitable for visualisation of the bile ducts particularly after cholecystectomy. This method can be applied to slightly jaundiced patients in whom serum bilirubin is not more than 3. Very soon contrast medium appears in the bile with a concentration of 50 to 100 times that of the blood. Intravenous cholangiography has another advantage that it can confirm gallbladder affection in acute cholecystitis (where oral cholecystography is contraindicated). This technique may cause severe allergic reaction (cyanosis, stertorous respirations and inperceptible pulse), so a test dose is usually given before administering the dye into the vein. If such reaction takes place, treatment is to admi nister antihistamin drugs, oxygen and assisted respiration. During operation, before doing cholecystectomy, the cystic duct is isolated and opened. A fine polythene catheter is passed through the cystic duct into the common bile duct. Two ligatures are tightened — one distal to the opening of the cystic duct (on the gallbladder side) and one or. The catheter is filled with normal saline, so that no air bubble is pushed into the biliary tract which may give X-ray appearance of a radiolucent gallstone. A cassette is placed beneath the patient so as to include the entire biliary tract. A normal operative cholangiogram makes exploration of the common bile duct unnecessary. This technique should be performed in all cases of cholecystectomy in order to (i) know the congenital abnormali ties of the cystic duct, hepatic ducts and the common bile duct and (ii) to detect stone in the biliary tract particularly at the most distal part of the common bile duct which may not be detected by digital palpation and (iii) to know whether exploration of bile duct is necessary or not (this prevents morbidity due to many unnecessary explorations of common bile duct). This cholangiography is done prior to removal of the T- tube to demonstrate (i) patency of the common bile duct, (ii) presence or absence of retained stones and (iii) whether there is free passage of bile into the duodenum or not. One recent perspective study has shown little difference in sensitivity between ultrasonography and oral cholecystography if both are properly performed. Ultrasonography however remains the technique of choice as it is more innoquous and is capable of providing Fig. Inflammation of the gallbladder is seen as thickening of the layers of the gallbladder wall with mucosal irregularity. Acute and chronic inflammation are not readily separated but the presence of a pericholecystic collection or of fluid within the wall of the gallbladder indicates an acute process. Increase in bile density increases its echog- enisity and reports of sludge within the gallbladder or common bile duct lumen may be detected. This phenomenon is usually secondary to biliary stasis and is a physiological process. Sludge and pus are very similar in acoustic properties and are indistinguishable in ultrasonography. Immediately drainage under local anaesthetic with fine needle aspiration of the gallbadder under ultrasonography can produce spectacular results and greatly improves the condition of the patient before definitive surgery. Ultrasonography is less sensitive than scintigraphy in showing cystic duct obstruction but specificities of 99% have been reported in acute cholecystitis, and the morphological changes shown by ultrasonography are more relevant to treatment planning. Only small calculi and a single stone impacted in the cystic duct may be missed with this technique. Carcinoma of the gall bladder can present diag nostic problems to the ultrasonologists. Fixed mucosal polyps of less than 2 cm in diameter are rarely of any significance, but as the size increases beyond this limit likeli hood of malignancy in creases quickly. Majority of the failures to find out the cause of an obstructive jaundice now occur with either transient obstructions due to stones or to the presence of coexisting disease processes e. Conventional ultrasonography is used widely in the investigation of gallstone disease, but is limited in the detection of bile duct stones due to poor visualisation. It has been shown that endoscopic ultrasonography clearly visualises the entire extrahepatic biliary tree and accurately identifies the bile duct stones. Routine intra-operative cholangiography has been advocated to prevent bile duct injuries after laparoscopic cholecystectomy. After intravenous administration, this material is excreted by the liver into the biliary ductal system. Normally the scan outlines the liver and extrahepatic biliary tract including the gallbladder and shows the nuclide flowing into the upper small intestine as well. In acute cholecystitis, the gallbladder is not seen on the scan, presumably because the gallbladder outlet or the cystic duct is obstructed. Sensitivity of this test is almost 100%, that means the test will be positive in all patients who actually suffer from acute cholecystitis. The height of the meniscus in the burette at that point indicates the biliary pressure. High pressure is noted (i) where there is stone in the distal part of the duct, (ii) pancreatitis, (iii) thickened and fibrosed sphincter of Oddi, (iv) underlying functional change of the sphincter causing dyskinesia. Choledochoscopy can be used for removal of stones and bile duct tumour and for biopsy. A few surgeons advocate the use of operative choledochoscopy; either rigid or flexible, in patients following gallstone removal and regard this as a mandatory part of common bile duct exploration. The major indications remain acute obstruc tive suppurative cholangitis, acute cholangitis and duct stones after cholecystectomy. There is continuing controversy with regard to endoscopic removal of common bile duct stones. This investigation shows intra- or extra- hepatic biliary obstruction due to various causes. This should be done in the operation theatre keeping everything ready for operation, if be needed. The needle ensheathed by a flexible polypro pylene tube is pushed through the liver into dilated intrahe- patic biliary cannalicula. Women arecontrast medium into the duodenum since this stimulates affected more often than men in the ratio of 4 : 1. It is said that gallstone is more common in Fat, Fertileperistalsis and makes cannulation difficult. Both biliary and pancreatic ductal systems fill, but usually one Composition of gallstone veries considerably. Gallstone also includes iron, carbonates, phosphorus, proteins, cellular debris, mucusmedmm more than 2 to 2 5 mJ should nQt be mjerted and carbohydrate. When the pancreatic ductules at the tail are filled injec tion must be stopped since overfilling will lead to extravasation and will cause pain.
The gross appearance of remodelling scars suggests that collagen fibres are altered and rewoven into different architectural patterns with time generic nizagara 25 mg on-line impotence nerve damage. Approximately 12 hours after injury has occurred and when inflammation is established order nizagara mastercard impotence yahoo, epithelial migration discount nizagara 50 mg free shipping erectile dysfunction joliet, which is the first clear cut signs of rebuilding occurs order nizagara 50mg free shipping impotence jelqing. In a secondary healing wound migration of cells is rapid, as the line of cells from the wound margin become extended, but progress becomes slower, so that days or even weeks may elapse before epithelialization is complete. Later on granulation tissue appears as mentioned earlier but collagen synthesis which is the main feature of scar remodelling cannot be found before 4th to 6th day. On or about the 7th day wounds will show a delicate fine reticulum of young collagen fibres. As fibrogenesis proceeds, purposefully oriented fibres seem to become thicker presumably because there occurring more collagen particles. The overall effect appears to be one of lacing the wound edges together by a 3-dimensional weave. There is one of replacing granulation tissue, allowing the surface to become covered with epithelium and filling the remaining skin defect with scar tissue after contraction is complete. As far as the filling of the defect is concerned, contraction is the major influence. The central scar seems to remodel itself to fill the defect after contraction is over. Development of tensile strength (strength of per unit of scar tissue) and burst strength (strength of the entire wound) is the result initially of blood vessels growing across the wound, epithelialization and aggregation of globular protein. There is an almost imperceptable gain in tensile strength for 2 years subsequent to that. Collagen content of the wound tissue rises rapidly between the 6th and 17th days, but increases very little after 17 days. It must be remembered that secondary wounds contain slightly less collagen than primary wound of the same age. More effective cross-linking of better physical weave of collagen subunits is responsible for rapid gain in strength for secondary wounds. Experimentally it may be estimated by measuring the force necessary to disrupt the wound. In the first few days the strength of a wound is only that of the clot which cements the cut surfaces together. Later on various changes take place in the wound healing process as mentioned above and at the end the tensile strength of the wound corresponds to the increase in amount of collagen present. Tensile strength of the wound becomes more when this is parallel to the lines of Langer. That is why the transverse abdominal incisions produce stronger scar than the longitudinal ones. This effect is well accepted in the experimental animals, but corticosteroid in normal dosage may not influence wound healing in human beings. Healing of a clean incised wound, the edges of which are closed (closed wound) — takes place by a process known as healing by first intention. The following changes take place — (i) initial haemorrhage results in the formation of a fibrin-rich haematoma. In the first 24 hours basal cells mobilise from the undersurface of the epidermis. By 48 hours the advancing epithelial edge undergoes cellular hypertrophy and mitosis. Epithelial cells gradually line the wound deep to the fibrin clot and it also lines the suture tracks. The use of adhesive tapes instead of sutures for closing wounds avoids these marks and gives better cosmetic result. The main bulk of tissue which performs the healing process is the granulation tissue and that is why this type of healing is also called healing by granulation. But this does not mean that granulations are not formed in the simple incised wounds. The followings are the various important processes of this type of wound healing :— (i) Initial inflammatory phase affects the surrounding tissues and the wound is filled with coagulum. It must be remembered that the skin wound contracts by stretching the surrounding skin to close the defect and not by the production of new skin. Between 5 and 10 days, the wound edges move rapidly and after 2 weeks it becomes slowed down again. In fact this granulation tissue forms a temporary protective layer against infection until the surface is covered by epithelium. It must be remembered that specialised epithelial structures like interpapillary processes, hair follicles and sebaceous glands are not reformed. The epithelial cells in fact slide into the wound forming a thin tongue of cells between the granulation tissue and the clot. Gradually as the epithelialization continues, there is also remodelling of the granulation tissue and scar, so that the wounded area which was at first depressed, ultimately forms a flat scar. This may be due to uncontrolled growth with invasive potentiality of the surrounding epithelial cells which are concerned with epithelialization. In these cases there is not only mitosis, but there is pleomorphism, disorganization and loss of polarity. It should be noted that it is not always due to inadequate intake, but may be due to excessive loss e. Cortisone and its derivatives decrease the rate of protein synthesis, stabilize liposomal membranes and inhibit the normal inflammatory reaction. High doses of corticoids limit capillary budding, inhibit fibroblast proliferation and decrease the rate of epithelialization. Any agent that inhibit the division of local fibroblasts or epithelial cells should prevent or delay healing. Similarly high doses of radiation especially during first 3 days delay strength of the wound significantly. That is why wounds in the pretibial region take much more time to heal than those in the face, which are well vascularized. Due to infection, fibroblasts face tough time to persist as they have to compete with inflammatory cells and bacteria for oxygen and nutrients. The delicate capillary loops of the granulation tissue and the delicate epithelium are damaged due to movement. Frequent change of dressing also has the same adverse effect and should be avoided. Adhesions to bony surfaces cause delay in wound healing probably by preventing proper wound contraction. Faulty technique of wound closure is obviously responsible for delay in wound healing in many cases. It is a peripheral circulatory failure which results from a discrepancy in the size of the vascular bed and the volume of the intravascular fluid. It is a clinical condition which is characterized by signs and symptoms arising when the cardiac output is insufficient to fill the arterial tree with blood under sufficient pressure to provide all the organs and tissues with adequate blood flow. The characteristic features are decreased filling pressure of the heart, decreased systemic arterial pressure, tachycardia and increased vascular resistance. This is clinically manifested by low cardiac output, tachycardia, low blood pressure and vasoconstriction revealed by cold clammy extremities. In this type of shock there is hypovolaemia due to bleeding both externally and internally (intraperitoneal haemorrhage) from ruptured liver or spleen or from torn vessels of the mesentery alongwith toxic factors resulting from fragments of tissue entering the blood stream. Injury to the chest may cause damage to the respiratory system resulting in hypoxia and shock. Chest injury may also lead to contusion of the heart which may cause failure of pump resulting in shock. This becomes worse with more than 20% of the whole body surface bum in which there occurs generalized capillary leakage in the first day leading to gross hypovolaemia. This causes an intravascular inflammatory response with increase in vascular permeability, which requires large volumes of colloidal and crystaloid fluids for resuscitation. So there is low blood pressure with a normal cardiac output and normal pulse rate and a warm dry skin. In case of spinal anaesthesia and trauma to the spinal cord, low blood pressure can be easily corrected by putting the patient in Trendelenburg position (i. Vasovagal or vasogenic shock is also a part of neurogenic shock in which there is pooling of blood due to dilatation of peripheral vascular system particularly in the limb muscle and in the splanchnic bed. This causes reduced venous return to the heart leading to low cardiac output and bradycardia. This condition can also be corrected by Trendelenburg position which increases cerebral flow and consciousness may be restored. Psychogenic shock, which may follow sudden fright from unexpected bad news or at the sight of horrible accident, is also included in this group. Its effect may vary in intensity from temporary unconsciousness to even sudden death. The left ventricle mainly fails, so that there is over-distension of the right ventricle and ultimately there is increase of back pressure in the pulmonary capillaries. Gradually the vascular volume will increase as a result of salt and water retention by hypoperfused kidneys. In case of massive pulmonary embolism, if the embolism obstructs 50% of the pulmonary artery, it will cause acute right ventricular failure. This will severely reduce venous return to the left ventricle and thus the cardiac output falls drastically to cause severe cardiogenic shock and even sudden death. Cardiac compressive shock is usually caused by pericardial tamponade, tension pneumothorax or by large diaphragmatic hernia. This is a type of cardiogenic shock, in which the heart is compressed from outside leading to failure of its pumping mechanism, though the heart itself is normal. Such type of shock may occur in cases of severe septicaemia, cholangitis, peritonitis or meningitis.
Place the cord and ilioinguinal nerve lateral to this leaﬂet drain for purposes of traction order nizagara no prescription erectile dysfunction medicine. Often a small branch of the genitofemoral nerve runs along the ﬂoor of the inguinal canal together with the external spermatic vessels buy cheapest nizagara and nizagara erectile dysfunction normal testosterone. Make a scalpel incision through the bulging attenuated transversalis fascia from the pubic tubercle to a point just medial to the deep inferior epigastric vessels (Fig cheap 100mg nizagara mastercard impotence under 30. When lobules of preperitoneal fat bulge through the scalpel incision 50mg nizagara for sale erectile dysfunction zinc supplements, extend the incision with Metzenbaum scissors if preferred. If one is in the proper plane of dissection, the deep inferior epigastric vessels have been entirely cleared of areolar tissue; Cooper’s Fig. If any branches of the deep inferior epigastric vessels join the deep surface of the transversalis fascia, carefully divide and ligate them so a the epigastric vessels can be pushed down away from the repair. Otherwise, retroperitoneal bleeding may be caused by inadvertently piercing these vessels with a needle while suturing the transversalis layer. Excise the attenuated por- tions of transversalis fascia and apply straight hemostats to the free cut edge of the medial leaﬂet of the transversalis fascia for purposes of traction. Apply a moist gauze sponge in a sponge holder to the preperitoneal fat and bladder to push these structures posteriorly. Shouldice Repair Layer 1 Anchor the initial stitch (3-0 Tevdek on a C-5 atraumatic needle) by catching the lacunar ligament and pubic perios- teum in one bite and the undersurface of the medial ﬂap of transversalis with overlying rectus fascia in the other. Apply upward traction on the straight clamps b holding the medial leaﬂet of transversalis fascia; this maneu- ver reveals a “white line” of ﬁbrous tissue on the undersur- face of the transversalis fascia. The “white line” represents the aponeurosis of the transversus muscle as seen through the transversalis fascia. This aponeurosis of the transversus abdominis muscle is thought by McVay and Halverson and Fig. This arch of aponeurotic tion of the caudal margin of the transversalis fascia is also tissue becomes muscular as it approaches the internal ingui- termed the iliopubic tract. Include the “white line” in the continuous stitch that ter muscle ﬁbers that cover the iliopubic tract and femoral attaches the cut lateral edge of the transversalis fascia to the sheath. Otherwise it is not possible to identify these struc- undersurface of the medial leaf of the transversalis tures accurately for proper suturing. Insert the needle into the lateral leaﬂet of Each stitch should contain 4–6 mm of tissue. Continue the transversalis fascia near the point where this layer appears to suture in a lateral direction until the newly constructed 100 Shouldice Repair of Inguinal Hernia 901 Fig. A worthwhile modiﬁcation of the Shouldice technique is to excise the lower 2 cm of the internal oblique muscle to expose the underlying aponeurosis of the transversus muscle. This step is in fact an integral part of McVay’s method of hernia repair as shown in Fig. After accomplishing this step, one can invert the sutures for Shouldice’s layer 3 into the transversus aponeurosis instead of into the ﬂeshy, internal oblique muscle. If the internal oblique muscle is internal ring has been closed snugly around the spermatic ﬂimsy, resect the muscle and sew to the underlying aponeu- cord so only the tip of a Kelly hemostat ﬁts loosely between rosis of the transversus muscle. Do not leave any gap in the suture line Layer 2 near the pubic tubercle as this oversight is a common cause Excise the attenuated portion of the transversalis fascia and of recurrent hernia adjacent to the pubis. Then use the same continuous strand of suture material as L a y e r 4 in layer 1 and sew the free cut edge of the medial leaﬂet of Use the same continuous suture to create a fourth layer by transversalis fascia with adjacent internal oblique muscle to taking ﬁrst a bite of internal oblique muscle just cephalad to the anterior aspect of the iliopubic tract. Include 2–3 mm of the previous layer and then a 4 mm bite of the undersurface the shelving edge of the inguinal ligament in the continuous of external oblique aponeurosis just anterior to the previ- suture going medially (Figs. Anchor the last stitch by suture until it approaches its point of origin at the internal inserting it into the pubic periosteum. At this point, terminate ring, where the suture is terminated by being tied to its tail. This move prevents the testis from descending to an abnormally low point in the scrotum as a consequence of resecting the cremaster muscle. Laxatives may be given on the night of the ﬁrst post- Although the classic Shouldice repair calls for the four layers operative day to avoid patient discomfort at defecation. Berliner found no differences in the incidence of recurrence between the two-layer, three-layer, Complications and four-layer Shouldice repairs. Systemic complications of a pulmonary, cardiac, or urologic Closure of External Oblique Aponeurosis nature are rare. Meticulously inspect the cord and obtain complete hemosta- Wound infections are rare. Treat them promptly by open- sis with a combination of ﬁne ligatures and electrocoagula- ing the skin and subcutaneous tissues for adequate drainage tion. Replace the cord in the canal, which is now displaced and by prescribing appropriate antibiotics. Elevate the medial portion of the external Hematomas may occur in the wound and are generally oblique aponeurosis to provide adequate space for the sper- treated expectantly. Close the two leaﬂets of the external oblique may be secondary to injecting agents for local anesthesia. At the new external inguinal ring, include in the last bite of Although it is sometimes due to excessive constriction of the this suture the proximal cut edge of the cremaster muscle newly reconstructed internal ring, it is more often the result of 904 C. Chassin trauma, hematoma, or inadvertent ligature of the internal sper- Recurrent inguinal hernia is possible. Although this complication a discussion of the incidence, causes, and treatment of this may lead to testicular atrophy or necrosis, in most cases satis- problem. Persistent pain in the area innervated by the ilioinguinal or genitofemoral nerves is a rare but disturbing complication Further Reading of inguinal hernia repair. Starling and Harms reported on 19 Amato B, Moja L, Panico S, Persico G, Rispoli C, Rocco N, patients with ilioinguinal neuralgia and 17 patients with gen- Moschetti I. Seven steps to local anesthesia for inguinofemoral hernia achieved by reexploring the hernia incision and resecting the repair. Open the external oblique aponeurosis with an incision along the line of its ﬁbers from Symptomatic direct or indirect inguinal hernia when use of the external inguinal ring laterally for a distance of about prosthetic mesh is not desired 5–7 cm (see Fig. Excise Femoral hernia the entire cremaster muscle from the area of the inguinal canal (see Fig. Explore the cord carefully for the presence of the indirect Operative Strategy sac. Open the sac, explore it, close it at its neck with a suture-ligature, ampu- The McVay repair uses autogenous tissue to close the ﬂoor of tate it, and permit the stump to retract into the abdominal the canal. Identify the external spermatic vessels at the point good repair to use when an associated femoral hernia is found where they emerge from the transversalis fascia (see Fig. If exploration of the groin reveals tenuous about 4–5 cm of the vessels; ligate them again at the pubic fascia, a prosthetic mesh repair is required (see Chap. In patients with an indirect inguinal hernia, identify the margins of the transversalis fascia around the internal ingui- Documentation Basics nal ring. If the internal inguinal ring is only slightly enlarged, close it with several sutures between the healthy transversalis • Findings fascia along its cephalad margin and the anterior femoral • Presence or absence of incarceration sheath at its caudal margin. If the hernia has eroded more • Primary or recurrent than 2 cm of posterior inguinal wall, complete reconstruction is necessary. In this case, incise the transversalis fascia with a scalpel beginning at a point just medial to the pubic tuber- Operative Technique cle (see Fig. Carry the incision laterally with a scal- pel or Metzenbaum scissors, taking care not to injure the Incision and Exposure underlying deep inferior epigastric vessels. Sweep the Make a skin incision over the region of the external inguinal preperitoneal fat away from the undersurface of the transver- ring and continue laterally to a point about 2 cm medial to salis fascia. Free the deep inferior epigastric vessels so they may be retracted posteriorly together with the preperitoneal C. This constitutes a vertical line that Identify the anterior femoral sheath by gently inserting curves as it continues in a superior direction. The anterior the back of a scalpel handle between the shelving edge of belly of the rectus muscle is exposed as downward traction Poupart’s ligament and the femoral sheath overlying the is applied to the transversus arch (Fig. Then identify the anterior sur- face of the external iliac vein and artery and retract them gently in a posterior direction with a peanut sponge dissec- Inserting Cooper’s Ligament Sutures tor. To see the femoral sheath clearly, be certain to excise Suture the transversus arch to Cooper’s ligament using atrau- 100 % of the overlying cremaster muscle ﬁbers. Take substantial bites of both the transversus arch and Cooper’s ligament and place the sutures no more Making the Relaxing Incision than 5 mm apart. As the suture line progresses laterally, the external iliac A relaxing incision is essential to prevent tension on the vein is approached (Fig. Lateral to this suture, sew the transversus arch to the femo- Make a 7- to 8-cm incision in the anterior rectus sheath ral sheath. Continue to insert sutures until the internal ring is sufﬁciently narrowed to admit only a Kelly hemostat along- side the spermatic cord (Fig. After all the sutures have been inserted, tie each suture proceeding from medial to lateral. Suture the incised anterior rectus sheath down to underly- ing muscle along the lateral aspect of the relaxing incision with a few 3-0 interrupted silk sutures. Close the external oblique aponeurosis superﬁcial to the cord and complete the wound closure as described in Chap. Longterm results of a prospective study of 225 fem- oral hernia repairs: indications for tissue and mesh repair. Preliminary results of a prospective randomized study of Cooper’s ligament versus Shouldice herniorrhaphy technique.
But these patients usually do not live longer than 5 to 10 years after the diagnosis is made cheap 25 mg nizagara visa erectile dysfunction 30 years old, unless dialysis or renal transplantation is made available discount 50 mg nizagara fast delivery erectile dysfunction drugs compared. This condition may arise from bygone trauma or a haematoma may be converted into a cyst buy discount nizagara 50 mg on-line erectile dysfunction medication list. The cyst usually contains a clear amber fluid which is serous in nature and contains albumin and salts cheap 25mg nizagara otc erectile dysfunction treatment vitamins, rarely urea. In about 5% of cases there may be haemorrhagic and about half of these patients have papillary cancers on their walls. So haemorrhagic solitary renal cyst should be taken as suspicious of malignant condition. When it is deeply situated, the cyst wall is adjacent to the pelvis or calyces, but the cyst does not communicate with the renal pelvis. But rarely a significant amount of renal tissue may be destroyed to cause renal insufficiency and uraemia. The pain may be severe only when there is bleeding inside the cyst causing distension of the cyst wall. The cyst may become infected when the patient complains of pain in the loin with malaise and fever. If the cyst is in the lower pole, the upper part of the ureter is displaced more medially. The space occupying filling defect is seen with smooth border in contradistinction to a space occupying lesion due to renal neoplasm in which the filling defect will be seen irregular. Clear fluid from aspiration is probably not dangerous, yet it should be subjected to cytologic examination. Now the whole cyst fluid is aspirated and it is replaced with a radio-opaque fluid. Films are taken in the various positions to see whether the cyst wall is smooth or not. But Kirwin’s method is a curative technique in which recurrence of cyst is impossible. The kidney is explored, the portion of the cyst wall lying above the kidney surface is excised. The cyst cavity is now filled with perinephric fat and the cut edges of the cyst wall are sutured. The basic pathology is widening of the distal collecting tubules causing cystic dilatation of the renal collecting tubules. Though the pelvis and calyces are normal, yet dilated tubules may be seen lateral to them. This is usually due to the fact that a second ureteric diverticulum arises from the mesonephric duct later and distal than usual. The diagnosis can be made from history, in which a girl or a woman gives history that she is dribbling since childhood (as long as she can remember), yet she has a desire to void and does urinate. The diagnosis can be established by giving intravenous injection of indigocarmine and placing a swab in the urethra and another in the vagina. The positions of ectopic orifice in females are — (a) Into the urethra just below the sphincter urethrae. Posterior urethroscopy or intravenous injection of indigocarmine is helpful in detecting ectopic ureter. The usual positions of ectopic ureteric orifice in male are — (a) Apex of trigone. However if the affected portion of the kidney drained by ectopic ureter is hydronephrotic and chronically infected to cause severe parenchymal damage, that segment ofthe kidney has to be excised. Blood count— (a) Hypochromic anaemia may occur in association with chronic pyelonephritis, uraemia and carcinoma. In tuberculosis of the kidney there will be increased lymphocytes in the blood and there will be increased E. After curative surgery the erythropoietin level and red cell count return to normal. For this he should retract the prepuce, cleanse the glans and start urination into the urinal. First part of urination is supposed to properly cleanse the urethra, the next stream is voided in a sterile glass test-tube. The labia are held apart and the vulva and labia are cleansed properly with antiseptic solution. After the first stream of urine has been rejected, the midstream is collected in a sterile container. Finding of bacteria in a stained smear means there are at least 10,000 organisms per ml and this is pathognomonic of infection. Culture of tubercle bacilli is a lime consuming procedure, but it is a definite proof of presence of tuberculosis. Analy sis of 24-hours specimen of urine is especially useful in the investigation of calculus disease to find out abnormal excre tion of oxalate, uric acid, calcium and other products of metabolism. Estimation of chorionic gonadotrophin in urine in testicular tumour assists to detect presence or absence of particular type of testicular tumour. Presence or absence of various hormones in the urine also indicate prognosis of breast cancer. Determination of the amounts of testosterone, oestrogen, corticosteroids, pituitary gonadotrophins in the urine is helpful to detect certain endocrine disorders. If the urine is macroscopically clear and negative on dipstick testing, the chance of finding of these elements in urine is negligible. These are — (I) Reduction of renal plasma flow as found in renal artery stenosis or severe hypertension. In obstructive nephropathy, back pressure on renal parenchyma causes all these 3 types of damages. When urinary tract is normal and unobstructed, the plasma urea : creatinine ratio is 10 : 1. If this ratio rises to 20 or above, it indicates urinary stasis and diminished renal blood flow. Endogenous creatinine clearance approximates the glomerular filtration rate and its normal values vary between 90 to 140 ml/minute. Creatinine clearance gives an idea about glomerular filtration rate, but this is not very accurate. To assess glomerular function, clearance of chromium-51-labelled ethylenediaminetetra-acetic acid is better. The patient should drink no more than 200 ml of water during each of the 2 subsequent Vi hour periods. Urine specimens are collected after Vi an hour the average amount of dye normally recovered in the first Vi hour specimen is 50 to 60% and in 2nd Vi hour speciincn is about 10 to 15%. Similarly an enlarged kidney from hydronephrosis, polycystic disease or renal cancer can be diagnosed. A normal kidney extends from the top of the 1st to the bottom of the 3rd or middle of the 4th lumbar vertebra. In 90% of cases the right kidney is lower than the left because of displacement by the liver. Localised swelling as may be caused by a carbuncle, a tubercular cyst, a simple cyst or a tumour can be diagnosed. It is very difficult to assess the exact position of the radio-opaque stone in straight X-ray of the abdomen. A lateral view or visualisation of the urinary tract with radio-opaque dye is necessary. Numerous small calcific bodies in the parenchyma of the kidney may suggest tuberculosis or medullaiy sponge kidney or nephro-calcinosis caused by hyperparathyroidism. A renal calculus has to be differentiated from (i) a gallstone, (ii) calcified lymph nodes, (iii) calcified costal cartilage, (iv) phlebolith, (v) calcified aneurysm of the abdomi nal aorta or renal artery and (vi) small calcific bodies in the substance of a kidney as discussed above. A stone in the appendix or a faecolith in the colon may be confused with a stone in the ureter. It must be remembered that for the diagnosis of a stone either in the kidney, ureter or bladder, a straight film is all that is required and not a urogram. The characteristics of a renal stone are : (i) That a renal calculus moves with respiration which can be verified by taking two exposures, one at full inspiration and the other at full expiration, (ii) Density of a renal stone is uniform whereas gallstones are less dense in the centre, (iii) Renal stones take the shape of the renal pelvis and calyces whereas a solitary gallstone may be round and multiple gallstones are squeezed into the gallbladder and become faceted, (iv) In lateral view the renal stone lies superimposed on the shadow of the vertebral column, whereas gallstones are seen in front of the vertebral bodies. It is an imaginary line passing along the tips of the transverse processes of the lumbar vertebrae, over the sacro-iliac joint, down to the ischial spine from where this line deviates medially. A space-occupying lesion of the renal pelvis revealed in excretory urogram may show a faint opaque body compatible with stone but not tumour in the tomogram studies. If symptoms and signs of hypersensitivity appear during injection, it should be stopped immediately. Warning signs are respiratory difficulty, itching, urticaria, nausea, vomiting and fainting. Treatment consists of oxygen and intravenous dextrose for shock, intravenous injection of antihistaminic drug and intravenous injection of barbiturates for convulsion. Routine radiograms are taken at 10 seconds for nephrogram effect and at 5, 10 and 15 minutes with the patient in supine position. For hypertensive patients films should be taken 2 and 3 minutes after the schedule period. Delayed concentration of dye in one kidney may suggest decreased renal blood flow and function. At 25 minutes a film is taken in erect posture to note the efficiency with which the renal pelvis and ureters drain, ureterograms and also the mobility of the kidneys. All films should incl tide kidneys, ureters and bladder areas, as fine changes in the ureters which imply the presence of vesico-ureteral reflux may be detected. It is advisable to inject additional radio-opaque medium if there is impaired concentration in the initial films. In infants and children the films should be taken at 3,5,8 and 12 minutes as their kidneys excrete the fluid more rapidly than do those of the adult.