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    FMG Marathon Surgery 17-12-22

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    Sumit Gupta
    This document discusses intussusception and sigmoid volvulus. Intussusception is the telescoping of one segment of bowel into another and most commonly affects the ileocolic junction in children and the colocolic junction in adults. Sigmoid volvulus is the twisting of the sigmoid colon which can cut off blood flow. It is treated with colonoscopic detorsion or sigmoid colectomy if recurrent. Clinical features, investigations, treatment and pathological findings are described for both conditions.

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    FMG Marathon Surgery 17-12-22

    Uploaded by

    Sumit Gupta
    8 views58 pages
    This document discusses intussusception and sigmoid volvulus. Intussusception is the telescoping of one segment of bowel into another and most commonly affects the ileocolic junction in children and the colocolic junction in adults. Sigmoid volvulus is the twisting of the sigmoid colon which can cut off blood flow. It is treated with colonoscopic detorsion or sigmoid colectomy if recurrent. Clinical features, investigations, treatment and pathological findings are described for both conditions.

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    This document discusses intussusception and sigmoid volvulus. Intussusception is the telescoping of one segment of bowel into another and most commonly affects the ileocolic junction in children and the colocolic junction in adults. Sigmoid volvulus is the twisting of the sigmoid colon which can cut off blood flow. It is treated with colonoscopic detorsion or sigmoid colectomy if recurrent. Clinical features, investigations, treatment and pathological findings are described for both conditions.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    8 views58 pages

    FMG Marathon Surgery 17-12-22

    Uploaded by

    Sumit Gupta
    This document discusses intussusception and sigmoid volvulus. Intussusception is the telescoping of one segment of bowel into another and most commonly affects the ileocolic junction in children and the colocolic junction in adults. Sigmoid volvulus is the twisting of the sigmoid colon which can cut off blood flow. It is treated with colonoscopic detorsion or sigmoid colectomy if recurrent. Clinical features, investigations, treatment and pathological findings are described for both conditions.

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    FMG MARATHON

    INTUSSUSCEPTION

    • Telescoping of one segment of bowel into another


    • More common in children of age 4-10 months
    • MC type - ILEOCOLIC
    • MC type in adults - COLOCOLIC
    PARTS OF INTUSSUSCEPTION

    • Intussusceptum- incoming segment


    • Intussuscepiens- receiving segment
    • Neck- narrowest part of intussusception
    • Apex - most prone to gangrene
    • Middle layer is most prone to gangrene because it is sandwiched between
    outer and inner layer and has two acute bends
    • MC lead point is Meckel's diverticulum › Polyps
    • MC tumor responsible for intussusception in children – Lymphoma
    • MC tumor responsible for intussusception in adults – Villous Adenoma
    CLINICAL FEATURES

    • At time of attack
    o Child cries a lot, pulls legs towards abdomen
    o Colicky pain
    o Bilious vomiting (Multiple episodes)
    • In between attacks, patient is asymptomatic
    • After many attacks
    o Passage of small amount of stools mixed with blood (Red current jelly
    appearance)
    ON EXAMINATION

    • Sausage shaped mass in right lumbar region


    • Empty right iliac fossa known as Sign of dance
    INVESTIGATION

    • Diagnostic + therapeutic - Enema (air › barium)


    TREATMENT

    • Air enema (Enema creates pressure by which there will be reduction of bowel
    back to normal)
    • For Recurrence - Air enema is repeated.
    • If recurrence occurs for the third time - indication for surgery (Ileocolectomy +
    Ileo- transverse anastomosis)
    RADIOLOGICAL SIGNS
    SIGMOID VOLVULUS

    • MC Site of volvulus
    • Volvulus can be both
    o Anti- clockwise (MC)
    o Clockwise
    • Mandatory factors for volvulus
    o Constipation
    o Long narrow mesentery
    CLINICAL FEATURES

    • It is a type of Closed loop obstruction - Has signs & symptoms of LBO


    o Colicky pain in lower abdomen
    o Abdominal Distention
    o Absolute constipation / obstipation
    INVESTIGATIONS

    • On X-ray
    o Coffee Bean sign
    o Bent Inner Tube sign
    o OMEGA sign
    INVESTIGATIONS

    • On Barium enema
    o Bird beak sign
    o Ace of spade sign
    o Bird of prey sign
    TREATMENT

    • TOC- Colonoscopic Detorsion


    ↓ followed by
    Elective sigmoid colectomy (After 72 hrs)
    CECAL VOLVULUS

    • Misnomer - Cecocolic volvulus


    • Has involvement of part of ileum,
    cecum # Ascending colon
    • Mainly clockwise
    PREDISPOSING FACTORS

    • Multipara patients (due to release of relaxin)


    • H/O previous surgery (ligaments are divided)
    • Malrotation (abnormal location of cecum which is free)
    • Distal obstructing lesion (proximal part of colon distention leading to torsion)
    CLINICAL FEATURES

    • Has signs and symptoms of SBO (Because Twisting is at the level of ileum)
    o Colicky pain
    o Bilious vomiting
    o Absolute constipation
    INVESTIGATIONS

    • IOC- Abdominal X-ray


    • Findings
    o Kidney bean sign
    o Comma shaped cecum
    TREATMENT

    • leocolectomy + lleo-transverse anastomosis


    INCISIONS

    • Mc Burney's incision
    o Incision centered on Mc Burney's point # perpendicular to umbilical ASIS
    line.
    o Aka Gridiron incision
    o Aka Mc Arthur incision
    o This is a muscle splitting incision
    • Rutherford- Morrison incision
    o In retrocecal appendicitis (appendix difficult to be visualized) extend the MC
    Burney incision, upward $ laterally by cutting conjoint tendon.
    o This incision is Muscle Cutting incision
    o Preferred for retrocecal appendix.
    • Lanz incision
    o This incision is a muscle splitting incision placed transversely2cm below
    umbilicus on the line joining midpoint of clavicle to midpoint of inguinal
    ligament
    o Aka modified Mc Burney's incision
    o Aka Rocky Davis incision
    o Aka Bikini incision
    o Transverse skin crease incision
    o Preferred nowadays
    q Better exposure
    q Easier extension
    ABDOMINAL WALL DEFECTS

    Omphalocele
    • Intestine fails return to the
    intra-abdominal cavity
    • Covered by 2 layers
    o Amnion
    o Peritoneum
    GASTROSCHISIS

    • Splitting of abdominal wall from right side


    with herniation of bowel.
    • Bowel is exposed, not covered and becomes
    thickened, matted and edematous
    • Associated with Intestinal atresia Risk factors
    STONE CRYSTALS
    STONE CRYSTALS
    STONE CRYSTALS
    STONE CRYSTALS
    STONE CRYSTALS
    BLADDER RUPTURE

    • 2 types
    o Extra- peritoneal (responsible for 80% cases)
    o Intra- peritoneal (responsible for 20% cases)
    EXTRAPERITONEAL BLADDER RUPTURE

    • Caused by - Road traffic accident


    • RTA causes Pelvic fracture ↓ leads to Extra-peritoneal rupture of bladder and
    Posterior Urethral injury
    CLINICAL FEATURES

    • Suprapubic pain
    • Difficulty in passing urine
    • Hematuria
    INVESTIGATIONS

    • IOC - CT cystography/ Cystogram


    • Findings
    o Flame sign
    o Pear sign
    o Tear drop bladder
    MANAGEMENT

    • Foley's catheterization
    • Spontaneous healing within 7-10 days
    INTRA PERITONEAL BLADDER RUPTURE

    • External blow/ kick to full bladder may lead to intraperitoneal bladder rupture
    • MC in Males
    CLINICAL FEATURES

    • Suprapubic pain
    • Difficulty in passing urine
    • Hematuria
    • Peritonitis
    MANAGEMENT

    • Exploratory Laparotomy + Peritoneal lavage + Repair of defect + Suprapubic


    catheter / Foley's catheterization
    HYPERTROPHIC SCAR KELOID
    Hypertrophic Scar Keloid
    Genetic • Not Familial • May be familial
    Race • Not race related • More common in
    Blacks > whites
    Sex • Females = males • Females > males

    Age • Children • 10 to 30 years

    Border • Remains within the wound • Outgrows wound area

    Sites • Flexor surface • Sternum


    • Shoulder
    • Face
    Etiology • Related to tension • Unknown
    Development • Within 4 weeks • 3 months to 1 year
    Clinical • Raised • Pain
    findings • Some pruritis • Pruritis
    • Respects wound confines • Grows beyond the
    wound margins
    Histology • Parallel orientation of type • Thick wavy type I & III
    III collagen fibers collagen in random
    EDH SDH
    EDH SDH
    EDH SDH
    TENSION PNEUMOTHORAX
    PATHOLOGY

    1. Collapse of Ipsilateral lung


    2. Shift of Mediastinum (Due to High pressure)
    3. Depressed Diaphragm
    4. Decreased venous return (Due to compression SVC ¢ IVC)
    • Mediastinum
    o Displaced to opposite side
    o Decreased venous return & compression of opposite lung
    INVESTIGATION

    • Diagnosed clinically
    TREATMENT

    • Emergency treatment - Put a large bore needle into 2nd I/C space in
    Midclavicular line
    Note
    • According to ATLS manual 10*edition - Recent evidence supports placing large
    bore needle in 5th I/C space slihtly anterior axillary line

    • Definitive Rx/ TOC- ICD insertion in Triangle of safety (5th V/C: space in
    Anterior-axillary line)
    ABDOMINAL TRAUMA

    One liner on Abdominal trauma


    • Most commonly injured organ in BTA - spleen › liver
    • Most commonly injured organ in penetrating trauma - liver › stomach> SI
    • Most commonly injured part of bowel in BTA – Jejunum
    • Most commonly injured organ in Gunshot injury - Small intestine
    • Most commonly site of injury in deceleration injury -Duodenojejunal junction
    • Most commonly injured structure in seat belt injury - Mesentery
    • 1st inv. Done in patient of BTA – FAST
    • Gold standard investigation for stable patient of BTA – CECT
    FAST (Focused Assessment with Sonography for Trauma)
    • It is an Emergency ultra sound i.e. performed
    very fast Lin 2 - 4 minutes]
    • Assess Potential sites of thoracoabdominal
    injuries(4P’s)- Pericardial sac
    o Perihepatic region
    o Peri-splenic region
    o Pelvis
    • 4 traditional views in FAST
    e-FAST (extended FAST)
    • Has two additional views(so, has a total of 6 views)
    o Right thoracic view
    o Left thoracic view
    THANK YOU

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