By M. Dudley. Simpson College, Redding California.

Consequently buy nizagara now, a mild cathartic the night before operation constitutes the Coding for anorectal procedures is complex order 100 mg nizagara overnight delivery. In general discount nizagara 25 mg, it is important to document: Pitfalls and Danger Points • Findings • Extent of sphincterotomy Injury to external sphincter • Open or closed? Inducing fecal incontinence by overly extensive • Excision of hypertrophied papilla or not? Feel for a distinct groove between the subcutaneous external sphincter and the lower border of the tense internal Place the patient in the lithotomy position buy cheap nizagara. There is a gritty sensation while the internal sphinc- ter is being transected, followed by a sudden “give” when the blade has reached the mucosa adjacent to the surgeon’s left index finger. Remove the knife and palpate the area of the sphincterotomy with the left index finger. Any remain- ing muscle fibers are ruptured by lateral pressure exerted by this finger. It is rarely necessary to make an incision in the mucosa to identify and coagulate a bleeding point. An alternative method of performing the subcutaneous sphincterotomy is to insert a No. Then turn the cutting edge of the blade so it faces laterally; cut the sphincter in this fashion. This approach has the disadvantage of possibly lacerating the external sphincter if excessive pressure is applied to the blade. Then the lower border of the internal sphincter and intersphincteric groove are identified. Divide the lower portion of the internal sphincter up to a point level with the dentate line. Removal of the Sentinel Pile If the patient has a sentinel pile more than a few millimeters in size, simply excise it with a scissors. If in addition to the chronic anal fissure the patient has symptomatic internal hemorrhoids that require surgery, hem- orrhoidectomy may be performed simultaneously with the lateral internal sphincterotomy. If the patient has large inter- nal hemorrhoids, and hemorrhoidectomy is not performed Fig. During this insertion keep the flat portion of the blade paral- lel to the internal sphincter. Insert the left index finger into the anal canal Apply a simple gauze dressing to the anus and remove it the opposite the scalpel blade. Generally, there is dramatic Further Reading relief of the patient’s pain promptly after sphincterotomy. Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs fissurectomy—midline sphincterotomy. Segmental internal sphincterotomy – a Complications new technique for treatment of chronic anal fissure. Cochrane Database Syst Some patients complain that they have less control over the Rev. The treatment of anal fissure by lateral subcutaneous internal sphincterotomy: a technique and results. Efficacy of management algorithm for reducing porary, and the problems rarely last more than a few need for sphincterotomy in chronic anal fissures. Patients with mild forms of anal stenosis may respond to a simple Symptomatic fibrotic constriction of the anal canal not internal sphincterotomy if there is no loss of anoderm. In general, it is important to document: Pitfalls and Danger Points • Findings • Nature of flap Fecal incontinence • Sphincterotomy or not? Slough of flap Inappropriate selection of patients Operative Technique Operative Strategy Sliding Mucosal Flap Some patients have a tubular stricture with fibrosis involving Incision mucosa, anal sphincters, and anoderm. This condition, fre- With the patient under local or general anesthesia, in the prone quently associated with inflammatory bowel disease, is not position, and with the buttocks retracted laterally by means of susceptible to local surgery. This incision elevating the anoderm and mucosa in the proper plane frees should extend from the dentate line outward into the anoderm for these tissues from the underlying muscle and permits forma- about 1. This should permit dila- tation of the anus to a width of two or three fingerbreadths. Then advance the mucosa so it can be sutured circumferentially to the sphincter muscle (Fig. This suture line should fix the rectal mucosa near the normal location of the dentate line. Advancing the mucosa too far results in an ectropion with annoying chronic mucus secretion in the perianal region. In a few cases of severe stenosis, it may be necessary to repeat this process and create a mucosal flap at 6 o’clock (Figs. Hemostasis should be complete following the use of accurate electrocautery and fine ligatures. Sliding Anoderm Flap Incision After gently dilating the anus so a small Hill-Ferguson spec- ulum can be inserted into the anal canal, make a vertical inci- sion at the posterior commissure, beginning at the dentate line and extending upward in the rectal mucosa for a distance Fig. Then make a Y extension of this incision on 73 Anoplasty for Anal Stenosis 673 to the anoderm as in Fig. Be certain the two limbs of the incision in the anoderm are separated by an angle of at least 90° (angle A in Fig. Now by sharp dissection, gently elevate the skin and mucosal flaps for a distance of about 1–2 cm. When the dissection has been completed, it is possible to advance point A on the anoderm to point B on the mucosa (Fig. Internal Sphincterotomy In most cases enlarging the anal canal requires division of the distal portion of the internal sphincter muscle. Insert a sharp scalpel blade in the groove between the internal and external sphincter muscles. Advancing the Anoderm Using continuous sutures of 5-0 atraumatic Vicryl, advance the flap of anoderm so point A meets point B (Figs. When the suture line has been completed, the original Y incision in the posterior commissure resembles a V Fig. It is not necessary to mobilize the Gelfoam because it tends to dis- solve in sitz baths, which the patient should start two or three times daily on the day following the operation. Thereafter a bulk laxative, such as Metamucil, is pre- scribed for the remainder of the postoperative period. Discontinue all intravenous fluids in the recovery room if there has been no postanesthesia complication. Complications Urinary retention Hematoma Anal ulcer and wound infection (rare) Fig. Chassin† Indications Preoperative Preparation Perineal procedures are used in patients with full-thickness Basic workup includes colonoscopy with biopsy of any rectal prolapse. Rectal ulcers are common and must be attractive alternative for poor-risk patients who might not differentiated from cancer. It is It is crucial that the proper operation be chosen and that the also sometimes used in young male patients to avoid the procedure is tailored to the patient (see Further Reading). Accurately assess and document the degree of preoperative In women, the perineal approach may be combined with continence by: repair of any cystocele or other perineal problem. Finally, abdominal and perineal procedures com- • Colon transit times if severe constipation is present. The Thiersch operation is indicated in extremely poor-risk Bowel preparation as for resection. Other perineal operations, including the Delorme procedure, are excellent alternatives in poor-risk Pitfalls and Danger Points patients and have largely supplanted this legacy procedure Perineal Proctosigmoidectomy When surgery is performed for recurrent prolapse (e. Chassin Operative Strategy Perineal Proctosigmoidectomy The procedure is most easily performed with the patient in the prone jackknife position. Injecting the rectal wall with lidocaine solution containing epinephrine will help minimize bleeding and display the correct dissection plane. Begin with a full-thickness incision in the posterior rectal wall above the dentate line.

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The pulse is characteristically water-hammer with high systolic and low diastolic pressure resulting in a large pulse pressure nizagara 25mg for sale. Its incidence is highest in Finland followed by United States 50mg nizagara with amex, whereas Japan has the least incidence discount 50mg nizagara overnight delivery. A common pattern is occlusion of the proximal anterior descending coronary artery with distal 50% remaining patent The significant pathological feature is that the disease affects segments of coronary arteries larger than 2 mm in diameter order nizagara in united states online. In a small percentage of patients congestive cardiac failure may eventually develop. The most important is the coronary angiography and left ventricular angiography to know the function of left ventricle and measure the left ventricular diastolic pressure. The decision of successful operation depends on the presence of patent distal arterial segment shown by angiography and on the proper functioning of the left ventricular muscles evaluated by left ventricular angiography. The right coronary artery is usually approached from the posterior border of the heart near the posterior descending coronary vein. The preferred graft is 5 inches reversed segment of saphenous vein attached proximally to the aorta and distally to the coronary artery as an end-to-side anastomosis. The distal anastomosis should be performed with a segment of about more than 1 mm in diameter and free from atherosclerosis. The by-pass grafts are done according to the necessity—either a single by-pass graft or double grafts usually to the anterior descending and the right coronary arteries and in a few patients tripple grafts to all the three major coronary arteries have been used. Patency is due to the presence of myocardial sinusoid and embryonic capillary like remnants, which provide some immediate run-off of blood from the implanted artery. In addition the rhythmic myocardial contraction produces an alternating to and fro motion of blood in the implant flowing away from the heart in systole and towards the heart in diastole. In the ensuing weeks after implantation, arterial tributarily, progressively appear around the implant and may connect the regional coronary vessels. With the evolution of these tributaries, there will be an increase in blood flow through the implant. Most of these aneurysms are located in the anterior portion of the left ventricle in the area supplied by the anterior descending coronary artery. Aneurysms of the posterior portion of the ventricle is the area supplied by the circumflex artery are much less frequent. Aneurysm can impair function of the left ventricle as contraction of it is dissipated into expanding the wall of the aneurysm. The wall of the aneurysm is divided about 2 cm from its junction with the ventricular muscle. After excision the opening is sutured, the line of which will be through the scar near the junction of the ventricular muscle, thus avoiding interruption of collateral circulation around the margins of the aneurysm and also avoiding any reduction in size of the ventricular cavity. If concomitant coronary by-pass grafting is to be done, this should be attached first. Attachment of all grafts may not be possible until the heart is mobilised and the aneurysm excised. In majority of cases cardiac tamponade occurs due to trauma either blunt or penetrating injury. On clinical examination, the pathognomonic signs of cardiac tamponade are — (i) increased venous pressure, (ii) decreased pulse pressure, (iii) pulsus paradoxus, (iv) an enlarged area of cardiac dullness. Pulsus paradoxus means the pulse becomes weaker on inspiration than on expiration. This is due to normal inspiratory fall in the intrapericardial and right atrial pressure during inspiration. If the cause is cardiac wound, immediate thoracotomy is usually required to repair it. It is the children who are more often affected nowadays usually younger than 5 years of age. This occurs then as a mainfestation of generalised infection with lack of resistance. It may be secondary to acute myocardial infarction, trauma, neoplastic infiltration or uraemia. Pathologic changes in the pericardium consists of an acute inflammation with increased pericardial vascularity and fibrin deposition. Fibrinous adhesions between the pericardial parietes and exudation of fluids into the pericardial space are typical features. Echocardiogram is probably the most sensitive test for evaluation of pericardial effusion. Surgical drainage of the pericardium is required if aspiration proves ineffective in controlling the disease. The advantage of this site is that — (i) it does not puncture the pleura, (ii) It aspirates the pericardial cavity through the most dependent part, (iii) It is less likely to damage any coronary vessel. Once the paricardium is reached a window is excised of approximately 3 cm2 and this is sent for histological examination (pericardiotomy). The heart is in fact is confined in a rigid inelastic case preventing it from its proper functioning. The pathological effect of this condition is that it prevents ventricles from proper filling in diastole. There is corresponding increase in right atrial pressure and right ventricular diastolic pressure. This venous hypertension may produce peripheral oedema, hepatic enlargement and ascites. Gradually the patient complains of oedematous swelling of the feet and abdominal enlargement due to ascites. On examination, peripheral oedema, enlargement of liver and ascites should be detected. The pulse pressure is normally decreased and a paradoxic pulse is found in a small percentage of cases. The patient is prepared with diuretics and aspirations of pleural or ascitic fluid. The constricting pericardium should be removed from the entire heart, although removal of pericardium from the ventricles may relieve the diseased condition. It is always the technique to free the left ventricle first to prevent pulmonary congestion. It is sometimes difficult to remove the adherent pericardium from the diaphragmatic part of the ventricle. Removal of pericardium from the atria and vena cava is physiologically less important, though it should be done. The risk of operation varies with the age of the patient and the severity of the case. Pericardiotomy or pericardial biopsy may be required for establishing the cause of pericardial disease. Post pericardiotomy syndrome is sometimes come across in 10 to 40% of cases by the appearance of fever, pericarditis and pleuritis. It begins at the lower border of the pharynx which is situated opposite 6th cervical vertebra or at the lower border of the cricoid cartilage. It descends through superior and posterior mediastinum and ends at the cardiac orifice of the stomach at level of the 11th thoracic vertebra. It descends vertically almost through midline but presents two slight curves to the left. At the commencement it is placed in the midline, as it descends downwards it slightly inclines to the left upto the root of the neck. It again moves towards the midline as it descends downwards and reaches the midline at the 5th thoracic vertebra. It follows the midline course till the 7th thoracic vertebra when again it gradually shifts to the left till it passes through the oesophageal orifice of the diaphragm at the level of the 10th thoracic vertebra. The oesophagus also presents anteroposterior curvatures following the curvature of the cervical and thoracic portions of the vertebral column. During its course it is constricted at 4 places — (i) at its commencement, 6 inches from the incisor teeth, which is the narrowest point in the gastointestinal tract measuring 14 mm in diameter, (ii) where it is crossed by the aortic arch, 9 inches from the incisor teeth; (iii) where it is crossed by the left main bronchus, 11 inches from the incisors and (iv) where it crosses the diaphragm (the diameter is about 16 to 18 mm), about 16 inches from the incisors.

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Be careful not to injure the right gastric or right 23 Bile Diverting Operations for Management of Esophageal Disease 235 Bile Diversion by Duodenojejunostomy Roux-en-Y Switch Operation Incision and Exposure Make a midline incision from the xiphoid to a point about 3–4 cm below the umbilicus discount nizagara online visa. Duodenojejunostomy Perform a thorough Kocher maneuver cheap nizagara 50mg otc, freeing the head of the pancreas and duodenum anteriorly and posteriorly buy nizagara discount. Place a marking suture on the anterior wall of the duode- num precisely 3 cm distal to the pylorus cheap nizagara online visa. Divide and carefully ligate the numerous small vessels emerging from the area of the pancreas and entering the duodenum on both anterior and posterior sur- faces until a 2 cm area of the posterior wall of duodenum has been cleared. Do not dissect the proximal 2–3 cm of duodenum from its attachment to the pancreas. Dissecting the next 2 cm of duodenum free of the pancreas provides enough length to allow stapled closure of the duodenal stump and a duodenojejunal end-to-end anastomosis. To divide the duode- After this step has been completed, make a 2 cm trans- num, first free the posterior wall of the duodenum from the verse incision across the anterior wall of the duodenum near pancreas for a short distance. Then divide the duodenum gallbladder and liver, observing the influx of bile into the flush with the stapling device. Leave 1 cm of the posterior wall of the Complete the transection of the duodenum after the stapler duodenum free (Fig. Bring the open distal end of the At a point 20 cm distal to the ligament of Treitz, tran- divided jejunum (Fig. Limiting but occasionally it is feasible to bring it through an incision the incision in the mesentery to 3 cm helps preserve the in the mesocolon (retrocolic). Then per- creating an end-to-side jejunojejunostomy at a point 60 cm form an end-to-side jejunojejunostomy to the descending distal to the duodenojejunostomy using the technique shown limb of jejunum (Fig. Irrigate the abdominal cavity and abdominal wound and close the abdomen in the usual fashion with- Intestinal obstruction out drainage. Anastomotic leak 23 Bile Diverting Operations for Management of Esophageal Disease 239 Fig. Determinants of intestinal of oesophageal reflux symptoms after gastric surgery with com- metaplasia within the columnar-lined esophagus. Surgical technique for management of reflux cal treatment for recurrent postoperative gastroesophageal reflux. Cricopharyngeal Myotomy and 2 4 Operation for Pharyngoesophageal (Zenker’s) Diverticulum Carol E. Symptomatic Zenker’s diverticulum If the pharyngoesophageal diverticulum is a small diffuse bulge measuring no more than 2–3 cm in diameter, we per- form only a myotomy and make no attempt to excise any part Preoperative Preparation of the diverticulum because after the myotomy there is only a gentle bulge of mucosa and no true diverticulum. On the other Perioperative antibiotics hand, longer, finger-like projections of mucosa should be amputated because there have been a few case reports of recurrent symptoms due to the persistence of diverticula left Operative Strategy behind in patients in whom an otherwise adequate myotomy had been done. Belsey advocated suturing the most depen- Adequate Myotomy dent point of the diverticulum to the prevertebral fascia in the upper cervical region. This procedure effectively upends the Performing a cricopharyngeal myotomy is similar to per- diverticulum so it can drain freely into the esophageal lumen forming a cardiomyotomy. We prefer to amputate diverticula larger than 3 cm geal sphincter is considerably wider than the anatomic rather than perform a diverticulopexy. The transverse muscle fibers are stapling device, amputation of the diverticulum takes only only about 2. Endoscopic alternatives have been developed Consequently, a proper cricopharyngeal myotomy should and are described in the references at the end of this chapter. The incision in the Documentation Basics muscle is carried down to the mucosa of the esophagus, which should bulge out through the myotomy after all the Findings muscle fibers have been divided. Free the anterior border Divide the areolar tissue anterior to the carotid artery and of the sternomastoid muscle and retract it laterally, exposing identify the inferior thyroid artery and the recurrent laryn- the omohyoid muscle crossing the field from medial to lat- geal nerve. The diverticulum is inferior thyroid artery arising from the thyrocervical trunk, located deep to the omohyoid muscle. Identify the carotid in which case the lower thyroid is supplied by branches of sheath and the descending hypoglossal nerve and retract the superior thyroid artery. The thyroid gland is seen in the thyroid artery emerging from underneath the carotid artery medial portion of the operative field underneath the strap and crossing the esophagus to supply the lower thyroid (see muscles. Often it is not necessary to divide the inferior thyroid artery or its branches to develop adequate exposure for diverticulectomy. Dissecting the Pharyngoesophageal Diverticulum The pharyngoesophageal diverticulum emerges posteriorly between the pharyngeal constrictor and the cricopharyngeus muscles. Its neck is at the level of the cricoid cartilage, and the dependent portion of the diverticulum descends between the posterior wall of the esophagus and the prevertebral fascia overlying the bodies of the cervical vertebrae. Elevate the hemostat in the posterior midline and incise the Grasp it with a Babcock clamp and elevate the diverticulum fibers of the cricopharyngeus muscle with a scalpel. Mobilize the diverticulum by sharp this dissection down the posterior wall of the esophagus for and blunt dissection down to its neck. Now elevate the incised sion about the anatomy, especially in patients who have muscles of the cricopharyngeus and the upper esophagus undergone previous operations in this area, ask the anesthe- from the underlying mucosal layer over the posterior half of siologist to pass a 40F Maloney bougie through the mouth the esophageal circumference by blunt dissection. Guide the tip of the bougie past After the mucosa has been permitted to bulge out through the neck of the diverticulum so it enters the esophagus. The the myotomy, determine whether the diverticulum is large exact location of the junction between the esophagus and the enough to warrant resection. Fire the staples Lightly incise it with a scalpel near the neck of the sac down and amputate the diverticulum flush with the stapling device. At this point the transverse fibers of the The 40F Maloney dilator in the lumen of the esophagus pro- cricopharyngeus muscle are easily identified. After removing the stapling device, carefully inspect the staple line and the staples for proper closure. An alternative method for performing the myotomy is Insert a blunt-tipped right-angled hemostat between the illustrated in Fig. Initiate a liquid diet on the first postoperative day and progress to a full diet Drainage and Closure over the next 2–3 days. After carefully inspecting the area and ensuring complete hemostasis, insert a medium-size latex drain into the prevertebral space just below the area of the diverticulectomy. When the fistula is small and drains pri- sutures to the muscle fascia and platysma. Flexible endoscopic management of Zenker diver- secondary to excessive traction on the thyroid cartilage or ticulum: the mayo clinic experience. Cervical esophageal dysphagia; indications for and results of cricopharyngeal myotomy. Esophagomyotomy for Achalasia 2 5 and Diffuse Esophageal Spasm: Surgical Legacy Technique Carol E. Chassin† Indications Operative Strategy Achalasia Length of Myotomy for Achalasia Extended myotomy sometimes performed for diffuse esoph- ageal spasm Ellis et al. At the esophagogastric junction, several veins run in a transverse direction just superficial to the esoph- Obtain a barium swallow esophagram. One does not encounter any other transverse Perform esophagoscopy with biopsy and brushings of the vein of this size during myotomy of the more proximal esoph- narrowed portion of distal esophagus if any mucosal agus. In no case should more than 1 cm of gastric musculature Perform esophageal manometry. Continue the myotomy in a cephalad direction for For advanced cases, lavage the dilated esophagus with a 1–2 cm beyond the point at which the esophagus begins to Levine tube and warm saline for 1–2 days prior to opera- dilate. For early cases, where no significant esophageal dilata- tion to evacuate retained food particles. Laparoscopic myotomy is an excellent alternative for patients with achalasia in whom the narrow segment is limited to the Pitfalls and Danger Points distal esophagus (see Chap. Open esophagomyotomy may be performed through a thoracotomy incision (as shown Extending the myotomy too far on the stomach here) or transabdominally. The thoracic approach allows Perforating the esophageal mucosa excellent exposure without disrupting the phrenoesophageal Performing an inadequate circumferential liberation of the ligaments, potentially contributing to postoperative gastro- mucosa esophageal reflux. It facilitates a long myotomy in cases of Creating a hiatus hernia diffuse esophageal spasm. Chassin insert 100–200 ml of a methylene blue solution through the nasogastric tube. When a mucosal perforation is identified during the operation, careful suturing of the mucosa generally avoids further difficulty. Some surgeons close the muscle over the perforation and then rotate the esopha- gus so the myotomy can be performed at a different point on the esophageal circumference.

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