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In bronchiectasis the cough is chronic and productive with purulent expectoration purchase 160 mg tricor with amex cholesterol test preparation coffee, whereas in lung abscess cough is productive with foul-smelling sputum buy generic tricor 160 mg on-line cholesterol in eggs 2012. In carcinoma of lung this is the commonest manifestation and it may or may not be productive discount tricor 160mg otc cholesterol lowering foods american heart association. Whereas tuberculosis is the commonest cause of haemoptysis in India cheap generic tricor uk cholesterol medication pregnant, yet a few surgical conditions also manifest with this symptom. It is an alarming symptom of lung carcinoma and occurs in approximately 1/3 of cases. Occasionally haemoptysis may be massive in this condition constituting surgical emergency. In tuberculosis also it is seen but basically it is a medical disease and very occasionally it may need surgery. It is also a characteristic feature of actinomycosis of lung in which the patient presents with multiple sinuses in the chest wall with induration and bluish skin around. In a case of swelling of the chest wall or in a case who presents with haemoptysis and fever past history of tuberculosis suggests the possibility of cold abscess of flaring up of the old infection. Past history of pneumonia suggests the post-pneumonic empyema which is the commonest cause of empyema. A recent past history of persistent cough treated by medicine and now the patient presents with cough, dyspnoea, haemoptysis and weight loss should arouse suspicion of carcinoma of lung. If present, ask whether it was present previously or appeared after the beginning of the present illness. If there is undue prominence of ribs anteriorly on one side, exclude scoliosis before considering an intrathoracic disease. So there is concavity from above downwards, antero-posteriorly and side-to-side of the chest giving rise to the appearance of a funnel. Sluggish movement on one side of the chest may be due to pleural effusion, consolidation, collapse etc. The methods of examination have been discussed thoroughly in Chapters 3 and 5 respectively. Neck veins may be engorged due to congestive cardiac failure or secondary to long­ standing lung disorders. They are so placed that the tips of the two thumbs come in contact with each other in the centre. Deficient movement or immobility of one thumb indicates pleural effusion, consolidation, collapse etc. Position of trachea should be examined to know if this is shifted to one side or the other. Soft, fluctuating swelling mainly on the anterior axillary line or parasternal line is a cold abscess. Ascertain the mobility of the swelling over the chest wall and note whether the swelling is free or fixed to the chest wall. Fixed swellings are those arising from the ribs or may grow from within the thorax e. If the swelling is pulsatile, note whether it is an expansile or transmitted pulsation. Multiple encapsulated pleural empyema, a narrow opening between smuses with marked induration may be the ribs through which the empyema has burrowed due to actinomycosis of the lung. If they externally presenting a collection of pus in the subcutaneous extrude sulphur granules diagnosis is tissues giving rise to a fluctuating swelling. Diminished breath sounds will be heard in pleural effusion, pneumothorax, haemo­ thorax etc. Presence of blood in unknown cases of pleural effusion indicates malignant disease. It should be sent for culture excluded by looking for impulse on coughing which is positive and sensitivity tests. In case of bronchial carcinoma it may show a hilar or peripheral shadow and features of obstructive emphysema, atelectasis or consolidation as secondary changes, (b) In chronic empyema with a sinus, injection of lipiodol followed by skiagraphy will show the position and extent of the empyema cavity. Diagnosis of bronchiectasis can also be made with certainty by this method, (d) Tomography is very helpful in studying a cavity inside a dense shadow which is not clearly visualized in an ordinary film. Skiagram is taken while the tube is moving in one direction and the film in the opposite direction, so that all the objects above and below the cavity throw blurred shadows but the cavity stands out clearly. This will also help in demonstrating enlarged mediastinal nodes and lung cancer, (e) Skiagraphy after barium swallow may show deviation of the oesophagus in the case of mediastinal deposits. This examination, of course, fails to reveal any lesion in the segmental division of the upper bronchus and the peripheral lesions. Cytology study can be performed by bronchial washing and brushing through bronchoscopy. Screening of diaphragm will give a clue whether the phrenic nerve has been involved or not. Liver, brain and bone scanning should be done if these organs are suspected to be involved. Exploratory thoracotomy should be performed if an early diagnosis and radical extirpation are desired. Primary rib tumour may be a chondroma, osteoma, osteoclastoma, chondrosarcoma, osteosarcoma etc. Secondary carcinoma of rib may be seen in cancer of the breast, bronchus, suprarenal, prostate, kidney etc. In case of malignant tumours pain and tenderness are often come across, which become more obvious in case of secondary growths. Neurofibroma arising from the intercostal nerves and ganglioneuroma from the sympathetic chain. The former appears close to the neck of the rib while the latter lies more medially close to the vertebral bodies. These tumours are detected by straight X-ray as they tend to erode the adjacent ribs and the vertebrae. Costochondritis is nothing but a swelling at the junction of a rib and the costal cartilage. This swelling must not be confused with the breast swelling as the whole of the breast can be moved over the swelling. Only rarely perinephric abscess may burrow superficially to give rise to an abscess in the posterior aspect. Cold abscess in the chest wall is usually seen along the anterior axillary line and the parasternal line. This is because of the fact that the abscess follows the lateral and the anterior cutaneous branches of the intercostal nerves to become superficial. Empyema necessitatis means pus of the empyema burrows to the chest wall and becomes superficial either in the lateral or anterior aspect (See Fig. Hernia of the lung is very rare and seen usually at the root of the neck behind the clavicle.

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Wexner on some occasions order tricor australia cholesterol test kit australia, such as with diverticulitis or segmental Crohn’s colitis discount 160 mg tricor free shipping cholesterol water solubility, a water-soluble contrast enema may pro- vide more useful data generic tricor 160mg on-line cholesterol test no fasting. In patients with low rectal cancer discount tricor 160mg fast delivery cholesterol side effects, endorectal ultrasonography can be performed for staging. Preoperative placement of ureteric stents may be useful when severe pelvic and/or retroperitoneal inflammatory pro- cesses are anticipated. Operative Technique Room Setup and Patient Positioning The video monitors should be placed near the patient’s left shoulder and the patient’s right knee because a right-hand dominant surgeon typically stands on the patient’s right side, with the assistant on the contralateral side and the camera operator on the ipsilateral side cephalad to the surgeon at the commencement of the surgery. The light sources, electrosur- gical units, camera system, insufflator, and pressure monitor are on the patient’s right side. The patient should be secured to the operating table allowing various positioning including steep Trendelenburg and lateral rotation during the procedure. The patient is placed in the modified lithotomy position allowing the access to the perineum without interfering with the mobility of the surgical instruments. Both arms are tucked to the sides (adducted) enabling flexibility in the sur- geon’s position around the operating table. Irrigation is accomplished should be placed at least a hand width from each other to through a mushroom-tipped catheter initially with normal avoid instrument crowding. The port is secured to the fascia by suture materials on both sides of Mobilizing the Left Colon and Identification the port. Following camera insertion into the abdominal of the Left Ureter cavity, an exploration commences with a view at the entire abdomen. Anatomy, resectability, adhesions, and concomi- We typically perform the “lateral-to-medial” technique. Following positioning of the patient to right side tilted down, 52 Laparoscopic Left Hemicolectomy and Low Anterior Resection 491 Fig. This maneuver typically starts at the level of the sigmoid colon using either an elec- trocautery or the ultrasonic scalpel. The ultrasonic scalpel Dissecting the Splenic Flexure has among its several advantages in improved visualization and the Transverse Mesentery as vessels and tissue are dissected without production of smoke. The dissection should be undertaken in the plane The operating table is placed in the reverse Trendelenburg between the posterior aspect of the colonic mesentery and position and tilted down towards the right side. The left ureter is usually iden- adequate mobilization to enable a tension-free anastomo- tified in the left iliac fossa overlying the iliac vessels. This maneuver requires great attention not to trauma- ureteric stents can be useful to assist with this step especially tize the spleen (Fig. The surgeon may place the additional trocars as colon facilitates the isolation of the transverse mesen- previously described, in the suprapubic midline or left para- tery; injuries to the pancreas body or tail must be carefully umbilical so that he or she can face both the splenic flexure avoided. The dissection should be continued as close to the bowel as possible, staying laterally and on the plane between Gerota’s Identification and Transection fascia and the mesentery. The divi- next phase is to identify and transect the inferior mesenteric sion of the gastrocolic ligament can be performed with vessels. The surgeon moves back to the patient’s right side 52 Laparoscopic Left Hemicolectomy and Low Anterior Resection 493 Fig. Providing gentle countertraction is performed, giving an adequate tension to countertraction with the Babcock clamp, the inferior mes- the transverse mesentery. The respective instrument must be the mesentery based on the indication for surgery. The left ure- planned proximal margin of the colon is gently deliver to the ter and the gonadal vessels may have to be gently reflected pelvis in order to assure that adequate length of the colon has laterally to avoid being transected with the inferior mesen- been mobilized for a tension-free anastomosis. After verification that the left ureter is not cal blood supply to the proximal margin of the colon needs incorporated, whatever instrument is used, the vessels are to be evaluated as well. It is crucial to visualize the distal tips of stapler application to insure that no extraneous tissue is incorporated. Vascular division may be extended to the left branch of the middle colic vessels depending upon The total mesorectal excision and the mobilization of the the pathology and the location of diseased segment. The dissection is usually accom- plexuses parasympathetic, coated by the pelvic fascia. The upper rectal dissection is continued with the same exposure as the lateral peritoneum is divided. Proceeding anteriorly, the anatomical reference will be Transection of the Distal Colon or the seminal vesicles in males or the superior vaginal wall Rectosigmoid Junction in Left Hemicolectomy (Douglas’ cul-de-sac) in females. An atraumatic clamp or the Rectum in Low Anterior Resection placed in the left paraumbilical or suprapubic port is used to gently retract the rectum or sigmoid upwards, and the right To obtain an adequate distal margin, the dissection of the or left second clamp can be used to gently retract the bladder bowel may be extended over the sacral promontory and 52 Laparoscopic Left Hemicolectomy and Low Anterior Resection 495 Fig. Termination of the Exteriorization of the Left Colon or the Rectum colonic teniae and the appendices epiplocae at the sacral promontory is the landmark of the rectosigmoid junction. Once the left colon or the rectum has been completely mobi- Verification of the distal level of the bowel transection must lized, a trial reach to the intended level of anastomosis is be done prior to the application of the linear stapler by the undertaken. The bowel is then exteriorized through introduced through the 12 mm right lower port, and the either the left lateral or the suprapubic midline incision, and bowel is transected at the endoscopically and laparoscopi- a 10–12 mm port is placed in the left lower quadrant position cally selected resection margin, insuring that no extra- (if this port has not been placed prior to this point). More than one clamp is then used to gently hold the proximal colon in order application of the stapler may be necessary to accomplish to deliver it from the abdominal cavity. Assess the length of mesentery to enlarged along the trocar length; typically 5 cm incision is insure a tension-free anastomosis in the following phase. A wound protector may assist in If more length is necessary, further scoring of the perito- minimizing potential contamination. After the purse string clamp is removed, anvil into pelvis and then to approximate it to the circular the vascularity of the resection margin is verified. The camera can be repositioned as needed so that the entire team can circumferentially visualize both the distal and proximal portion of the anastomosis. Performing the Anastomosis While closing the stapler, any extraneous tissue must be reflected away, and the surgeon must verify that there is no The distal margin will almost be at or distal to the rectosig- tension and proper alignment prior to the firing. The stapler moid junction or necessitating an intracorporeal anasto- is then fired after verifying that both mesentery and bowel mosis. The anvil of the 29 or 33 mm circular stapler is are oriented in their appropriate anatomical position. To placed into the proximal margin of the bowel, and the check the integrity of the anastomosis, a noncrushing clamp purse string suture is then secured (Fig. The edge is once again gently placed on the proximal bowel, in con- of the proximal bowel with anvil is appropriately trimmed junction with transanal endoscopy with air insufflation into by removing the attached appendices. The proximal bowel the water-filled pelvis ideally as part of flexible endoscopy with the anvil is then returned into the abdominal cavity, with anastomotic visualization. The abdominal team then and the incision is closed after which a pneumoperitoneum verifies that no air leaks are present. The laparoscopic phase is resumed as the surgeon moves between the legs to introduce the 29 or 33 mm circular sta- Closure of the Wound pling device into the rectum. A Babcock clamp through the right lower quadrant port can help stabilize the distal stump After irrigation of the wounds, each wound is closed by reap- of the bowel adjacent to the staple line. The skin may be then closed by either against the top of the stump, the spike is made to protrude staples or subcuticular sutures.

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Chronic retention is gradual accumulation of urine in the bladder due to inability of the patient to empty the bladder completely buy tricor 160 mg with visa sitosterol cholesterol ratio. If infection supervenes on chronic retention it becomes painful and it is often described as acute-on-chronic retention buy 160 mg tricor visa kresser cholesterol ratio. The patient is likely to have some symptoms related to chronic retention previous to the acute episode purchase tricor 160mg fast delivery cholesterol test home. Sudden inability to pass urine with severe pain and with an exaggerated desire to micturate is the main presenting feature of this condition order tricor 160 mg fast delivery cholesterol levels and alcohol. Rectal examination will reveal that the prostate or uterus is pushed backwards and downwards by the bladder which can be easily felt as a cystic mass. It must be remembered that one cannot assess the size of the prostate gland when the bladder is full. Sensory, motor and reflex functions of the nerves of the perineum and lower limbs should be assessed carefully. Chronic retention is a painless condition and the patient is often unaware of his/her destended bladder. The symptoms may be in the form of increased frequency of micturition, difficulty of micturition or even overflow incontinence. On examination the foreskin and urethral meatus should be examined for phimosis or meatal stenosis. The length of the urethra as far as the bulb should be palpated for a stricture, periurethral abscess or presence of a stone or a foreign body. The prostate must be examined, as this is the commonest cause of retention of urine in the male. It may reach the umbilicus or somewhere in between the pubic symphysis and umbilicus. The bladder is obviously dull to percussion and may elicit fluid thrill if the patient is thin. Absent ankle jerk and diminished or absent cutaneous sensation in the perineum and perianal regions are usually associated with such lesion. In infants and children the urinary bladder is more of an abdominal organ and can be palpated without retention of urine. If there is difficulty or inability to pass urine the cause is most likely to be neurological in origin or due to obstruction from the presence of posterior urethral valves. From outside — Pregnancy (retroverted gravid uterus), fibroid, ovarian cyst, carcinoma of the cervix uteri and rectum and any pelvic growth and paraphimosis. Neoplastic — Angioma, carcinoma of the kidney, nephroblastoma of the kidney, papilloma or carcinoma of the renal pelvis. Diseases of the adjacent viscera :— Acute appendicitis, salpingitis and pelvic abscess. Carcinoma of the rectum and cervix uteri may infiltrate the bladder to cause haematuria. Drugs :— Anticoagulant drugs, hexamine, sulphonamides and salicylates — when given in large doses. If the total amount of urine remains normal, causes of increased frequency are : 1. Vesical — any form of cystitis and stone; inflammatory condition of the pelvis, e. Urethral — posterior urethritis (Gonococcal), stone, pin-hole meatus, phimosis and balanitis. Enquire whether frequency is more marked during the day or night, or there is no such distinction. Diurnal frequency is peculiar to vesical calculus and is due to irritation of the trigone in the erect position; nocturnal frequency, when complained of by an elderly man, is due to senile enlargement of the prostate; whereas in cystitis, frequency is equally marked by day and night. It must be remembered that frequency in a young adult with sterile acid urine containing pus should be regarded as being due to renal tuberculosis until this can be excluded. The other common cause in a young adult is gonococcal posterior urethritis in which the history is often helpful. In the middle-aged person one should think of diabetes in which the triad is polyuria (excessive discharge of urine), polydipsia (extreme thirst) and polyphagia (excessive eating). Physical examination and special investigations are carried out as discussed above in order to arrive at a definite diagnosis. The term can be applied to protrusion of a muscle through its fascial covering or of brain through fracture of skull or through foramen magnum into the spinal canal. But by far the commonest variety of hernia is protrusion of a viscus or a part of it through the abdominal wall and will be discussed here. Of the abdominal herniae the common varieties are inguinal, femoral, umbilical, incisional and epigastric, while the rare varieties are obturator, lumbar, gluteal and Spigelian. Indirect or oblique inguinal hernia comes out of the abdominal cavity through the deep inguinal ring, traverses all along the inguinal canal and ultimately becomes superficial through the superficial inguinal ring. Inguinal hernia is said to be complete when the contents have reached the bottom of the scrotum. Femoral hernia comes out through the femoral canal and becomes superficial through the saphenous opening. Of course, there should be associated underlying weakness of the abdominal muscles or persistence of processus vaginalis. It continues so long as the hernia is progressing but ceases when it is fully formed. At this time the patient may complain of pain all over the abdomen due to drag on the mesentery or omentum. The followings are the set questions to be asked in case of any inguinoscrotal swelling : (a) How did it start? If it had appeared below the groin crease and gradually ascends above it — the swelling is a femoral hernia, (c) What was the size and extent when it was first seen? If the hernia reaches the bottom of the scrotum at its first appearance, it is a congenital hernia developed into a preformed sac. It must be remembered that though it is a congenital hernia it may appear at any age. In the acquired type the swelling is small to start with and gradually increases in size, (d) Does it disappear automatically on lying down? They are colicky abdominal pain, vomiting, abdominal distension and absolute constipation. If the patient is vomiting, note the character of the vomitus — whether bilious or faecal smelling. Persistent coughing of chronic bronchitis, constipation, frequency of micturition or urgency of benign enlargement of prostate may be the earlier complaints which the patients deliberately do not mention considering them to be irrelevant. During appendicectomy division of nerve may lead to weakness of the abdominal muscles at the inguinal region and a subsequent direct inguinal hernia.

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There is no generalized infection order genuine tricor cholesterol test new, so the cervical nodes involvement is not secondary to tuberculosis anywhere in the body 160mg tricor with mastercard is cholesterol medication expensive. In about 80% of cases the tuberculous process is virtually limited to the clinically affected group of lymph nodes buy tricor 160 mg line cholesterol clarity. The cervical nodes are most frequently involved followed by mediastinal purchase tricor visa cholesterol shrimp, mesenteric, axillary and inguinal nodes according to the order of frequency. In tuberculosis, the lymph nodes on section show translucent, greyish patches in the early stage. As the disease advances these become opaque and yellowish, which is the result of necrosis and caseation. Microscopically the tubercles will be seen which consist of the epitheloid cells and giant cells having peripherally arranged nuclei in the early stage. After one week, lymphocytes with darkly stained nuclei and scanty cytoplasm make their appearance. By the end of the second week caseation appears in the centre of the tubercle follicle. So in the centre of the tubercle follicle lies eosin stained caseation surrounded by giant cells and epitheloid cells around which remains a zone of chronic inflammatory cells e. Recently Ethambutol in the dose of 25 mg/kg body weight and Rifampicin in the dose of 15 mg/kg body weight are prescribed daily for at least 9 months. With fine dissections the surrounding adhesions are released and the lymph nodes are removed enmasse. Aspiration is performed with a thick needle through the healthy skin preferably from above. Aspiration is never done through the most prominent and the most dependent part of the abscess lest a sinus should be formed along the path of the aspiration. In the secondary stage generalized involvement of nodes may occur affecting particularly the epitrochlear and occipital groups. There may be ulcers in the mouth and various skin rash (pink macular rash appears 4 to 8 weeks after the sore followed by the papular eruption and more severe form is the ecthymatous type in which the papule breaks down quickly and the underlying tissues become eroded or ulcerated). A history of periodic fever with pain ( especially during the full or new moon ) is very characteristic. Swelling of the spermatic cord with dilatation of lymphatic vessels (lymphangiectasis ) is often found in filariasis. The primary lesion is insignificant and is not revealed if leading questions are not put to the patients. The liquified mass may break down and discharge thick yellowish-white pus free from organisms. In females pararectal lymph nodes are involved through the posterior vaginal wall and an intense pararectal inflammation with dense fibrosis involve the rectal wall. Pus from unruptured bubo of a patient suffering from this disease is diluted 10 times with normal saline and sterilized at 60° C. Appearance of a reddish papule within 48 hours of at least 6 mm in diameter at the site of injection indicates the test to be positive. The earliest change in a lymph node is an accumulation of large mononuclear cells which form small solid granuloma. The primary skin lesion is a red papule in the skin at the site of inoculation usually appearing between 7 and 12 days following contacts. The causative organism is probably virus ofrickettsia group, though controversy still exists regarding the responsible agent. The generalized lymph node enlargement is due to intense hyperplasia without loss of architecture. In almost every case there is enlargement of cervical lymph nodes and those in the posterior triangle are affected as much as those in other groups. Axillary and inguinal groups are affected less frequently than the cervical group. Abdominal pain and tenderness are common and may be explained by mesenteric node enlargement. The clinical picture resembles plague and is characterized by an ulcer at the site of infection, enlargement and inflammation of the regional lymph nodes and severe constitutional symptoms. The enlarged local lymph nodes show features indistinguishable from those of tuberculosis. The onset is gradual with early symptoms of mild fever, malaise, headache, generalized muscular pain and mild gastrointestinal disturbances. After some weeks or months a pyrexial attack occurs which lasts a few days to some weeks. With each attack there is enlargement and tenderness of the spleen and to a lesser extent the liver. Presence of large cells resembling Reed-Sternberg cells may suggest the latter condition. The most commonly affected are, in order of frequency, the lungs, the lymph nodes, the skin, the eyes, the liver, the spleen, the salivary glands, the heart, the skeleton and the nervous system. The characteristic lesion of sarcoidosis is an epitheloid cell granuloma or tubercle. Probably this is the only criterion which differentiates this condition microscopically from tuberculous lymphadenitis. The positive result is shown in 4-6 weeks by the appearance at the site of injection of a nodule with the histological pattern of sarcoid. The parasite multiplies by longitudinal fission within the endothelial and tissue cells of its hosts. When the virulent strains are formed these cells rupture releasing the parasites which then invade fresh cells. Toxoplasmosis may be transmitted to the foetus in utero by an infected mother when it is called congenital toxoplasmosis. The clinical features of acquired toxoplasmosis can be easily described under four headings — (i) Cerebrospinal form is characterized by meningoencephalitis, fever, severe headache, vomiting, delirium, convulsions, deafness etc. I have used both old and new classifications to make the students understand both the views clearly. Neoplasms of lymphoid tissue means malignant lymphoma, as benign neoplasm is almost unknown in lymphoid tissue. The sinusoides are obliterated in contradistinction to the dilated sinusoides characteristics of chronic lymphadenitis. The involvement of the small intestine may be so diffuse that the bowel is converted into a stiff tube. Microscopically, the normal structures of lymph nodes disappear and are replaced by diffuse arrangements of monotonously uniform large lymphoblasts with hyperchromatic nuclei and scanty cytoplasm. Diffuse infiltration of the capsule and surrounding tissue is one of the most characteristic features. Another important feature is that there is no increase in reticulum as shown by silver stains.