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Perioperative antibiotics Preoperative assessment of colon or jejunum by contrast Documentation Basics studies buy cheap viagra sublingual 100mg line xeloda impotence, colonoscopy buy viagra sublingual pills in toronto erectile dysfunction drugs without side effects, and arteriography (if necessary) Routine bowel preparation Coding for esophageal procedures is complex generic viagra sublingual 100 mg with mastercard impotence reasons and treatment. In Operative Strategy general buy generic viagra sublingual 100mg impotence nitric oxide, it is important to document: • Findings Resect the damaged esophagus and replace it with a conduit • Partial or total esophagectomy whenever possible. When this is not feasible, a bypass leav- • Choice of conduit ing the damaged esophagus in situ is occasionally warranted. Esophagectomy is also performed on patients who have undergone failed oper- ations for neuromotor esophageal disorders or who have had Operative Technique diversion-exclusion operations (see Chap. Transhiatal esoph- Incision and Resection of Esophagus agectomy is an alternative (see Chap. The colon is a versatile conduit that is applicable to most The choice of incision is determined by whether, and how situations unless the patient has had a previous colon resec- much, esophagus is to be resected. Sufficient length can be obtained to perform a cervical tomy is an option that obviates the need for a thoracic inci- anastomosis if necessary. We prefer a sixth-interspace left thoracoabdominal inci- sion for most of these esophagectomies (see Figs. After cases permits transection of the middle colic vessels close to the esophagus has been freed to the arch of the aorta, dissect the point of origin and yields a segment of colon that could the esophagus from underneath the arch of the aorta, as illus- include a good portion of the descending colon as well as the trated in Fig. Temporarily leave the esophagus in its entire transverse colon if it should be necessary. However, verify this by careful palpation of the Long-Segment Colon Interposition: Colon marginal artery and transillumination of the mesentery. Apply Dissection bulldog vascular clamps along the marginal artery at the points selected for division and check the adequacy of the pulse in the The initial step for preparing a long colon segment is to liber- vessels being retained to supply the transplanted segment. If necessary, extend the thoracoabdominal incision of the transverse colon, with sufficient length to reach the below the umbilicus. Dissect the omentum away from the cervical region, ligate and divide the middle colic artery at a transverse colon and its mesentery, as illustrated in Figs. This allows the blood flow from With this accomplished, inspect the blood supply of the left the left colic artery to enter the left branch of the middle colic and transverse colon. Preserving the left colic artery in most artery and to continue along the right branch to nourish the a Fig. Estimating the Length of Colon Cologastrostomy Required to Reach the Neck Elevate the stomach with its attached omentum away from the pancreas. Divide the avascular attachments between the After the omentum has been dissected off the colon and after peritoneum overlying the pancreas and the back wall of the both the left and right colon segments have been freed from stomach. Also incise the avascular portion of the gastrohe- the posterior abdominal wall, grasp the splenic flexure at the patic omentum; then draw the colon transplant with its point of termination of the left colic artery and draw this seg- mesentery in an isoperistaltic direction through the retrogas- ment of colon in a cephalad direction toward the sternum. This distance approxi- the colon does indeed reach the cervical esophagus without mates the amount of colon required going in a proximal direc- tension. Add about Prepare to anastomose the open end of the distal colon 4–5 cm to the estimate and insert a marking stitch in the right transplant to a point on the stomach approximately one-third transverse colon at this point. The anas- is at the right of the middle colic vessels, indicating that divi- tomosis may be made on the anterior or posterior side of the sion of the origin of the middle colic artery and vein is required. Restore continuity to the colon by from the fundus; then insert the cutting linear stapler—one Fig. Place a guy suture through the midpoint of the stab wound of the stomach as illustrated in Fig. First, apply the stapler just deep to the Allis clamp and the guy suture to close the left half of the gap. After firing the stapling device, cut away the surplus tissue and lightly electrocoagu- late the mucosa. This creates a fairly large anastomosis between the stomach and colon, as illustrated in Fig. If the marginal artery is not divided, it provides an added avenue of blood flow to the colon that has been trans- planted into the neck. By carefully transecting the colon behind the stomach and then dividing and ligating the end Fig. If the anastomosis is made at the junction terior wall of the stomach, and the distal segment of between the upper third and the lower two-thirds of the 18 Operations to Replace or Bypass the Esophagus Colon or Jejunum Interposition 185 stomach, it seems not to matter whether the cologastrostomy artery of the descending colon, it is necessary to place the is constructed on the posterior wall or the anterior wall of the cologastrostomy on the posterior wall of the stomach stomach. The posterior cologastric anastomosis may be constructed by suturing (as illustrated here) or by stapling (as described in Figs. In this manner the colocolostomy can also be performed close by, preserv- ing the marginal artery (Fig. Pyloromyotomy In most conditions for which a thoracic esophagectomy is being performed, the vagus nerves are destroyed, which impairs gastric emptying to a fairly severe degree in about 20 % of cases. To prevent this complication, a pyloromyot- omy may be performed by the technique illustrated in Figs. Advancing the Colon Segment to the Neck Be certain to enlarge the diaphragmatic hiatus (see Fig. The most direct route to the neck follows the course of the original esopha- geal bed in the posterior mediastinum. Place several studies between the proximal end of the colon transplant and the distal end of the esophagus; then draw the colon up into the neck by withdrawing the esophagus into the neck. This brings the colon into the posterior mediastinum behind the arch of the aorta and into the neck posterior to the trachea. If there is no constriction in the chest along this route, the ster- num and clavicle at the root of the neck are also not likely to Fig. Before closing the anterior portion of the of adjacent sternal manubrium to be certain there is no anastomosis, ask the anesthesiologist to pass a nasogastric obstruction at that point. Obtain a sterile plastic Retrosternal Passage of Colon Transplant sheath such as a laser drape and suture the end of this plastic When the posterior mediastinum is not a suitable pathway cylinder to the termination of the rubber catheter. Insert the for the colon or if the esophagus has not been removed, make proximal end of the colon into this plastic sheath and suture a retrosternal tunnel to pass the colon up to the neck. By withdrawing the cath- left lobe of the liver is large or if it appears to be exerting eter through the thoracic cavity into the neck, the colon with pressure on the posterior aspect of the colon transplant, liber- its delicate blood supply can be delivered into the neck with- ate the left lobe by dividing the triangular ligament. If the xiphoid process curves posteri- nal cavity lies in a straight line and there is no surplus of orly and impinges on the colon, resect the xiphoid. Leaving redundant colon in the thorax Enter the plane just posterior to the periosteum of the ster- may produce a functional obstruction to the passage of food. Start the dissection with Metzenbaum scissors; then Then suture the colon to the muscle of the diaphragmatic insert one or two fingers of the right hand. Finally, pass the hiatus with interrupted sutures of atraumatic 4-0 Tevdek at entire hand just deep to the sternum up to the suprasternal intervals of about 2 cm around half the circumference of the notch. This helps maintain a direct passageway from the segment so the mesentery enters from the patient’s left side. Be sure not to pass the needle deep Resect the medial 3–4 cm of clavicle using a Gigli saw.

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Despite the prominent medial deviation 100mg viagra sublingual free shipping erectile dysfunction creams and gels, there is no obstruction; deviation of a similar degree by extrinsic masses discount viagra sublingual line erectile dysfunction treatment fruits, such as enlarged lymph nodes buy genuine viagra sublingual erectile dysfunction weight loss, tends to be associated with some degree of ureteral obstruction buy 100mg viagra sublingual amex erectile dysfunction protocol book. Cystocele or uterine Low position of the bladder causes symmetric prolapse medial displacement of the pelvic ureters. Neoplasm of bony pelvis Lesion arising from the lateral bony wall (eg, chondrosarcoma) with an associated mass extending into the pelvis can cause medial dis- placement of the ureter. Coned view shows the medially displaced distal ureters compressed at the level of the levator sling (arrows). Localized tumor infiltration causes may demonstrate punctate, coarse, or linear marked bladder deformity. There is often calcifications that are usually encrusted on the unilateral or bilateral ureteral obstruction. There may be associated filling defects detectable abnormality (the wall may be thickened (fungus balls, blood clots). Characteristic mural and irregular because of severe mucosal and and luminal gas in emphysematous cystitis. May have a pointed dome (pine tree include spinal neoplasm or trauma, syphilis, bladder). After surgery or radiation Small bladder with a smooth or irregular Radiation cystitis develops several months to sev- therapy surface. Six months after repeated cycles of cyclophosphamide therapy, the bladder volume is greatly reduced and the bladder wall appears ulcerated and edematous. The calcification is initially of ova passing through or lodging in the wall of the most apparent and extensive at the base of bladder stimulates an inflammatory response the bladder, but may surround the bladder (granuloma formation, obliterative vasculitis, pro- completely. The development of squamous (parallel dense lines, especially in the pelvic cell carcinoma of the bladder is a frequent com- portion of the ureter). Tuberculosis Initially, thickening and trabeculation of the Almost invariably associated with renal and bladder wall. There may be reflux and, decrease in bladder capacity and a smoother occasionally, dilatation of one or both ureters wall. Eventually, the bladder virtually disap- and pelvocalyceal systems secondary to bladder pears and the ureters seem to enter directly muscular hypertrophy that produces ureteral into the urethra. Differs from a spastic neurogenic bladder, which is small and heavily trabeculated. Destruction of myenteric plexuses due to infection by the protozoan Trypanosoma cruzi (endemic to South America and Central America). Megacystis syndrome Large, smooth-walled bladder with bilateral or Most commonly occurs in childhood, especially in unilateral ureteral reflux occurring either at low girls. Large, atonic bladder in a child with traumatic paralysis of the lower extremities. Continual overloading of the urinary tract in nephrogenic diabetes insipidus (no tubular response to endogenous or exogenous antidiuretic hormone). Absent abdominal Diffuse dilatation of the bladder, ureters, and Rare congenital condition that occurs almost musculature (Eagle-Barrett, pelvocalyceal systems. Psychogenic/drug-induced Smooth-walled, markedly distended bladder No underlying neurologic disease. The lowermost portion of the bladder is visualized slightly below the upper edge of the symphysis pubis, a finding that is consistent with that in a cystocele. Contrast material is well below the symphysis pubis, indicating a marked cystocele. Most are circular or associated lesions include bladder outlet obstruc- oval, but they can be amorphous, laminated, or tion, urethral stricture, neurogenic bladder, bladder even spiculated. Upper urinary tract bladder diverticula, lying in an unusual position stones that migrate down the ureter are occa- close to the lateral pelvic wall or having a sionally retained in the bladder. Blood clot Irregular intraluminal filling defects of various Common causes of bleeding (originating from sizes. Large clots may occupy almost the entire the kidneys or the bladder itself) include tumor, bladder lumen but are still completely sur- trauma, instrumentation, vascular malformation, rounded by contrast material (unlike tumors). Air bubble Smooth, round, freely movable intraluminal Causes of air in the bladder include instru- defect. A large amount can produce an air-fluid mentation, surgery, penetrating trauma, fistulas to level on a film obtained with a horizontal gas-containing hollow organs, and emphyse- beam. There may be associated intramural matous cystitis (usually in diabetic patients). Instrument Opaque or nonopaque intraluminal filling Most commonly, the inflated balloon of a Foley defect. Tumors originating near produce only focal bladder wall thickening and the ureteral orifices may cause early ureteral rigidity. May be associated with other transi- is occasionally encrusted on the surface of the tional tumors of the pelvocalyceal system or ureter. Because urography can detect only approxi- mately 60% of symptomatic bladder carcinomas, all patients with lower urinary tract hematuria should undergo cystoscopy. Polyp Single or multiple filling defects that may be Common tumor consisting of a fibrous stalk with a pedunculated and movable. Papilloma Solitary or multiple polypoid defects with Benign, frond-like tumor that usually arises on smooth or irregular margins. Metastases Direct extension of tumor causes an extrinsic Direct extension from primary carcinomas of defect with irregular margins. Bladder Noninvading pelvic lymph node metastases tumors may also be secondary to papillary tumors cause a smooth extrinsic impression on the of the kidney or ureter and clear cell adenoma of bladder wall. Lymphoma Direct invasion from perivesical lymphoma Primary lymphoma of the bladder is extremely causes an irregular defect. Secondary involvement is not uncommon ment without invasion (more common) causes with advanced lymphoma. There may be single or localized bladder masses occasionally occur in multiple well-circumscribed foci limited to the leukemia. Histologic types include leiomyoma, neurofibroma, hemangioma, fibroma, pheochromocytoma, and rhabdomyosarcoma (most common bladder tumor in children and often termed sarcoma botryoides). Although the chronic process, there is trabeculation of the contour of the filling defect is usually more irregular bladder wall and diverticula formation. Bladder in carcinoma, benign hypertrophy and carcinoma outlet obstruction causes dilatation of the usually cannot be differentiated unless there is pelvocalyceal system and the ureter. The distal evidence of tumor invasion into neighboring ureters often have a fishhook deformity (due to structures or distal metastases. Often an incidental finding, but (2–3 mm) radiolucent halo representing the may predispose to obstruction, infection, and stone wall of the prolapsed ureter and the bladder formation. The ectopic ureter enters the with a duplicated collecting system (ureter- bladder wall near its normal site of insertion. If the orifice is stenotic, proximal distention of the ureter under the submucosa of the bladder produces the eccentric filling defect.

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Extend this incision also down to the cul-de-sac and identify and preserve the right ureter order viagra sublingual with american express erectile dysfunction mental. Join these two inci- sions by dividing the peritoneum at the depth of the rectovesi- Fig generic 100 mg viagra sublingual overnight delivery erectile dysfunction treatment after surgery. Further dissection between the rectum and the prostate or vagina is generally not necessary purchase cheap viagra sublingual impotence leaflets. Presacral Dissection For rectal prolapse the rectum can be elevated with ease from the hollow of the sacrum order genuine viagra sublingual line erectile dysfunction drugs over the counter canada. Enter the presacral space via a Metzenbaum dissection, a method similar to that described for anterior resection (see Chap. Inspect the presacral area for hemostasis, which should be perfect before the procedure is continued. Application of Mesh Fit a section of Prolene mesh measuring 5 × 10 or 5 × 12 cm Fig. The upper margin 66 Ripstein Operation for Rectal Prolapse: Surgical Legacy Procedure 627 Fig. Using a small Mayo needle, insert three interrupted sutures of 2-0 Prolene or Tevdek Irrigate the pelvic cavity. Use the same technique to insert three interrupted sutures in the left lateral margin of the mesh and through the sacral fascia and periosteum Wound Closure (Fig. After all six sutures To close the Pfannenstiel incision, grasp the peritoneum with have been inserted, have the assistants draw them taut. Use several sutures of the same material check the tension of the mesh, thereby ensuring that there loosely to approximate the rectus muscle in the midline. Now tie Close the transverse incision in the rectus sheath and exter- all six sutures. Bass described fixation of the mesh to the presacral fascia using sutures or a fascial stapler. The mesh is then partially wrapped around and sutured to the rectum, leaving the ante- Postoperative Care rior third of the rectal circumference free to dilate as neces- sary (Figs. This condition is use of laxatives, although in some cases there is a definite alleviated over time in more than 30 % of patients who are improvement in the patient’s bowel function following the placed on a regimen of high fiber and muscle-strengthening operation. A prospec- assisted resection rectopexy for rectal prolapse: ten years’ experi- tive randomized study of abdominal rectopexy with and without sig- ence. Dis Colon Laparoscopic prosthesis fixation rectopexy for complete rectal pro- Rectum. Cromwell Anatomy and Physiology The anal canal is surrounded by cylindrical muscles that make up the anal sphincter: internal anal sphincter and exter- The anorectum is a particularly complicated region and func- nal anal sphincter (Fig. In order to effectively made up of smooth muscle and is contiguous with the smooth treat disease of the anus and rectum, it is critical to have a muscle of the rectum. It is supplied by sympathetic and para- solid understanding of the anatomy and physiology of the sympathetic nerves and thus is under involuntary control. The internal anal sphincter provides half of the resting anal The anal canal is typically 3–4 cm in length and repre- tone, which is the baseline muscle tone which maintains anal sents the terminal segment of the gastrointestinal tract. The remainder is extends from the anorectal junction to the anal verge, which contributed by the external anal sphincter and the puborecta- represents the edge of the anal orifice. The external anal sphincter surrounds the inter- verge, the skin is pigmented and contains hair follicles and nal anal sphincter and is made up of cylinder of skeletal glands. The innervation is derived from the sacral and demarcation which represents the mucocutaneous junction. In response to increased abdominal pres- Proximal to the dentate line is transitional epithelium; distal sure (such as coughing and sneezing) or rectal distention, the to the dentate line is anoderm made up of squamous epithe- external anal sphincter and puborectalis muscles contract lium, and therefore, there is cutaneous sensation in this area. The levator ani muscles are broad mus- Hemorrhoids are sinusoidal fibrovascular cushions which cles that make up the pelvic floor. Hemorrhoids Several potential spaces exist around the anal canal that occur proximal to the dentate line are termed internal (Fig. The space between the internal and external anal hemorrhoids, whereas those that occur distal to the dentate sphincter is termed the intersphincteric space. Hemorrhoids are part sphincteric space is contiguous with the perianal space which of normal anatomy that contribute to baseline anal conti- surrounds the external portion of the anus circumferentially. In addition, during times of increased intra-abdominal Lateral to the external sphincter muscle on each side is the pressure, such as during coughing or sneezing, the vascular ischiorectal space which is also bound by the levator ani cushions engorge, maintaining continence. These two ischiorectal spaces connect posteriorly though the deep postanal space, which lies between the levator ani and the anococcygeal ligament. Inspection of the anal area examined for masses, induration, stricturing, or the presence is the first portion of the anorectal examination and should be of a rectocele. Baseline anal tone should be noted and the done with the buttocks retracted laterally. Abnormal masses, patient is asked to squeeze their anal sphincter in order to scarring, swelling, erythema, fluctuance, fissures, and hem- evaluate anal squeeze function. Several types of anoscopes next step is the digital rectal examination which should be are available and should be utilized according to operator 67 Concepts in Surgery of the Anus, Rectum, and Pilonidal Region 635 preference. Anoscopic examination assists evaluating the Operating Room Positioning mucosa of the distal rectum and anal canal. For operative anorectal surgery, both high-lithotomy and Proctoscopy, either rigid or flexible, should be utilized to prone-jackknife positioning are used. In the author’s experience, most anorectal procedures can be done well in Ambulatory Management this position. Prone- jackknife positioning has a distinct advantage when dealing with anterior rectal pathology such Many common anorectal conditions such as hemorrhoidal as performing transanal excision of an anterior rectal lesion, rubber band ligation can be managed in the office setting. This position The components for successful treatment in this setting must also be used for the treatment of pilonidal disease as the include a willing patient, an appropriate environment, and upper gluteal crease is not exposed in high-lithotomy the correct instrumentation. Clinical Conditions: Symptoms The need for excellent lighting cannot be understated and and Management Concepts the absence of headlights or procedural lighting can be a sig- nificant barrier to performing anorectal procedures in the Hemorrhoids office setting. If a table for prone posi- Hemorrhoidal disease is the most common anorectal com- tioning is not available or the patient is unable to accommo- plaint for which patients present to physicians, and often the date this position, the Sims’ position may be used with the actual diagnosis is unrelated to hemorrhoids. Hemorrhoids patient on their left side, left leg extended and right leg are a normal part of anorectal anatomy, but they can enlarge flexed. A trained assistant is invaluable for exposing the glu- secondary to chronic straining. When internal hemorrhoids teal crease, supporting the anoscope, passing instruments, enlarge, the overlying mucosa can become thin and friable and comforting the patient. It may range from a small amount on the toilet paper to dripping in the Local Anesthesia for Anorectal Procedures toilet bowl, but it is typically self-limited. Local anesthesia can be used for office procedures alone or Severity of internal hemorrhoids is categorized according to combined with sedation for procedures performed in the oper- degree of prolapse. A common technique involves injection of bupiva- exhibit any prolapse with straining. Buffering the hemorrhoids prolapse with straining, but spontaneously anesthetic solution with 0. Third-degree internal hemorrhoids prolapse but immediately before injection decreases pain. Fourth-degree internal thetic solution is injected into each quadrant of the subcutane- hemorrhoids are not reducible.