Category Archives: SURGERY

Jejunoileal atresia

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Type I:
intraluminal diaphragm or web may present with windsock anomaly.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type II
Connected by fibrous atretic cord.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type IIIA
NO FIBROUS CORD
VSHAPED MESENTERIC DEFECT
SHORTENED LENGTH

Type IIIB
bowel wraps around a single perfusing vessel( christmas tree app)
LARGE MESENTERIC DEFECT
SIGNIFICANTLY SHORTENED

Type IV
MULTIPLE DEFECTS

Whereas associated anomalies are found in 30-40% of neonates with duodenal atresias, associated anomalies are found in only 10% of neonates with jejunoileal atresias

There is maternal polyhydramnios

RX
RESECTION AND ANASTOMOSIS
TAPERING ENTEROPLASTy(for shortenede bowel)

From emedicine:

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Intestinal atresia type IIIa. A clamp is applied on the distal bowel, and sodium chloride solution is instilled through a purse-string suture to dilate the intestine and diminish the size discrepancy between the two loops to facilitate the anastomosis. The dotted line marks the area of the resection.

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The proximal dilated pouch is transected in a 90° angle to maximize its vascularity, while the distal intestine is transected obliquely to diminish the size discrepancy between the segments.

Malrotation and volvulus neonatorum

Volvulus always associated with malrotation

Two presentations
Acute:bilious vomiting(metabolic acidosis) The volvulus may compromise blood flow leading to ischemia hence tender rigid abdomen

We fear from massive loss of small intestine if neglected…he may not survive…or the lesser catastrophe is the SHORT GUT SYNDROME

Chr: chr intmt abd pain, constipation.

DOUBLE BUBBLE SIGN

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Normally SMV IS ON THE RIGHT. IF THE REVERSE HAPPENS, SUSPECT MALROTATION.(BY U/S!!!!!)
DILATED STOMACh AND DUODENUM WITH TWISTING OF THE MIDGUT LOOP: applepeel, twisted ribbon, corkscrew

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Do ladds procedure:
Untwist
Divide( ladds band)
appendectomy

Neonatal duodenal obstruction

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SEARCH FOR ASSOCIATED ANOMALIES!

Normal or scaphoid abdomen is obs is proximal!

FIRST OF ALL, RESUSCITATE AND DECOMPRESSION

ITS DANGEROUS!!! WHY??
close proximity to the ampulla of vater & pancreatic blood supply.

Rx: DUODENODUODENOSTOMY AND DUODENOJEJUNOSTOMY. IF THERE IS MALROT- LADDS PROCEDURE
we can also do DIAMON SHAPED ANASTOMOSIS BECAUSE THE DIAMETER OF THE PROXIMAL AND DISTAL PART TO THE OBSTRUCTION IS NOT PROPORTIANATE.

In duodenal web, do DUODENOTOMY. BE CAREFUL OF OTHER DEFECTS AND AMPULLA OF VATER.

?

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About ladds band(excerpt from emedicine)

abnormal cecal peritoneal bands that cross over the duodenum in the right upper quadrant may be found in cases of malrotation. These abnormal cecal attachments are called Ladd bands. In both nonrotation and incomplete rotation, cecal bands may cause obstruction and ischemia before birth, leading to congenital duodenal atresia or stenosis

In many cases, the abnormal Ladd bands cause only partial and intermittent obstruction, which can manifest as intermittent episodes of bilious vomiting and/or feeding intolerance.

I5

Previously healthy baby

Red currant jelly stool is a late sign..dont sit and wait for that to happen

Not so hi mortality rate but we fear of transmural gangrene

Commonest age…age of weaning 4m-10m

If more than 2 y, suspect a secondary cause..the most common 2ry cause is ileocecal lymphoma and meckels

Important signs:
Dance s
Target s
Cobra head s
Air fluid level
Pseudokidney s

25% of abdominal surgical emergencies less than 5, EXCEEDING APPENDICITIS

ANY CHILD W BILIOUS VOMITING, CONSIDER IT A SURGICAL DISEASEUNTIL PROVED OTHERWISE

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IHPS

More common in males

First male

Hypochloraemia, hyponatremia, hypokalemia metabolic alkalosis

U/s! Thickness >4mm, length >16 mm

Dehydration, failure to thrive, HUNGER AFTER FEEDING,OLIVE MASS, PROJECTILE, NON BILIOUS VOMITING, persistent and progresses with time.

IT IS NOT CONGENITAL HENCE IT NEVER PRESENTS before 2weeks of life. It takes time for the circular muscle to undergo HYPERTROPHY AND HYPERPLASIA ( >2wks- 8wks)

DDX OF NON BILIOUS VOMITING: physiological GERD/ proximal to ampulla of vater duodenal obstruction/ errors in feeding/ NON SPECIFIC MARKER OF ILLNESS

TREATMENT: RESUSCITATE FIRST, THIS IS NOT AN EMERGENCY.
DEFINITIVE TREATMENT= RAMSTEDT PYLOROMYOTOMY

Important! Look for target sign.
String sign.

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Tagged

School starts

Holidays are over. And my heart is still not back from the holidays….( not that my holidays are so much fun though…)

Tell me how can i gather my enthusiasm to face surgery dept??

Btw, i had a pretty structured holiday. Not so much of the typical holiday…most people watched movies and shows( if not travelling) and i dont even watch movies but only malay dramas..
I Read books. Medic ,non medic, motivational, my life’s manual… I am beginning to love reading.and did other trivial but wonderful things. I think ive just realized that spending futile hours n hours of tv entertainment would leave me feeling sick and depressed. And i dont wish to have back my addiction of watching too much dramas…i used to …

Aha…

Renew your intention and when you feel like you start to procrastinate.kill it! Say 1,2,3 and start moving. Dont rest on your laurels. Excellent doctors never rest on their laurels.get out of your comfort zone!!

Lets warm up and get back on track! YOU CAN DO THIS!

Descent of testis, hydrocele

Surgery needs anatomy so badly!!

Need to revise………hope ill remember this forever.

In a nutshell, about the descent of the testis.
Testis is like a balloon attached to its thread(gubernaculum) which is ‘tied’ to the scrotum. Yes… So a balloon with the thread attached to the scrotum. Lol

And it pulls it down and anterior passing through the inguinal canal and then the scrotum.

That is the most simple explanation for the descent of testis.haha.

Oh yes, the thread is not only attached to the testis but also the peritoneum in front of testis and tail of epididymis.

So… Its attachment to the peritoneum forms processus vaginalis which obliterates a few weeks before birth till a few weeks after birth.

So… Note that in premature infants patent PV is more common and also undescended testis.

IF YOU FIND AN EMPTY BAG(scrotum )

There are several possibilities:
Undescended testis
Ectopic
Retractile
Hypoplastic
Anorchia
Atrophy

The doctor said that in both congenital inguinal hernias and hydrocele both have patent PV, only the neck is wider in hernias.

My question is, how to DDx congenital hydrocele with hydrocele of hernial sac???

Hmm…Im not that sure…i asked the dr just now but i cant seem to understand it clearly.

Remember!!! In tense hydrocele,(when we cant indent our fingers) we must do surgery, for fear of impaired blood supply.

Tagged ,

Hello !

Currently in surgery dept… We are approaching the end of medicine school. But that does not mean its the last time we’ll see medic books.

As ive said before, gaining knowledge is a continuous and endless process!!! ( yawnssss.i know everyone knows that)

To tell you the truth, i miss internal medicine so much!! ;(

Come on , come on, lets gather some gusto for surgery!!!
1st week will always be the most blurry week, i suppose.
There are so many items to catch up on!!!

I am ready for you, surgery..

Btw, i feel relatively stupid for the first 2 days.
That always happens…for the first few days.

A reminder for moi:
We are always insufficient in terms of knowledge.
Seek for knowledge like a hungry lion.
There is nothing absolutely correct in medicine.
Speak up your frank opinion.
Have some confidence!!!
Respect your own time, by not procrastinating
Be humble
Renew your intentions
Itqan fil amal!!!