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It also indicates presence of any atrial tumour or pericardial effusion with certainty discount cialis 2.5 mg on line erectile dysfunction blood flow. Recent developments have included investigation of all forms of congenital heart disease by two dimensional and pulsed Doppler echocardiography discount cialis 5 mg otc erectile dysfunction treatment karachi. This investigation alone can find out various important informations of the diseased heart, so that cardiac catheterisation and angiocardiography can be dispensed with. If radioactive material is coupled with specific antimyocardial monoclonal antibodies, areas of heart damaged during heart attack can be defined. This is also proving useful in investigating cases with myocardial infarction, ventricular aneurysm, intracardiac thrombi and tumours. It also helps both in diagnosis and demonstrating the extent of dissecting aneurysm. The examples arepericardiectomy, resection of thoracic aortic aneurysms, systemic-pulmonary anastomosis, ligation of patient ductus and excision of coarctation of aorta. Mitral valvotomy is probably the only operation which is still performed as a closed intracardiac operation. If the heart is made motionless, blood supply to the various tissues will be stopped. So some alternative arrangement must be made to continue blood supply to the vital organs of the body, so long as the heart is operated on and kept without its function of pumping blood. This type of machine is now widely available in the market in many commercial models. Basically the machine consists of an oxygenator (alternative of lungs) and a pump (alternative of the heart). The circulating blood is diverted from the heart and lungs and is passed through this heart-lung machine, so that the surgeon can operate on the heart while it is not functioning. By this technique, majority of complicated congenital and acquired cardiac abnormalities are operated on. The ascending aorta is cannulated with a plastic tube through a purse-string suture placed in the coat of adventitia. So the deoxygenated blood from the venae cavae are coming to the heart-lung machine, where it is oxygenated and then pumped into the ascending aorta. This is the procedure, with which the heart and lungs of the patient are made inactivated for operation on the heart. Before starting the heart lung machine one must be sure that all air bubbles have been eliminated. After the operation is over, the cannulae are removed, the purse-string sutures are tightened and the heparin is counteracted with protamine (6 mg/kg body weight). A few of these are measurement of blood gases, determination of serum potassium and measuring urinary output. The surgeons prefer a motionless relaxed heart for a considerable period to operate on. This solution also contains an elevated concentrationof potassium to make the heart to stop in diastole. As temperature of the myocardium is considerably reduced, its consumption of oxygen is also dramatically reduced. The blood from the left atrium is diverted through a pump into the left femoral artery. With this technique the left ventricle continues to pump to send oxygenated blood to the head and upper extremities. The extracorporeal pump is supplying blood to the lower extremities and the abdominal viscera through the femoral artery. With this technique the thoracic aorta is made empty for operations to be performed on this region. The blood is diverted from the femoral vein through an extracorporeal oxygenator and a pump and the blood is sent back into the femoral artery. Through this local by-pass system, the operations on the important arteries are performed without jeopardizing the viability of their supplying organs. By cooling the tissues, the metabolic needs of the body can be considerably reduced, so that these tissues can survive total deprivation of oxygen for a short period of 10 minutes or partial deprivation for longer periods. Both these cannulae are joined with a cooling chamber, so that blood from the superior vena cava is diverted into the cooling chamber and the cold blood is sent back to the inferior vena cava. With this technique the body temperature can be reduced to 15 to 18°C and periods upto 45 minutes of circulatory arrest may be tolerated. Surgery of congenital heart disease in infants may be carried out with this method. It should be remembered that ventricular fibrillation may start at a temperature below 25°C particularly in adults, so cardiopulmonary by-pass is the best technique. In this section I shall discuss the important common congenital heart diseases v/hich are well amenable to cardiac surgery. About 6 babies in every thousand live births have congenital abnormalities in the heart. These congenital cardiac abnormalities can be broadly classified into two groups — I. Through this channel blood by-passes the collapsed lungs in embryonic life so that blood flows directly from the pulmonary artery into the aorta by-passing the lungs. The blood in the pulmonary artery passes to the lungs, so the ductus arteriosus usually closes within a few days and becomes fibrotic, which is then called ligamentum arteriosum. It is said that changes in the oxygen tension of the arterial blood exerts a direct stimulus on the closure of the ductus. In case of a large ductus, the shunt may constitute 50 to 70% of the output of the left ventricle. With this pulmonary blood flow increases to as high as 10 to 15 litres per minute. With this increase of blood in the lungs the pulmonary vessels become dilated (pulmonary plethora) and their pulsation becomes increased (hilar dance). This additional blood flow to the lungs will cause more blood to the left side of the heart resulting in left ventricular hypertrophy. Many cases may remain asymptomatic, whereas a few with large patent ductus may cause serious heart failure during the first year. More definite symptoms of congestive heart failure are usually seen only in adult patients. With smaller patent ductus, this murmur becomes audible earlier much before the patient develops cardiac failure. Electrocardiogram is usually normal with a small ductus, but will show left ventricular hypertrophy with large ductus. With appropriate manipulation the cardiac catheter can be passed through the patent ductus confirming the diagnosis.

Transection tion of the proximal ducts with Bakes dilators or other intralu- along the plane without deviation results in a reduced risk of minal devices order 2.5 mg cialis mastercard erectile dysfunction desi treatment, which in turn allows tactile and visual hemorrhage and elimination of partial devascularization of identification of the major ducts for appropriate management cialis 2.5mg discount erectile dysfunction statistics. Operative Technique Vascular Control Incision and Exposure Safe major hepatic resection primarily depends on avoid- ing and controlling hemorrhage. Early during the dissec- A bilateral subcostal incision affords wide exposure for most tion, obtain circumferential access to the hepatoduodenal hepatic resections (Fig. This permits total hepatic vascular inflow occlu- extension with a partial or complete sternotomy if necessary sion (Pringle maneuver) to control hemorrhage from the for additional exposure in difficult situations. Some surgeons high-pressure afferent vasculature at any time during resec- prefer a right thoracic extension for this purpose. Estimate the planned margin of resection by palpation and score the liver capsule with cautery to outline the margin. Drainage is generally not necessary for simple wedge resections within a single segment or adjacent segments unless concurrent biliary tract disease is present. Anatomic Unisegmental and Polysegmental Resections For anatomic uni- or polysegmental resections, define the segmental location of the tumor with intraoperative ultraso- nography. They may be accessed by proximal dissection from the hilar bile ducts and vasculature to the appropriate pedicle or by direct rapid parenchymal transection along an estimated intersegmental plane with ultrasound guidance. The parenchymal transec- tion approach is more appropriate for ligation of the posterior segmental pedicles to segments 7 and 8. Alternatively, methylene blue injection of the segmental or portal pedicle using ultrasound guidance can provide accu- Fig. Once the appropriate portal venous branch is injected, segmental boundaries are defined by parenchymal staining, and resection proceeds For limited resections of segments 2 through 6, a vertical according to the defined boundaries. Tumor approach is more technically demanding and requires exper- involving segments 7 and 8 or extended lobar resections are tise in operative ultrasonography. Confirm Divide the gastrohepatic omentum and expose the foramen accurate segmental pedicle identification by ultrasonogra- of Winslow for inflow vascular occlusion. Use temporary or Peripheral) Resection inflow vascular occlusion during dissection of the pedicle and parenchymal transection as needed. Few vessels or For a wedge resection, after mobilizing the liver, place lapa- ducts require ligation if the resection is truly along interseg- rotomy pads posteriorly between the liver and diaphragm to mental planes. If the margins are narrow, Polysegmentectomy is performed in a manner similar to extend the resection either nonanatomically into contiguous unisegmentectomy except that each segmental pedicle is liver segments or anatomically by adjacent segmentectomy. Once all appropriate pedicles are ligated, the con- tion drain in the resection bed and close the abdomen. First, ligate the right hepatic artery, which (Left Lateral Lobectomy) generally traverses the triangle of Calot. Excise the peri- choledochal lymph nodes to further expose the bile duct, For a left lateral lobectomy, mobilize the left lobe of the liver portal vein, and hepatic artery. Take aspect of the hepatoduodenal ligament longitudinally just care to avoid the left hepatic vein. Seek are always found lateral to the common hepatic duct, at and preserve any recurring or feedback structures that drain the point where they enter the liver parenchyma. Divide the parenchyma, lymphatic vessels around the hepatic arteries before divid- taking care to remain to the left of and preserve the left hepatic ing them to reduce postoperative lymph drainage. Temporarily occlude the right hepatic artery while palpat- ing the artery to the opposite lobe to ensure patency of the arterial supply to the liver remnant. Having confirmed Anatomic Right Hepatectomy this, double-ligate the right hepatic artery with heavy silk (Right Hepatic Lobectomy) and divide it (Fig. Retract the bile duct anteriorly with a vein retractor to For right hepatic lobectomy, fully mobilize the liver and expose the portal vein bifurcation. Expose the right portal perform cholecystectomy to enhance exposure of the hilar vein from the right of the hepatoduodenal ligament. Free the right portal vein branch After the afferent vessels are controlled, approach the from surrounding lymphoareolar tissue and ligate it with a hepatic veins. Multiple small short hepatic veins between vascular stapler or a running vascular suture after division the inferior vena cava and segments 1, 6, and 7 must be between clamps (Fig. Do not use a simple ligature ligated as the liver is retracted anteriorly and to the left because dislodgement risks life-threatening hemorrhage. Ligation starts infrahepatically and proceeds The bile duct to the right lobe may be ligated and divided at cephalad. Occasionally a large, right inferior hepatic vein this time if the anatomy is clear (Fig. Staple or suture closure for secure ligation is clear line of vascular demarcation along the principal liver preferred. Unless a large tumor precludes access, transect the right hepatic vein with a vascu- lar stapler (McEntee and Nagorney 1991) and ligate the parenchymal side with a running vascular suture before parenchymal transection (Fig. Alternatively, ligate the right hepatic vein as the final step of a formal lobectomy after parenchymal transection. As the hilus is approached, the bile ducts to the lobe being resected are exposed. Again, ligation is performed only when patency of the remaining lobar duct can be ensured. Look for the smaller ducts to segment 1 posterior to the main ductal con- fluence, and ligate them if encountered. Chassin inferior vena cava, to expose the anterior surface of the infe- inal wall. Continue parenchymal transection along the mated to prevent torsion of the liver remnant and postoperative principal plane until the main hepatic veins are encountered. The omentum is not attached to the If the major hepatic vein has been ligated, simply remove the parenchyma. Use inflow vascular occlusion during parenchymal transection to reduce intraoperative hemorrhage if necessary. Anatomic Left Hepatectomy (Left Hepatic Obtain hemostasis and bile stasis but avoid large inter- Lobectomy) locking parenchymal liver sutures. A suction drain is placed adjacent to the transected used for the anatomic right hepatic lobectomy, first identify liver surface and bought out dependently through the abdom- and divide the left hepatic artery and portal vein. After divi- sion of the gastrohepatic omentum, approach the left hepatic artery through the lesser sac via the left lateral aspect of the hepatoduodenal ligament. The main left hepatic artery is gen- erally found just inferior to the base of the round ligament as it enters the left lobe between segments 3 and 4 (Fig. An accessory left hepatic artery, arising from the left gastric artery, always courses through the gastrohepatic omentum and is often divided during division of the gastrohepatic omentum. Confirm the patency of the arterial supply to the right liver by temporarily occluding the left hepatic artery before clamping, ligating, and dividing the vessel (Fig. While retracting the bile duct with a vein retractor, iden- tify the left portal vein at the left aspect of the hepatoduode- nal ligament.

The other organs from where perinephric tissue may be involved are the gallbladder discount cialis 2.5 mg without prescription erectile dysfunction 29, the appendix and pelvic organs purchase cialis 20mg amex impotence of proofreading poem. Occasionally perinephric tissue may be involved by infection ascending upwards through periureteral lymphatics. Delay in treatment of pyonephrosis or renal carbuncle may burst into the perinephric space to cause abscess. Cold perinephric abscess from tuberculosis may occur from tuberculous kidney or tuberculosis of a nearby vertebra. According to the cause of perinephric abscess the different organs may be affected accordingly. Occasionally the pus may pass up and form a subphrenic abscess or may be pass down into the pelvis. If suppuration is confined to the upper portion of the perinephric fat, tenderness lies just beneath the lower ribs. When suppuration involves the lower part of the perinephric fat local physical signs become more prominent, e. Occasionally a localised collection of gas formed by the gas forming organisms (coliform) may be observed in the perirenal area. Space-occupying lesions due to carbuncles may become evident as the primary cause. The inicision must be large enough to open up all the pockets above and below the kidney. The surface of the kidney is carefully palpated to detect any unruptured cortical abscess, which should be incised and drained. A specimen of pus should always be sent for bacteriological examination, culture and sensitivity test. If the condition is secondary to renal disease like calculous pyonephrosis or infected hydronephrosis with extensive damage to the kidney parenchyma and while the other kidney is normal, nephrectomy should be considered. Tubercle bacilli invade kidney through blood from a distant focus either lungs, lymph nodes or bones. Sometimes it is almost impossible to demonstrate with certainty the active primary focus. When any part of the body is affected by tuberculosis a shower of tubercle bacilli hit the renal cortex. Minute tuberculous lesions in the kidney can be detected in every case in which there were tubercle bacilli in the urine. Evidence of this in the form of only scars in the kidneys may be seen in autopsies of persons who have died of tuberculosis. However if enough bacteria of sufficient virulence become lodged in the kidney, a clinical infection is established. Kidney tuberculosis is almost always unilateral at the commencement and may remain so for a remarkably long time. Tuberculosis of kidney progresses slowly and it may take 15 to 20 years to destroy a kidney in a patient having good resistance. Usually no clinical disturbance appears till the lesion has involved the calyces or the pelvis, at which time pus and organisms are discharged through the urine. The real clinical criterion of active renal tuberculosis is the presence ofpus and red cells in the urine alongwith tubercle bacilli and not just the presence of tubercle bacilli alone. First the infecting agent passes through the kidney filter and settles down in the collecting tubules. The pathological process is first noticed in one of the positions — (a) at the base of a pyramid or (b) at the apex of a papilla. The appearance of a tuberculous kidney varies greatly with the extent of the lesion. In early stage small lesion may be observed at the base of the pyramid or in one of the papillae. In later stage there is progressive destruction of renal tissue with cavity formation. The pelvic mucosa becomes roughened and the sides of the papillae become ulcerated. So the cut surface of a tuberculous kidney shows (i) caseous yellowish tuberculous masses at the base of the pyramids at one or both poles, (ii) Cavities of varying size with rough walls containing thick creamy cheesy material are seen, (iii) Extension ulceration and dilatation of the pelvis with destruction of the papillae are noted, (iv) Thickening and dilatation of the ureter, although in some cases there may be tuberculous stricture In thefinal stage thekidney becomes a functionless mass of tuberculous tissue. Sometimes kidney, in the process of tuberculosis, becomes shut off from the rest of the urinary tract due to sealing-off of the renal pelvis or ureter. The disease process continues in the kidney to complete destruction, though there is no urinary symptom. As the disease continues the surrounding kidney is affected and a typical tuberculous lesion is very soon detected. Such lesion from outside inwards show fibrosis, small round cell and plasma cell infiltration. Within this fibrosis are epitheloid and foreign body giant-cell typical of tuberculosis, inside which is the cas­ eous material seen as an amorphous mass. Tuberculous infection from one kidney passes down the ureter infecting the bladder and then passes up the other ureter to infect the other kidney. The infection passes down in the submucous coat of the ureter, in which definite tubercles may be seen This is followed by ulceration of the mucosa. It is the upper and lower thirds of the ureter which are more often affected than the middle-third. Only occasionally scar formation may give rise to localised stricture of the ureter. Peculiarly enough the right kidney is somewhat more commonly affected than the left. Though it is mostly due to patchy tuberculous cystitis, yet it may be occasionally due to polyuria as a result of renal tubular inflammation, (b) Burning sensation at the time of urination is another very frequent symptom. A few drops of blood at the end of micturition is particularly due to tuberculous cystitis, (d) If ulceration in the urinary bladder occurs patient often complains of suprapubic pain, particularly when the bladder is full. Presence of pus cells without organisms in acid urine in ordinary staining is very much suggestive of tuberculous affection of kidney. In fact when on careful examination a kidney becomes palpably enlarged it is often the normal kidney which has undergone compensatory hypertrophy. Acid fast stains should be done on the concentrated sediment from 24 hours specimen, which is usually positive in 70% of cases. Such calcification may rarely be seen at lower end of the ureter, but more often seen in seminal vesicles. Tubercles gradually appear usually lateral to the affected ureteric orifice and later on in the dome of the same half of the bladder.

The lateral popliteal portion is affected nine times more commonly than the medial popliteal portion as the latter passes down on the inner and deep aspects of the sciatic nerve purchase cialis 2.5 mg visa erectile dysfunction doctor in bangalore. The lower part of the lateral part of the leg is supplied by the superficial peroneal (musculocutaneous) nerve discount cialis uk erectile dysfunction drugs associated with increased melanoma risk. The medial border of the foot is supplied by the saphenous nerve, whereas the lateral border of the foot is supplied by the sural nerve so these portions are exempted. Using these tests it is possible to distinguish between a nerve injury in which axons have not degenerated distal to the lesion (neuropraxia) and one in which Wallerian degeneration has occurred (axonotmesis or neurotmesis). Electromyography helps to read the electrical activity of a muscle during rest and activity. During weak contraction it records single action potential and in powerful contraction an interference pattern is observed due to more action potentials. Denervated muscle shows denervation potentials which appear within 1 to 2 weeks after injury. It also indicates whether any nerve injury is complete or incomplete and whether regeneration is taking place or not. Even the level of nerve injury can be determined by showing the changes of denervation of the muscles supplied by the nerve distal to the nerve injury. The duration and strength of the current used to excite a muscle is plotted in a graph as the strength duration curve. A normal muscle responds to stimuli varying in duration from 300 milliseconds to 1 millisecond without any increase in strength of the current. If the duration of current is decreased, the strength of current is to be increased to produce contraction. A totally denerved muscle needs either more strength of current or for a longer duration. Presently this investigation is mainly used to know the damaged of the cervical nerve roots after brachial plexus injury. Usually the pain starts following incomplete injury or division of the nerve, though occasionally such pain may not appear before 2 or 3 months. Accumulation of this substance causes vasodilatation and the part becomes red, sweats profusely and becomes increasingly painful. According to the site, cervico-thoracic or lumbar sympathectomy may be required, which are discussed below. These are mapped out by applying sweat-sensitive starch and iodine dusting on the axilla. When the hands are too much sweating, cervico-thoracic sympathectomy should be the treatment of choice. When the feet are sweating excessively with sodden and offensive feet, lumbar sympathectomy is justified. The arteries which have got smooth muscles in their walls, will be released of their spasms due to sympathectomy. These arteries are generally medium sized, small arteries, arterioles and arteriovenous communications. The limb will be warm, pain will be less and the ulcers may show signs of regression. The pathological conditions under this category, which are benefited by sympathectomy, are as follows : (a) Atherosclerosis. Some vascular surgeons suspect whether sympathectomy really increases the deep collateral circulation or simply increases vascularisation of the superficial tissue and skin. But one thing is certain, that if amputation is at all required, previous sympathectomy will definitely limit its extent. The symptomatic relief is rather temporary and almost always fails to yield permanent relief. By sympathectomy, one can only delay the progress of the disease, but cannot have a long term good effect. When sweating is sufficiently profuse to make one psychotic, this operation should always be called for. In the2 7 sympathetic trunk these fibres pass up to synapse about cells, situated mainly in the cervico- thoracic ganglia, from where post-ganglionic fibres pass to the brachial plexus, mainly the lower trunk. Most of the vaso-constrictor fibres supplying the arteries of the upper limb, emerge from the spinal cord in the ventral roots of 2nd and 3rd thoracic nerves. So these arteries can be denervated surgically by cutting the sympathetic trunk below the 3rd thoracic ganglion, severing the rami communicantes connected with the 2nd and 3rd thoracic ganglia and dividing the sympathetic trunk proximally just above the lower half of the cervico-thoracic ganglion (Tl part) distal to the attachment of the white ramus. Sympathetic fibres to the lower limb emerge from the spinal cord between T and L They9 r pass to the sympathetic trunk and then pass downwards, synapsing with the cells in lower lumbar and sacral ganglia from where post-ganglionic fibres arise and innervate the vessels of the lower limb. So removal of the lumbar sympathetic trunk just below the first ganglion proximally and below the 3rd ganglion distally will denervate the blood vessels of the lower limb. This denervation is essentially pre-ganglionic and particularly of those vessels below the knee level, as the cells lie in the lower lumbar and sacral sympathetic ganglia. This may be the main reason why sympathetic denervation of the vessels of the lower limb is more effective than that of the upper limb, which is a mixed pre- and post-ganglionic denervation. For axillary hyperhidrosis, the upper four or five thoracic ganglia should be removed (so axillary approach is more convenient). Cervico-thoracic sympathectomy can be performed by one of the three following approaches:— A. The head is rotated to the opposite side and the hand of the corresponding side is pulled downwards. An incision is made about 1/2 inch above the clavicle starting from the lateral border of the sternal head of the stemomastoid muscle to the medial border of the trapezius. After incising the skin, superficial fascia, platysma and investing layer of the deep cervical fascia, the clavicular head of the stemomastoid is divided and the inferior belly of omohyoid is retracted upwards to expose the scalenus anterior and the phrenic nerve. The phrenic nerve is safeguarded and the scalenus anterior is divided at its insertion to the first rib. The pleura is pushed downwards and laterally to expose the sympathetic trunk and the corresponding posterior ends of the ribs. The proximal divided end is drawn upwards and all the rami communicantes joining the 3rd and 2nd thoracic ganglia are divided. Finally the sympathetic trunk is divided just below the level of the attachment of rami communicantes to the stellate ganglion. This operation can also be performed above the subclavian artery, which is probably a better approach for the short necked patients. But in that case the thyrocervical trunk should be divided between ligatures for better exposure. An incision, about 5 inches in length, is made on the medial wall of the axilla along the line of the 2nd intercostal space. The lung is drawn downwards and forwards to expose the sympathetic chain covered with parietal pleura. The pleura is incised and the sympathetic trunk is removed according to necessity.

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