The fascia transversalis the space of Bogros

The fascia transversalis lies deep to the transverse abdominal muscle plane. It is continuous from side to side and extends from the rib cage above to the pelvis inferiorly. In the upper abdominal wall the fascia transversalis is thin, but in the lower abdomen and especially in the inguinofemoral region the fascia is thicker and has specialized bands and folds within it. In the groin region, where the fascia transversalis is an important constituent of the posterior wall of the inguinal canal...

Paranasal sinuses

Of paranasal sinus tumours, 80 occur in the maxillary sinus with the rest arising from the ethmoid, frontal and sphenoid sinuses. The maxillary sinuses are lined by ciliated columnar epithelium and the majority of the malignant epithelial neoplasms are squamous cell carcinoma. Oral signs and symptoms appear early while nasal obstruction and bloody nasal discharge are late symptoms. Invasion of the orbit is associated with ocular signs, including unilateral proptopsis and diplopia. Anterior...

Necrotizing otitis externa

Necrotizing otitis externa is also known as 'malignant otitis externa'. It is not that the condition may become malignant, but because of the occasional fatal outcome. This typically occurs in elderly patient who is diabetic or is immunocom-promised for other reasons. There is usually a long history of ear discharge and otalgia is frequently present and pronounced. The causative organism is Pseudomonas pyocyanea. The clinical features of 'necrotizing otitis externa' are often misleading and...

Pathophysiology

Burns can occur through direct contact with hot objects, flames, steam or hot liquids. At temperatures above 40 C and particularly above 45 C, heat coagulates proteins and damages enzyme systems leading to cell death. The burn injury as classically described by Jackson has three zones - a central zone of coagulation (3rd degree or full thickness), surrounded by a zone of stasis (2nd degree or partial thickness) and peripherally a zone of hyperaemia (1st degree or simple erythema). The zone of...

Technique for local anaesthesia

The recommended local anaesthetic agent is a mixture of bupivacaine and lignocaine with the addition of adrenaline 1 200 000. The benefits of this mixture are the rapid onset of action of the lignocaine solution, the prolonged action of the bupivacaine and the possibility of reduced local haemorrhage with the addition of adrenaline. In practice 3 X 10 ml ampoules of bupivacaine 0.25 solution with adrenaline 1 200 000 are admixed with 3 X 10 ml ampoules of 1 ligno-caine to produce 3 X 20 ml...

Step 3 Strong opioids

Morphine is the main active constituent of opium and the strong opioid of choice for control of cancer pain. Its analgesic effect is mediated by the mu 1 opioid receptor in the cerebral cortex. Binding to the mu 2 receptor is responsible for its adverse effects (respiratory depression, gastrointestinal and urinary stasis). Morphine is readily absorbed by all routes of administration, but its potency varies according to route (oral subcutaneous 1 2 oral intravenous 1 3) as does plasma half-life...

Insulinoma

Insulin is produced by the p-cells of the islets of Langerhans of the pancreas. These tumours are usually solitary, < 3 cm in diameter, and may be situated in any part of the gland. Over 90 are benign. Multiple insulinomata should alert to the possibility of MEN I. Clinically, patients usually present with psychiatric symptoms with bizarre behaviour, sweating and tremulousness. Whipple's triad is present in most cases symptoms precipitated by fasting significant hypoglycaemia during...

Complications after splenectomy and asplenism

Bleeding may occur from the splenic bed, pedicle or short gastric vessels. Especially important where splenectomy was performed for thrombocytopaenia. Left lower lobe atelectasis is common after splenectomy. Active physiotherapy may prevent this complication. The tail of the pancreas is in close relation to the hilum of the spleen and may be injured during the surgical procedure. This may lead to a pancreatic leak and collection. Postsplenectomy fever can occur in the absence of any source of...

Nipple retraction inversion

The terms nipple retraction and inversion have come to be used interchangeably. However, nipple inversion is most often used when the whole of the nipple is permanently pulled inwards, whilst nipple retraction is used to describe variable degrees (usually intermittent) of the nipple being pulled inwards. Congenital nipple inversion (of variable degree) occurs in up to one-fifth of all women. This is usually of no clinical significance unless it interferes with breast feeding. The woman may...

Management

It is important to recognize the condition as circumcision is absolutely contraindicated the dorsal hood of foreskin is a valuable piece of tissue for reconstruction. Uncorrected, the penile curvature and abnormal urination and semen delivery could lead to major psychological and sexual sequelae and infertility. The goal of surgery is to straighten the penis, provide a urethra which opens at its tip and achieve a normal appearance. A variety of techniques have been employed. Most are repaired...

Gallstones

Gallstones are common, and are estimated to be present in 20-30 of people in developed countries. Only 20-30 of these people will develop problems related to their stones, and it is important to try and differentiate between symptomatic and asymptomatic stones. Gallstones contain cholesterol, bile pigments, or a mixture of these compounds, and it is clear that their aetiology is multi-factoral. Obesity, ileal resection, and haemolytic anaemia have all been linked to gallstone formation, the...

CNS infections

The CNS is particularly sensitive to infection and the infective agents can be bacterial, viral and fungal or agents such as prions (small-chain deoxyribose nucleic acid (DNA) fragments) which are the suspected causative agents in Creutzfeldt-Jakob disease. Bacteria and fungi cause meningitis or brain abscess, viruses lead to encephalitis and prions to spongiform encephalopathies. An acute infection of the subarachnoid space which invokes an inflammatory reaction from the meninges. Bacteria...

Enteral and parenteral nutrition

The metabolic role of the GI tract in both fasting and stressed states is increasingly recognized. The GI tract can act as a reservoir for bacteria that may cause systemic infections, by allowing bacterial translocation across the gut wall. Gut-derived endotoxin may therefore be the link between GI failure and multiple organ failure in patients without overt clinical evidence of infection. The relationship between GI bacteria, systemic host defences and injury in the development of bacterial...

Perforated peptic ulcer

Complications of peptic ulcer disease are now much less common than 20 years ago due to improved medical management (see Peptic Ulcer, below), but perforations still imply a mortality of approximately 10 (higher in older patients). The well-recognised risk factors for developing a perforation are long-term non-steroidal anti-inflammatory drug (NSAID) use, and Helicobacter pylori infection. The usual presentation is a sudden onset of severe epigastric pain, followed quickly by signs of...

Further Reading

Amid PK, Shulman AG, Lichtenstein IL. Local anaesthesia for inguinal hernia repair step by step procedure. Ann Surg 1994 220 735-737 Jenkins TPN. The burst abdominal wound a mechanical approach. Br Med J1976 131 130-140 Kirk RM. Basic Surgical Techniques, 4th edn. Edinburgh Churchill Livingstone, 1994 MacGregor IA, MacGregor AD. Fundamental Techniques in Plastic Surgery, 9th edn. Edinburgh Churchill Livingstone, 1995 Kirk RM, Mansfield AO, Cochrane J (eds), Clinical Surgery in General, 2nd edn....

Other groin swellings

Other structures in the groin each contribute to the harvest of swellings, pains and discomforts patients complain of. These include 1. Vascular disease (a) Arterial - aneurysms of the iliac and femoral vessels these may be complicated by distal embolization or vascular insufficiency which will make the diagnosis easy. Femoral aneurysm as a complication of cardiac catheterization or transluminal angioplasty is a recent arrival in the diagnostic arena. (b) Venous - a saphenovarix could be...

Chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is the commonest form of chronic otitis media. Clinically it is characterized by otorrhoea and conduction hearing loss of variable severity. Otoscopy reveals a perforated eardrum. The condition is classified into the safe (tubotympanic) and unsafe (atti-coantral) variety depending on the likelihood of coexisting cholesteatoma. The safe variety is CSOM without cholesteatoma. It can be further classified into active or inactive depending on whether there is...

Mammary duct ectasia

There has been much debate as to the relationship between periductal mastitis and mammary duct ectasia. Although it has often been held that these are variants of the same pathological process, with the former possibly resulting in the latter, the two conditions are probably different. Periductal mastitis occurs in young pre-menopausal women whilst mammary duct ectasia occurs more commonly in peri- and post-menopausal females. Histological examination shows there is dilatation of ducts filled...

Diagnosis

Careful inspection of the perineum should be an integral part of neonatal examination. Occasionally the diagnosis of anorec-tal anomaly may be delayed because of adequate bowel decompression through a perineal vestibular fistulous opening and failure to recognize the correct position of the anus. Rarely, in rectal atresia, there is a normal anal opening and the diagnosis is suspected on failure of attempts to pass a rectal thermometer. An abnormal skin tag (the so-called 'bucket handle'...

Videoassisted thorascopic surgery

Video-assisted thorascopic surgery (VATS) has the advantage of avoiding the necessity to spread the ribs, which reduces postoperative neuralgia and muscle damage. The patient is placed in the lateral position with a double-lumen tube and two or more ports introduced after collapsing the lung. The first port is generally introduced in the mid-axillary line at the sixth or lower interspace after carefully passing a finger into the chest to make sure there are no pleural adhesions. The other ports...

Pneumonia

Nosocomial pneumonia is a common, serious condition in critically ill patients. Ten percent of patients requiring post-operative ICU care will develop pneumonia. Intubated patients are at increased risk of pneumonia, with the chance of developing pneumonia increasing the longer the patient is ventilated. Risk ofVAP is 3 per day for the first 5 days of ventilation, 2 per day for days 5-10, and 1 per day for days 10-15. The mortality rate ofVAP ranges from 25 to 50 . Microorganisms involved in...

Foreign body

Human beings appear to have an inexhaustible fascination for inserting objects into their rectums. Retained rectal foreign bodies can present a challenge in management. Digital rectal examination, proctoscopy and abdominal radiography are helpful and soft or low-lying objects can be grasped and removed safely in the emergency department. However, simply grasping objects may result in upward migration toward the sigmoid. Insufflation of air with a rigid or flexible sigmoidoscope proximal to the...

Melanoma

Melanoma peaks at age 20-45 years, typically in fair-skinned persons with a history of severe sunburn. Other risk factors are past history of melanoma and family histories of melanoma and dysplastic naevi. Clinical types are superficial spreading melanoma, nodular melanoma and acral lentigi-nous melanoma (occurring in palm, sole, nail bed and mucus membrane). If possible, total excisional biopsy is preferred. The extent of treatment, risk of regional metastasis, risk of recurrence and overall...