FISTULA IN ANO
WHEN TO SUSPECT/RECOGNIZE?
When a patient presents with a discharging opening gin the perianal region, on e should suspect a fistula in ano
INTRODUCTION:
A fistula is an abnormal communication between two epithelial surfaces.
DEFINTION:
By definition a fistula in ano is a communication between the anal canal and skin by a tract which may be straight and simple or complex with ramifications or a horse shoe tract involving the right and / or left halves. The discharge may be pus, fecal matter, flatus or serosanguinous.
Fistula are classified as low or high
Based upon their relationship to the anal sphincter complex, anal fistulas are categorized into:
1. Intersphincteric
2. Trans sphincteric
3. Supra sphincteric
4. Extra sphincteric
Treatment options are based upon these classifications
INCIDENCE:
Indian incidence is not documented
DIFFERENTIAL DIAGNOSIS:
Furunculosis
Crohn’s disease
Pilonidal sinus
Tuberculosis
34
Actimycosis
Lymphogranuloma venereum
Granuloma inguinale
Perianal abcess
PREVENTION:
Adequate drainage of anorectal abscesses may prevent fistula formation
Predisposing causes
1. Crohn’s disease
2. Malignancy
3. Chlamydia
In the presence of a complex, recurrent, non healing fistula these should be suspected.
COUSELLING:
Surgical treatment alone offers permanent cure. So patients should be counseled for early surgey when it is a simple fistula so that it does not become complex.
OPTIMAL DIAGNOSTIC CRITERIA:
SITUATION 1:
CLINICAL DIAGNOSIS:
Patients with anal fistula commonly present with complaints of
 Discharge from external or internal opening, the external opening may be single or multiple
 Pain
 Swelling
 Fever
The presentation may be acute when there is acute perianal sepsis
A chronic anal fistula presents with periodic exacerbation and pus discharging openings around the anus per rectal exam and proctoscopy should be done to visualize both the internal and external openings. This may be adequate for a straight low tract.
35
INVESTIGATIONS:
Fistulogram may be done when branching is suspected, in recurrent fistulae and when internal opening is not appreciable.
Examination under anesthesia
Probe test, caution may cause now internal opening
Injection technique is useful in delineating the tract
Biopsy when specific cause is anticipated
Barium enema – when co existing disease is suspected
Blood sugar – to r/o diabetes mellitus
Complete blood count
Urine r/m
X ray chest – to rule out TB
TREATMENT:
Simple low fistulae can be managed in a secondary hospital where a surgeon is available
SURGICAL PROCEDURES:
Surgical options are dictated by the type of fistula. Aim is to drain the septic focus and remove the fistula with minimal injury to the sphincter complex
Fistulotomy
Fistulectomy
Seton
Combination of the above:
Fistulotomy (of superficial position), with seton division (of the cephalad position)
Staged procedures may be required in high anal fistulae
Fistula presenting as perianal abscess would require drainage, analgesics and antibiotics followed subsequently by a definitive procedure
Fistulotomy and curettage / Fistulectomy – low anal fistula
36
Trans sphincteric fistula that involve =<30 percent of sphincteric muscle – sphincteromy without risk of incontinence
High Trans sphincteric fistulas – seton placement
REFERRAL CRITERIA:
Complex/recurrent/high anal fistulae may need referral to a higher centre for adequate investigation and management. Colostomy and staged procedure may be required.
Co existing conditions like rectal cancers, Crohn’s disease, TB fistulae, HIV infection require referral
SOP:
In patient
SITUATION 2:
Clinical diagnosis as in situation 1
INVESTIGATION:
All investigations as in situation 1
Additional investigations:
MRI, MR Fistulogram in complex, high, trans sphincteric, supra and extrasphincteric fistulae
Colonoscopy – associated ulcerative colitis, carcinoma, TB etc
HIV test in suspected cases
Biopsy when multiple openings are present, malignancy or specific cause is suspected prothrombin time
HbA1C in cases of diabetes mellitus
TREATMENT: as in situation 1
Colostomy – when significant sphincter involvement is present, or non healing ulcer Multiple procedures – complex fistula with multiple tracts
SOP:
Day Care – Low fistulae – subcutaneous / submucous fistula
All others – should be admitted
37
WHO DOES WHAT?
Doctor:
Clinical examination
Diagnosis
Planning surgery
Post op care
Anesthesia
Nurse:
Siting of colostomy when required, by stoma nurse
Care of stoma
Dressing of the wound
Pre & post operative care
Assisting during surgery
Technician:
Pre op equipment and drugs to be checked and kept ready
Assist anesthetist in the OT
Assist the surgeon, positioning of the patient
REFERENCES
Owen G, Keshava A, Stewart P, Patterson J, Chapuis P, Bokey E, Rickard M.
Plugs unplugged. Anal fistula plug: the Concorf experience.
ANZ J Surg. 2010 May, 80 (5):341-3
Department of Colorectal Surgery, Concord Repatriation General Hospital, Hospital Road, Concord, NSW 2139, Australia. Owen_g@optusnet.com.
K.Rajgopal Shenoy, Manipal Manual of Surgery second edition; reprint 2009. CBS Publishers and Distributors (Pvt.) Ltd., India
38
Shackelford’s Surgery of the Alimentary Tract 6th Edition by Charles J. Yeo MD Saunders 2006 ISBN: 1416023577
RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60kgs)
Situation
Human Resources
Investigations
Drugs/Consumables
Equipment
1
Surgeon – 1
Medical Officer / Assistant Surgeon – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Haemogram
Urine Analysis
Blood Sugar
Antibiotics
Analgesics
I V Fluids
Sutures
Anesthetic drugs
Lignocaine
dressings
OT Table and lights
Autoclave
General surgery set
Cautery
Suction
Pulse Oximeter
Anesthetic equipment
2
Consultant – 1
Resident – 1
Staff nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Same as above +
hbA1C
coagulation
profile
ECG
X-Ray chest
Same as above + stoma bag
Same as above

COLECTOMY

INTRODUCTION:
Sir William Arbuthnot was one of the early proponents of the usefulness of total colectomies.
Colectomy is commonly performed for the treatment of colon cancer.

DEFINITION:
Colectomy implies the surgical resection of any extent of the large intestine (colon).
Based on the segment of colon removed colectomies are termed as
1. Right hemicolectomy.
2. Extended right hemicolectomy
3. Transverse colectomy
4. V resection
5. Left hemicolectomy
6. Extended left hemicolectomy
7. Sigmoidectomy
8. Proctosigmoidectomy
9. Total colectomy
10. Total proctocolectomy
11. Subtotal colectomy

INDIAN INCIDENCE: not documented
DIFFERENTIAL DIAGNOSIS:
 Polyps
 Inflammatory bowel disease-ulcerative colitis, Crohn’s disease
 Tuberculous stricture of the large bowel with obstruction
21
 Vascular malformations with lower gastro intestinal bleeding
 Amoebiasis
PREVENTION:
In familiar situations like FAP & HNPCC early colectomy is advised.
It is important to understand the carcinogenesis in colorectal cancer & the associated molecular events.
ENVIRONMENTAL FACTORS also pay an important role, particularly dietary factors & estrogen replacement.
Association between hyperplastic polyposis & colorectal cancer & adenomas called sporadic MIS tumuors
Colorectal cancers: are Sporadic in 75% cases & Genetic in 25% (younger age at diagnosis)
Positive Familial history is present in 15%-20%.
HNPCC (5%)-80% risk
FAP(less than 1%)-100% risk of development of CRC – prophylactic total colectomy/proctocolectomy
COUNSELLING:
GENETIC COUNSELLING
PREDISPOSITION SHOULD BE COUNSELLED & SCREENED FOR COLON CANCER.
Screening colonoscopy and polypectomy – reduces colon cancer mortality.
1. OPTIMAL DIAGNOSTIC CRITERIA:
Situation 1
Clinical Diagnosis
Anatomical locations and clinical manifestations of colon cancer
Distribution %
Ascending / Caecum
Transverse
Descending/Sigmoid
Manifestations
Bleeding
Anemia
Malena
Abdominal pain
Mass
obstruction
Abdominal pain
Obstruction
Mass
Changing bowel habit
Obstruction
Mass
Abdominal pain
Mass
22
Diarrhoea
obstruction
Perforation
Low back pain
INVESTIGATIONS:
 Haemogram
 Colonoscopy – investigation of choice
 – Biopsy & HPE
– Brush cytology if biopsy is not possible
 X-ray abdomen – if patient presents with features of large bowel obstruction
 Double contrast barium enema :
– When colonoscopy is contra indicated or not available
– Findings – constant irregular filling defect
– Detects associated lesions
– Small ulcerative lesions can be diagnosed
 USG abdomen
 Endoluminal ultrasound – if available
 CECT – if available is used in large palpable abdominal masses
= To determine local invasion
 Urograms – when evidence of hydronephrosis on USG/ CT in left sided tumours
TREATMENT:
1. Pre op evaluation of staging, respectability, patient’s operative risks are mandatory.
2. Accurate localization of tumour – of particular importance.
a. Sometimes known cancer may not be apparent on serosal aspect.
b. Localization by tattooing during colonoscopy, Barium enema.
c. Pre op CT, USG assessment of iver metastasis should be done
PRE OP PREPARATION:
Mechanical bowel preparation
Prophylactic antibiotics
23
Blood grouping and cross matching
Thromboembolism prophylaxis
OPERATIVE TECHNIQUES:
Resection should follow
Standard oncological principles:
 Proximal ligation of primary arterial supply at its margins
 Adequate proximal & distal margins(5 cm) determined by area supplied by the primary feeder artery
 Appropriate lymphadenectomy – harvesting of minimum 12 nodes
 Extent of resection is an important prognostic factor (SAGES guidelines 2000)
 Any tumour not removed intraoperatively strongly influences prognosis & therapy
Ro – absence of residual tumour, margins free histologically
R1 – no gross residual tumour but margins histologically positive
R2 – residual gross disease remains unresected
RADIAL MARGIN:
T4 lesions are a complex group & should be considered separate from other T groups
Radial tumour free margins should be resected. Radial margin should be histologically free of disease for resection to be curative.
Specimen labeling, marking are important for a good pathological report
R1 & R2 resection – incomplete resection for cure affects curability though TNM stage remains same
LATERAL CIRCUMFERENTIAL MARGIN:
In addition to radial, proximal & distal margins, circumferential margins should also be pathologically assessed. Positive margins are associated with increased rate of local and distal failure.
Disease free survival and mortality significantly related to margin involvement after TME
ADJUVANT Ro stage:
Adjuvant therapies require complete resection
A case is not Ro if it is
24
 Non enbloc resection
 Radial margins positive for disease
 Bowel margin positive for disease
 Residual lymph node disease present or
 Nx (incomplete staging)
LYMPHADENECTOMY:
Should be radical (up to the level of origin of primary feeding artery)
Apical nodes positive for disease may have prognostic significance in addition to number of positive lymph nodes
ENBLOC RESECTION of adherent tumours : En bloc removal of adjacent organs locally invaded by cancer colon can achieve survival rates similar to patients with tumour that do not invade an adjacent organ, provided negatgive resection margins are achieved.
PERFORATION OF TUMOUR SHOULD BE AVOIDED (SAGES GUIDELINE)
Inadvertent full thickness perforation of rectum would probably classify tumour as T4 and resection as R1
Perforation at the site of cancer, as opposed to an area remote from the tumour has a greater impact on survival & local recurrence.
Inadvertent local perforation predisposes to local recurrence and warrants post-operative radiotherapy.
INTRAOPERATIVE SPILLAGE:
HAS AN INDEPENDENTT EFFECT ON PROGNOSIS
Adjuvant radiotherapy may be considered to decrease rates of local recurrence
NO TOUCH TECHNIQUE:
Value inconclusive
25
SURGICAL PROCEDURES:
Anatomical Resection of Colon Cancer
Tumour location
Vascular Ligation
Colon resection
Anastamosis
Caecum, ascending colon
ileo-colic, right colic
Right hemicolectomy
ileotransverse colostomy
Hepatic flexure,
Proximal transverse colon
ileocolic right, middle colic
Extended right hemicolectomy with omentectomy
iIeodescending colostomy
Distal transverse colon splenic flexure
ileocolic right, middle or left branch of middle colic, left colic
Extended right hemicolectomy with omentectomy or Left hemicolectomy
ileosigmoid colostomy or Transverse sigmoid colostomy
Descending colon
Inferior mesenteric or left colic
Left hemicolectomy
Transverse colorectal anastamosis
Sigmoid colon
Inferior mesenteric or sigmoid
Left colectomy or Sigmoid resection
Transverse colorectal anastamosis or descending colorectal anastamosis
Colectomy may be performed by the
i) Conventional open technique
REFERRAL CRITERIA:
Patients suspected of colon cancer & biopsy proven should be referred to a higher centre for further evaluation and treatment when
1) Adequate surgical facilities are not available / surgeon does not have sufficient experience in colon cancer surgery.
2) Competent pathologist to report on malignant lesions as per standard oncological guidelines is not available.
3) For adjuvant / neo-adjuvant radio and chemo therapy
TREATMENT:
Patient requiring colectomy for biopsy proven cancer are best referred to a super specialty centre
26
In view of the need for multi modality treatment.
SITUATION 2:
All investigations as in situation 1
 Spiral CT in elderly patients more than 80 years
 CT colonoscopy also called virtual colonoscopy – 6 mm polyps may be picked up effectively
 CEA – fetal glycoprotein
– Increased pre op CEA in node positive Ca – indication for chemotherapy
 MRI :
 PET : detection of metastasis
 SPECT – if single photon emission is studied, such as technetium or thallium
 FDG-PET – useful in evaluation of recurrent colorectal cancer
-Differentiates post op changes from recurrent / residual disease
-Useful diagnostic tool but prohibitive cost
 CT-PET – fusion tests provide the most powerful integrated images
 NUCLEAR MEDICINE IMAGING:
-Using 131I, 111In, 99mTc bound to monoclonal antibodies, leucocytes & erythrocytes.
TREATMENT:
As outlined in situation 1.
Laparoscopic resection is gaining popularity. However it is not freely available & performed as per protocols.
SPECIAL CONSIDERATIONS
1. Synchronous malignancies or polyps
Patients with synchronous malignancies should be considered for subtotal colectomy depending on the distance between lesions
Colonic cancer with multiple adenomatous polyps – subtotal colectomy
27
(Due to increased risk of metachronous lesion and to facilitate surveillance of the remaining colon)
Factors that influence the decision to perform prophylactic subtotal colectomy
-number
-location
-size of accompanying polyps
-age
-compliance of patient
2. Cancer is a polyp
Complete endoscopic removal of polyp with cancer in situ – no further treatment
Histoplathology shows invasive carcinoma:
Ensure that endoscopic polypectomy was complete
Specimen was submitted with proper orientation to the pathologist for histopathology
Carcinoma at margin of resection requires formal resection
Carcinoma with free margins – a. thorough pathological review,
b. identification of adverse histological features
i. poor differentiation,
ii lymphatic or venous invasion
iii invasion into the stock of the polyp – formal
resection
It is difficult to locate the previous polypectomy site during surgery
Even if polyp is not removed it may be soft and difficult to palpate through the colon wall
28
Endoscopic distance (from anal verge or dentate line) misleading
Polypectomy site should be videotaped for later review and marked with vital dye that can be seen serosally at the time of surgery
3. Obstructing Cancers- 2% of colorectal cancers
Partial obstruction – Gentle bowel preparation over several days-Elective surgery
Total obstruction
– Rt colon cancers – Rt Hemi colectomy – immediate ileocolostomy
– Lt colon cancers
1) Endoscopic decompression by laser passed beyond the obstructed
Segment – This allows mechanical preparation and elective resection.
– This is possible only when the narrowed lumen can be traversed by the endoscope.
– It is not possible when obstruction is complete
2) Primary resection and immediate anastamosis with on-table colonic
washout with or without proximal colostomy.
3) Primary resection with colostomy. Anastamosis at second stage.
4) Subtotal colectomy with primary anastamosis
5) Decompressive colostomy followed by formal colonic resection
4. Adjacent organ involvement- 10%
Locally advanced tumours are potentially curable with multi organ resection.-Do not necessarily
Portend a dismal prognosis.
-A non metastasizing variant of colon cancer grows to a large size without spreading to regional nodes
-Separation of adhesions adjacent to a malignancy can lead to dissemination of tumour cells.
29
-Enbloc resection of these tumours, depending on location can lead to five year survivals of 70%
Hepatic metastases – 10% at the time of exploration.
-Solitary metastasis amenable to –wedge resection with clear margins can be removed concomitantly.
-Formal hepatic lobectomy done as a second stage procedure.
5. Ovarian metastasis – 7% at the time of colon resection
Oophorectomy: at the time of colorectal surgery
Indications
i) Large ovarian metastasis (Krukenbergt’s tumour) which are symptomatic (prevents second surgery for the metastasis, benefit of preventing primary ovarian cancer)
ii) Direct ovarian involvement
iii) Post menopausal women – prophylactic oophorectomy
6. Inadvertent Perforation
-Predisposes to local recurrence
-Warrants post op radiotherapy
Follow up
Aim: Early detection of recurrence or metachronous lesion
History
Physical examination
Faecal occult blood
CBC } every 3 months-first 3 years
LFT every 6 months additional 2 years
30
Tumour markers (CEA) – monthly – 3 years, 3 monthly-next 2 years
Colonoscopy – first colonoscopy within 6-12 months of surgery, yearly-next 2 years, 2-3 yearly thereafter.
CXR
CT abdomen and pelvis – if primary loco regionally advanced
-LFT ↑
-CEA ↑
80-90% of recurrence of colon cancers occurs in the first two years.
SOP
All patients should be admitted when a colectomy is planned
WHO DOES WHAT?
Doctor:
c) Surgeon: diagnosis & work up
Pre operative planning
Operative procedure
Post operative follow up
d) Radiotherapist : radiotherapy – neoadjuvant & adjuvant
e) Medical oncologist : Chemotherapy
f) Anesthetist: PAC, anesthesia, post op ICU management
NURSE:
 Siting of colostomy when required by some nurse
 Care of stoma
 Dressing of the wound
 Pre & post operative care
31
TECHNICIAN:
 Pre op equipment and drugs to be checked and kept ready
 Assist anesthetist in the OT
 Assist the surgeon, positioning of the patient

RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60 Kgs)
Situation
Human Resources
Investigations
Drugs/Consumables
Equipment
1
Surgeon – 1
Medical Officer /
Assistant Surgeon – 1
Anesthetist – 1
Pathologist – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Haemogram
Urine Analysis
Blood Sugar
S. Electrolytes
KFT
ECG
X-Ray – Chest
USG
Antibiotics
Analgesic
I.V. Fluids
Sutures
Drains
Catheters
Anesthetic drugs
Dressings
OT Table & lights
Instrument trolley
General Surgery Set
Cautery
Suction
Anesthetic Equipment
32
Sweeper – 1
Histopathology
Stoma bags
Monitors
2
Consultant – 1
Residents – 1
Anesthetist – 1
Pathologist – 1
Medical Oncologist – 1
Radiotherapist – 1
Staff Nurse – 2
Stoma therapist – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Same as above +
HbA1C
CEA
Coagulation Profile
Colonoscopy
EUS
CT Scan
CEA
Microbiology
ABG
Immunology
PET
Same as above
Same as above +
Laparoscopic Set
Harmonic Scalpel
Endo GI Staplers

by
Dr. V. Ramesh &
Dr Ajit Sinha
Department of Surgery
Safdarjung Hospital
New Delhi

CHOLECYSTECTOMY

INTRODUCTION:
Cholecystectomy is one of the commonest elective surgical procedure performed in India. Most are performed to address symptoms related to biliary colic from cholelithiasis, to treat complications of gallstones (eg, acute cholecystitis, biliary pancreatitis), or as incidental cholecystectomies performed during other open abdominal procedures. Currently, most cholecystectomies are done using the laparoscopic technique in cities; however, the open technique is required in places where facilities or trained staff are not available.
DEFINITION:
Cholecystectomy implies the surgical resection the gall bladder.
INDIAN INCIDENCE
In India, the incidence of gall stones is around six percent in the total population. It is 10 per cent in women and three per cent in men. In elderly people it may go up to 20 percent.
INDICATIONS:
Asymptomatic patients
Cholecystectomy is not indicated in most patients with asymptomatic stones because only 2-3% of these patients go on to become symptomatic per year. To properly determine the indications for elective cholecystectomy, the risk of the operation (taking into account the age and comorbid factors of the individual patient) must be weighed against the risk of complications and death without operation.
The widespread use of diagnostic abdominal ultrasonography has led to the increasing detection of clinically unsuspected gallstones. This, in turn, has given rise to a great deal of controversy regarding the optimal management of asymptomatic (silent) gallstones.
Patients who are immunocompromised, are awaiting organ allotransplantation, or have sickle cell disease are at higher risk of developing complications and should be treated irrespective of the presence or absence of symptoms.
Additional reasons to consider prophylactic cholecystectomy include the following:
 Calculi >3 cm in diameter, particularly in individuals in geographical regions with a high prevalence of gallbladder cancer
 Chronically obliterated cystic duct
 Nonfunctioning gallbladder
 Calcified (porcelain) gallbladder
 Gallbladder polyp >10 mm or showing rapid increase in size

 Gallbladder trauma
 Anomalous junction of the pancreatic and biliary ducts
 Morbid obesity is associated with a high prevalence of cholecystopathy, and the risk of developing cholelithiasis is increased during rapid weight loss. Routine prophylactic cholecystectomy prior to gastric bypass (RYGB) is controversial, but cholecystectomy should clearly precede or be performed at the time of RYGB in patients with a history of gallbladder pathology.
Symptomatic gallstone disease
Biliary colic with sonographically identifiable stones is the most common indication for elective cholecystectomy.
Acute cholecystitis, when diagnosed within 72 hours from the onset of symptoms, can and usually should be treated by surgery. Once 72 hours pass after the onset of symptoms, inflammatory changes in the surrounding tissues are widely believed to render dissection planes more difficult. Interval cholecystectomy after 4-6 weeks or percutaneous cholecystostomy are other options.
Biliary dyskinesia should be considered in patients who present with biliary colic in the absence of gallstones, and a cholecystokinin–diisopropyl iminodiacetic acid (CCK-DISIDA) scanning should be obtained. The finding of a gallbladder ejection fraction <35% at 20 minutes is considered abnormal and constitutes another indication for cholecystectomy.
Complex gallbladder disease
Gallstone pancreatitis
Cholecystectomy can be safely performed during the same hospitalization after the clinical signs of mild to moderate biliary pancreatitis have resolved. Patients diagnosed with gallstone pancreatitis should first undergo imaging to rule out the presence of choledocholithiasis.
Cholecystectomy should be delayed in cases of acute moderate to severe biliary pancreatitis (5 Ranson criteria).
Choledocholithiasis
The following treatment options are available for patients found to have choledocholithiasis:
Preoperative ERCP with sphincterotomy
Postoperative ERCP with sphincterotomy
Laparoscopic intraoperative cholangiogram with laparoscopic common bile duct (CBD) exploration
Open CBD exploration and T-tube placement
Mirizzi syndrome
P.L. Mirizzi described an unusual presentation of gallstones that, when lodged in either the cystic duct or the Hartmann pouch of the gallbladder, externally compressed the common hepatic duct, causing symptoms of obstructive jaundice.

Although an initial trial of dissection may be performed by an experienced laparoscopic biliary surgeon, one must be prepared for conversion and for biliary reconstruction.
Endoscopic stone fragmentation at ERCP, with papillotomy and stenting, is a viable alternative to operative surgery to treat Mirizzi syndrome in the acute setting.[24 ]Subsequent cholecystectomy may be performed.[25 ]
Cholecystoduodenal fistula
Patients with cholecystoduodenal fistula leading to gallstone ileus should undergo exploratory laparotomy and removal of the stone, followed by exploration of the remainder of the gastrointestinal tract for additional stones. The fistula may be addressed at the time of the initial procedure but is probably better addressed at a second operation (3-4 wk postoperatively) after inflammation has subsided.[25 ]
Cholecystenteric fistula does not represent an absolute contraindication to laparoscopic surgery, although it does require careful visualization of the anatomy and good laparoscopic suturing skills.
Acalculous cholecystitis
A greater proportion of patients with acalculous cholecystitis are too ill to undergo surgery. In these situations, percutaneous cholecystostomy guided by CT or ultrasonography is advised. Ninety percent of these patients demonstrate clinical improvement. Once the patient has recovered, the cholecystostomy tube can be removed, usually at 6 weeks, without sequelae. Interval cholecystectomy is not necessary.[27 ]
Incidental gallbladder cancer
Gallbladder cancer may be an incidental finding at cholecystectomy, with an incidence ranging from 0.3-5.0%.
Uncertainty of diagnosis, uncertainty of the degree of tumor spread, or postoperative identification of cancer on pathological examination of a routine cholecystectomy specimen should engender early reoperation.
Before reoperation, distant metastases should be excluded by a detailed clinical examination including a per-rectal/per-vaginal examination, examination for supraclavicular lymph nodes, and CT/MRI of the chest and abdomen.
Special situations
Children
Cholecystectomy is a safe and effective treatment for most children diagnosed with biliary disease (BD).
Cirrhosis
Cholecystectomy in safe in patients with Child class cirrhosis.
9
Diabetes mellitus
The presence of diabetes mellitus, in and of itself, does not confer sufficient risk to warrant prophylactic cholecystectomy in asymptomatic individuals.
However, consider that acute cholecystitis in a patient with diabetes is associated with a significantly higher frequency of infectious complications such as sepsis.
Pregnancy
The treatment of biliary colic or uncomplicated cholecystitis in a pregnant patient is conservative management followed by elective cholecystectomy. Using antibiotics, analgesics, and antiemetics help most pregnant women avoid surgical intervention. Surgery is generally indicated for patients with recurrent acute cholecystitis who have failed maximal medical therapy.
Classically, the second trimester is considered the safest time for surgery. This is because of the findings of increased risk for spontaneous abortion and teratogenesis during the first trimester, and the increased risk for premature labor and difficulties with visualization in the third trimester.
Pregnancy was formerly considered to be an absolute contraindication to the laparoscopic approach because of concern for potential trocar injury to the uterus and the unknown effects of pneumoperitoneum to the fetal circulation. However, this has not been borne out in the literature, and cholecystectomy is now considered safe.
Recommendations for pregnant patients who undergo laparoscopic cholecystectomy include placing them in the left lateral recumbent position to shift the weight of the gravid uterus off the vena cava and maintenance of insufflation pressures between 10 and 12 mm Hg. In addition, maternal PaCO 2 monitoring must be performed by measuring either arterial blood gases or end-tidal CO 2 , but arterial PaCO 2 may be more accurate.
Other recommendations include avoiding rapid changes in intraperitoneal pressures, avoiding rapid changes in patient position, and using open technique for the umbilical port placement.
Distance from medical centres
In India, another indication can be distance from a treating hospital as long travel that may be needed can lead to complications.
INVESTIGATIONS:
 Haemogram
 Liver Function Tests
 Blood sugar
 Serum creatinine
 Bleeding time, clotting time and prothrombin time
 Xray chest

 ECG
 USG abdomen
 In patients with dilated common bile duct or raised liver functions, MRCP or ERCP may be indicated based on availability. Alternatively, an on table cholangiogram or CBD exploration may be done during surgery. Patient can be referred to another centre in case of non availability of expertise or experience.
OPERATIVE TECHNIQUES:
Principles of surgery remain the same regardless of whether it is being done by open or laparoscopic technique.
 Safe access to abdomen.
 Clear definition of anatomy in the calots triangle showing either the continuity between cystic duct and gall bladder or junction between cytic duct and common bile duct.
 Avoiding diathermy close to common bile duct.
 Securing cystic artery safely and close to the gall bladder.
 Dissection from liver bed staying close to gall bladder.
 Early conversion to open procedure in case of a difficult laparoscopic surgery.
REFERRAL CRITERIA:
 Common bile duct stones if no facilities for management available.
 Suspected gall bladder cancer.
 Bile duct injury during surgery. Patient should be referred to a tertiary centre as soon as possible.
WHO DOES WHAT?
Doctor:
a) Surgeon: diagnosis & work up
Pre operative planning
Operative procedure
Post operative follow up

b) Anesthetist: PAC, anesthesia, post op ICU management
NURSE:
 Dressing of the wound
 Pre & post operative care
TECHNICIAN:
 Pre op equipment and drugs to be checked and kept ready
 Assist anesthetist in the OT
 Assist the surgeon, positioning of the patient
RESOURCES REQUIRED FOR ONE PATIENT / PROCEDURE (Patient weight 60 Kgs)
Human Resources
Investigations
Drugs/Consumables
Equipment
Surgeon – 1
Medical Officer /
Assistant Surgeon – 1
Anesthetist – 1
Pathologist – 1
Staff Nurse – 1
Technician – 1
Nursing Orderly – 1
Sweeper – 1
Haemogram
LFT
Blood Sugar
S. Electrolytes
KFT
ECG
X-Ray – Chest
USG
Histopathology
Antibiotics
Analgesic
I.V. Fluids
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OT Table & lights
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General Surgery Set
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BLUNT ABDOMINAL TRAUMA
1. Name of the condition: Blunt abdominal trauma
2. When to suspect/ recognize?
a. Introduction: Blunt abdominal trauma (BAT) is an increasingly common problem encountered in the emergency department. The usual causes of BAT include vehicular accident, assault, falls, sports injuries and natural disasters.
b. Case definition: BAT is suspected in any patient involved in above situations and presents with abdominal pain, distention or shock. It should be looked for in patients of polytrauma.
3. Incidence of the condition in our country: One study has reported 2.1% incidence of BAT amongst all surgical patients admitted to a tertiary hospital during 1 year.
4. Differential diagnosis:Abdominal trauma forms adifferential diagnosis of any patient presenting with acute abdomen.
5. Prevention and counseling: Use of appropriate safety measures during various activities associated with BAT can significantly reduce its incidence.
6. Optimal diagnostic criteria, investigations, treatment and referral criteria:
a. Situation 1 At Secondary Hospital/ Non-metro situation: Optimal standard of treatment in situations where resources are limited
I. Clinical diagnosis:This is based on
a. High level of suspicion of intra-abdominal injury
b. Presence of wounds/ bruising on the abdomen
c. Abdominal guarding/ tenderness
d. Presence of free gas/ fluid in the peritoneal cavity
e. Presence of fracture of lower ribs and/ or pelvis increases the likelihood of intra-abdominal injury
f. Note should be made of altered mental state, drug or alcohol intoxication and distracting injuries which may mask the features of BAT
g. Repeated examination increases the accuracy of diagnosis
II. Investigations:
a. All hemodynamically stable patients with suspected BAT should undergo Focused Abdominal Sonography in Trauma (FAST)or Diagnostic Peritoneal Lavage (DPL)
b. Urgent laparotomy is indicated in patients with evidence of BAT who remain hemodynamically unstable despite initial resuscitation
III. Treatment (Standard operating procedure):
a. Inpatient:

i. All patients should have initial cervical stabilization and resuscitation, if required
ii. Initial fluid resuscitation should be done with 2L warmed Ringer Lactate solution infusedrapidly through 2 peripheral lines
iii. A nasogastric tube and a Foley catheter should be put
iv. Laparotomy should be done, if indicated on the basis of clinical features, FASTor DPL
v. Laparotomy should be done through a long midline incision
vi. Bleeding should be controlled by clamping/ packing till definitive control is possible
vii. Hollow viscus should be repaired
viii. In case the intra-abdominal injuries are extensive, patient is very sick and OT facilities/ surgeon’s experience is suboptimal, Damage Control Surgery may be done. Definitive surgery should be done subsequently under improved circumstances or at a higher center.
b. Outpatient: Not indicated
c. Day care: Not indicated
IV. Referral criteria: After Damage Control Surgery if the local facilities are inadequate.
b. Situation 2 At Superspecialty Facility in Metro location where higher end technology is available
1. Clinical diagnosis: Same as 6a
2. Investigations:
a. Same as 6a
b. CECT abdomen is preferred investigation in all hemodynamically stable patients with BAT
c. Angiography and angioembolization may be considered in hemodynamically stable patients with solid organ injury who are suitable for non-operative management
3. Treatment (Standard operating procedure):
a. Inpatient:
i. Same as 6a
ii. In case the intra-abdominal injuries are extensive, patient is very sick and surgeon’s experience is suboptimal, Damage Control Surgery may be done. Definitive surgery should be done subsequently under improved circumstances
iii. Angiography and angioembolization may be considered in hemodynamically stable patients with solid organ injury who are suitable for non-operative management
b. Outpatient: Not indicated
c. Day care: Not indicated
4. Referral criteria: Not indicated
5
7. Who does what and timelines:
a. Doctor: Does initial evaluation, subsequent monitoring, decision regarding investigations and therapeutic intervention.
b. Nurse: Assists in resuscitation, monitoring, investigation and treatment.
c. Technician: Assists in resuscitation, investigation and treatment.
8. Further reading/ references
a. Udeani J, Steinberg SR. Blunt abdominal trauma. URL: http://emedicine.medscape.com/article/433404-print
b. Joint theatre Trauma System Clinical Practice Guideline: Blunt abdominal trauma.

c. M. Swarnkar, P. Singh & S. Dwivedi : Pattern Of Trauma In Central India: An Epidemiological Study With Special Reference To Mode Of Injury. The Internet Journal of Epidemiology.

 

By

Dr Sanjay Gupta
Professor, Department of Surgery
University College of Medical Sciences, Delhi

General Surgery

The Department of General and Minimally Invasive Surgery is a full-fledged healthcare facility providing complete evaluation, diagnosis, and surgical treatment for a wide variety of disorders. The department uses an integrated

approach to deliver superb care and compassion. In India uses the most advanced minimally invasive surgical innovations and technology to cure the patients.




Risk factor and Prevention of Cancer:

The old saying, “An ounce of prevention is better than a pound of cure”, holds true not only for infectious diseases but also for cancer.

Why cancer prevention is important?

Most cancers are lifestyle-related risk factors. In India, tobacco-related cancers account for 48% of the total cancer cases and cervical cancers form the bulk (36%) of cancers in females.

Primary Prevention

Primary prevention refers to a reduced or to eliminate exposure to carcinogens.

Primary prevention includes:

• Compulsory education about tobacco related cancers, unhealthy sexual habits and cancer preventive diet.

Modifiable cancer risk factors:

• Tobacco causes cancers at many sites. Alcohol consumption is associated with oral, oesophageal and other cancers;
• Obesity associated with increased risk of colon, breast and other cancers.
• Balanced mixed diet can prevent several cancers.

Chemoprevention

This includes the use of natural or synthetic substances to reduce the risk of developing cancer or its recurrence.

Eg: Selective oestrogen receptor modulators (tamoxifen), NSAIDs, (COX-2 inhibitors) for colon cancer, Retinoids (cis-retinoic acid) for primary cancers of the head and neck and Finasteride, an alpha-reductase inhibitor that can lower the risk of prostate cancer. Vaccines are used to prevent infection by oncogenic agents against hepatitis B for cancers of liver and Human papillomavirus (HPV) vaccine for prevention of Cervical Cancer.Genetic testing with BRCA1, 2 has lead to prophylactic oophorectomy and mastectomy for Breast & Ovarian Cancer, prophylactic colectomy in adenomatous polyposis gene mutation.

Diet and Cancer

Diet is one of the aetiological factors in carcinogenesis. Epidemiological studies (study done by Doll and Peto) have shown that 35% of cancers are associated with diet.

Fat present in red meat modifies DNA synthesis, alters the microflora and induces the production of oestrogens, associated with breast and colon cancers.

Micronutrients and cancer

Micronutrients – vitamins and minerals, non-nutrients such as proteins (legumes), monoterpenes (citrus fruits), polyphenoles (tea and spices) and allium (onion and garlic) have protective effects and prevent cancer. They act through metabolic, antioxidant, differentiation and immune modulation.

Dietary recommendations

• Increased intake of vegetables and fruits (minimum of five servings per day)
• Intake of 55% carbohydrates, <30% fats and 20-30g of fibre
• Avoidance of salt-cured and smoked food
• Limitation of alcohol.

Secondary prevention includes screening programmes.

Recommendations for the early detection in asymptomatic persons

Screening programmes are:

• Opportunistic, in which the population seeks medical professionals.
• Organized, in which medical professionals approach the public.

Neurosurgery (or neurological surgery) is the medical specialty concerned with the prevention, diagnosis, treatment, and rehabilitation of disorders which affect any portion of the nervous system including the brain, spinal cord, peripheral nerves, and extra-cranial cerebrovascular system.

Main divisions of neurosurgery

General neurosurgery involves most neurosurgical conditions including neuro-trauma and other neuro-emergencies such as intracranial hemorrhage. Most level 1 hospitals have this kind of practice.

Specialized branches have developed to cater to special and difficult conditions. These specialized branches co-exist with general neurosurgery in more sophisticated hospitals. To practice these higher specialization within neurosurgery, additional higher fellowship training of 1–2 years is expected from the neurosurgeon. Some of these divisions of neurosurgery are:

1. Vascular and endovascular neurosurgery
2. Stereotactic,functional and epilepsy neurosurgery
3. Oncological neurosurgery
4. Skull-Butt Surgery
5. Spine neurosurgery
6. Peripheral nerve surgery
7. Pediatric neurosurgery

Neuropathology

The pathology confronted by neurosurgeons could be either congenital, acquired, traumatic, due to infection, or neoplastic or degenerative conditions. Conditions like congenital hydrocephalus, pediatric tumors and myelomeningocele are encountered in children. Trauma with head or spine injury and bleeds due to arteriovenous malformation are encountered in young adults. Degenerative spine disease, aneurysm bleeds and Parkinson’s disease are encountered in much older patients. The science of neuropathology is a well developed branch of pathology.

Neuroanesthesia

Neuroanesthesia is a highly developed science that is linked to neurosurgery. This branch of medicine plays a very important part in day-to-day neurosurgery.

Neurosurgery methods

1. Vascular and endovascular neurosurgery.

2. Stereotactic, functional and epilepsy neurosurgery

3. Oncological neurosurgery

4. Skull- Butt surgery

5. Spine neurosurgery

6. Peripheral Nerve surgery

7.Pediatric neurosurgery

 

 

y plays a key role not only in diagnosis but also in the operative phase of neurosurgery.

Neuroradiology methods are used in modern neurosurgery diagnosis and treatment. They include computer assisted imaging computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), magnetoencephalography (MEG), and the stereotactic radiosurgery. Some neurosurgery procedures involve the use of intra-operative MRI and functional MRI.

In conventional open surgery the neurosurgeon opens the skull and uses a large opening to access the brain. Techniques of using smaller openings and using microscopes and endoscopes were developed later. With these smaller openings in conjunction with high-clarity microscopic visualization of neural tissue, excellent results can be obtained. However, the open methods are still used in trauma or emergency situations.^{[10] Principles of Neurosurgery-Rengachari, Ellenbogen}, ^{[11] Neurotrauma and Critical Care of the Brain-Jallo, Loftus} .’

Microsurgery is utilized in many aspects of neurological surgery. Microvascular techniques are used in EC-IC by-pass surgery and in restoration carotid endarterectomy. The clipping of an aneurysm is performed under microscopic vision. Minimally invasive spine surgery utilizes microscopes or endoscopes. Procedures such as microdiscectomy, laminectomy, and artificial disc replacement rely on microsurgery.^[5]

Using Stereotaxy neurosurgeons can approach a minute target in the brain through a minimal opening. This is used in functional neurosurgery where electrodes are implanted or gene therapy is instituted with high level of accuracy as in the case of Parkinson’s disease or Alzheimer’s disease. Using the combination method of open and stereotactic surgery, intraventricular hemorrhages can potentially be evacuated successfully.^[6]

Minimally invasive endoscopic surgery is commonly utilized by neurosurgeons when appropriate. Techniques such as endoscopic endonasal surgery are used in pituitary tumors, craniopharyngiomas, chordomas, and the repair of cerebrospinal fluid leaks. Ventricular endoscopy is used in the treatment of intraventricular bleeds, hydrocephalus, colloid cyst and neurocysticercosis. Endonasal endoscopy is at times carried out with neurosurgeons and ENT surgeons working together as a team.

Repair of craniofacial disorders and disturbance of cerebrospinal fluid circulation is done by neurosurgeons who also occasionally team up with maxillofacial and plastic surgeons. Cranioplasty for craniosynostosis is performed by pediatric neurosurgeons with or without plastic surgeons.

Neurosurgeons are involved in Stereotactic Radiosurgery along with Radiation Oncologists in tumor and AVM treatment. Radiosurgical methods such as Gamma knife, Cyberknife and Novalis Shaped Beam Surgery are used as well.

Endovascular Neurosurgery utilize endovascular image guided procedures for the treatment of aneurysms, AVMs, carotid stenosis, strokes, and spinal malformations, and vasospasms. Techniques such as angioplasty, stenting, clot retrieval, embolization, and diagnostic angiography are endovascular procedures.

A common procedure performed in neurosurgery is the placement of Ventriculo-Peritoneal Shunt (VP Shunt). In pediatric practice this is often implemented in cases of congenital hydrocephalus. The most common indication for this procedure in adults is Normal Pressure Hydrocephalus (NPH).

Neurosurgery of the spine covers the cervical, thoracic and lumbar spine. Some indications for spinal coed surgery include spinal cord compression resulting from trauma, arthritis of the spinal discs, or spondylosis. In cervical cord compression, patients may have difficulty with gait, balance issues, and/or numbness and tingling in the hands or feet. Spondylosis is the condition of spinal disc degeneration and arthritis that compresses the spinal canal. This can often result in bone-spurring and disc herniation. Power drills and special instruments are often used to correct any compression problems of the spinal canal. Disk herniations of spinal vertebral discs are removed by Kerrison pitiutary rongeurs. T

his procedure is known aa a discectomy. A laminectomy is the removal of the Lamina portion of the vertebrae of the spine in order to make room for the compressed nerve tissue. Radiology assisted spine surgery is a minimally-invasive procedure and includes the techniques of vertebroplasty and kyphoplasty in which certain types of spinal fractures are managed.

Surgery performed in order to produce spinal analgesia are also often performed by neurosurgeons. Some of these techniques include implantation of deep brain stimulators, spinal cord stimulators and pain pumps.

Surgery of the peripheral nervous system is also possible, and includes the very common procedures of carpal tunnel decompression and peripheral nerve transposition. Numerous other types of nerve entrapment conditions and other problems with the peripheral nervous system are treated as well.

 

 

 

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