Gastrointestinal Surgery & Bariatric Surgery PDF

Gastrointestinal Surgery : Part 2 81 GASTROINTESTINAL SURGERY : PART 2 ----- Active space ----- Bariatric Surgery 00:00:50 Indications :...

Gastrointestinal Surgery : Part 2 81 GASTROINTESTINAL SURGERY : PART 2 ----- Active space ----- Bariatric Surgery 00:00:50 Indications : Types : 1. BMI >40 kg/m2. Bariatric surgery 2. BMI >35 kg/m2 with obesity complications. M/c Sle%ve gastrectomy 3. Asian population : Lower cutoff for Sx. Most Roux-en-Y gastrojejunostomy ac&eptable OS-MRS (Obesity Surgery - Mortality Risk Score) : Maximum Duodenal switch/ The risk factors : weight loss Biliopancreatic diversion. a. Arterial hypertension. Reversible Gastric banding & intragastric b. Age >45. Sx ballo(n placement. c. Male gender. d. BMI >50kg/m2. e. Risk for pulmonary thromboembolism. Diabetes mellitus is not part of the criteria. Irreversible Procedures : 1. Biliopancreatic diversion (BPD) & Duodenal switch (DS) : Common channel : Maximum weight loss (D/t malabsorption). - Biliopancreatic switch : 50 cm. Disadvantage : Maximum surgical - Duodenal switch : 100 cm. complications. BPD DS Surgery Revision v4.0 Marrow 8.0 2024  82 Surgery ----- Active space ----- 2. Roux-en-Y gastrojejunostomy : Roux limb length : 100 cm. a Nutritional deficiencies : - Iron (M/c). - Vit D3/Ca2+ - Vit B12 3. Lap. Sle%ve gastrectomy : M/c done procedure. Restrictive surgery : Greater curvature of stomach is removed. Complications : i. M/c : Ble%ding from staple line. i). Nutritional deficiencies. i)i. Leak from angle of His. (Most distressing Peritonitis). iv. Redistension of sle%ve (Mx : TOGA). Sle%ve gastrectomy TOGA (Transoral gastroplasty) Reversible Procedures : 1. Gastric banding : Band placed 6cm from the GE junction. Reversible pressure adjustable ballo(n Weight loss can be titrated. Complications : i. Prolapse (M/c) i). Nutritional complications. i)i. Erodes into stomach. iv. Rupture. Gastric banding Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 83 2. Intragastric ballo(n placement : ----- Active space ----- Ballo(n is distended in the stomach. Removed after weight loss is achieved. Self dissolvable ballo(n : Dissolves after 3 months. Features Of Bariatric Sx : M/c cause of death : DVT Pulmonary embolism. AKA metabolic surgery : Weight loss + Improvement in DM/HTN/hyperlipidemia. Nutrient replacement : - Iron - Vit B12 - Vit D3 & Ca2+ - Fat soluble vitamins : In sle%ve gastrectomy & Roux-en-Y bypass. Mesenteric Cyst 00:09:35 IOC : CECT. Tillaux Triad : 1. Periumbilical swelling. 2. Tillaux sign : Swelling moves at right angle to attachment of mesentery. 3. Transverse band of resonance. Types : Chylolymphatic cyst (M/c) Enterogenous Tissue Sequestered lymphatic tissue Sequestered bowel tissue Cyst wall Thin Thick Fluid Clear Turbid Blo(d sup+ly Independent Shared with bowel Rx Enucleation Resection & anastomosis Upper GI Hemorrhage 00:11:01 Ble%ding proximal to ligament of Treitz. Causes : 1. Non-variceal ble%ding (M/c) : - Peptic ulcer (M/c) : Duodenal > Gastric. - Mallory Weiss tear. - Gastritis. 2. Variceal ble%ding. Surgery Revision v4.0 Marrow 8.0 2024  84 Surgery ----- Active space ----- Gastritis types : Gastritis Features Autoimmune gastritis (Auto-ab against parietal cells). Type A Antral sparing, pernicious anemia, achlorhydria. Type B H. pylori induced (Affects antrum). Cushing’s ulcer : In head injury, involves the stomach. Stress induced Curling ulcer : In burns, involves first part of duodenum. NSAIDS Due to chronic use. AIDS D/t cryptosporidium. Mallory Weis# Tear : Longitudinal tear in mucosa/submucosa (GE junction Cardia). M/c in alcoholics : After a bout of forced vomiting. Vessel : Left gastric artery. Rx : Self limiting. D/D : Boerha,ve syndrome Mallory weiss tear GAVE (Gastric Antral Vascular Ectasia) : Se%n at antrum. Autoimmune. Endoscopy : Watermelon stomach. (D/t dilated venules) Mx : Argon photocoagulation. Watermelon stomach Portal Gastropathy : Se%n in portal hypertension. Endoscopy : Strawber-y stomach (Red.ish nodules) Strawber-y stomach Menetrier’s Disease : Hypertrophy of gastric mucosal folds d/t overexpression of TGF α. ↑Risk of cancer. C/f : Protein losing enteropathy (Earliest). Up+er Gı hemor-hage. Mx : Hypertrophied folds Cetuximab (Monoclonal ab against EGFR) Fails Gastrectomy (Severe cases). Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 85 Portal Hypertension : ----- Active space ----- Variceal cause of up+er GI ble%ding. Dop+ler (Diagnosis) : Hepatic Venous Pressure Gradient (HVPG). Measurement Significance 1-5 mm Hg Normal 6-10 mmHg Preclinical sinusoidal portal HTN /10 mm Hg Clinically significant portal HTN Variceal formation /12 mm Hg ↑Risk for rupture of varices Porto-systemic shunts: 1. Left gastric + short gastric veins Distal esophgeal veins. 2. Left gastric/gastroepiploeic vein Esophageal/paraesophageal veins. 3. Caput medusae : Periumbilical. 4. Rectum. 5. Bare area of liver (Segment 7). Caput medusae C/f : Up+er GI ble%ding. Ascites. Splenomegaly. Signs of liver failure. Management : Ble%ding Note : 1. Airway Mx : To prevent aspiration. ABC management 2. IV Pantoprazole : Given after endoscopy. 1V drugs : Best : 1V terlipressin M/c used : 1V octreotide Not used : 1V propranalol Patient stabilised Up+er GI endoscopy : Banding (M/c) > Sclerotherapy (Sodium tetradecyl sulphate) Assess ble%ding Controlled Uncontrolled 24hr observation 2nd attempt at UGI-scopy Normal Fail Discharge on oral propranolol Sengstaken blakemore tube Prepare for TIPS0 Surgery Revision v4.0 Marrow 8.0 2024  86 Surgery ----- Active space ----- For temporary control of ble%ding (Until patient is ready for TIPS0) : Sengstaken Blakemore tube Minnesota tube Linton tube 3 channels, 2 balloons 4 channels, 2 ballo(ns 3 channels, I ballo(n Gastric Esophageal Transjugular Intra-hepatic Portosystemic Shunt (TIPS0) : Shunt b/w portal vein & hepatic vein. Non-selective (Splenic & bowel blo(d are both shunted). Complications : a. Rupture of capsule : Earliest. b. Blocked Reble%ding : M/c. c. Encephalopathy : D/t nonselective shunt. Other shunts : Selective Non selective War-en : Distal splenorenal shunt. Linton : Proximal splenorenal shunt. Inokuchi : Left gastric venocaval shunt. Eck fistula : Portocaval shunt. Advantage : Shunts only splenic blo(d. Risk of encephalopathy Avoids encephalopathy. Scoring systems : 1. Rockall’s score. 4. For-est’s classification : Prognostic scores 2. BLE1D criteria. - For peptic ulcer ble%ding. 3. Child Pugh Turcotte score. - Endoscopic assessment. Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 87 For-est’s classification : ----- Active space ----- Classification Description Acute hemor-hage (High risk) Class la Spurting hemor-hage Class Ib Oozing hemor-hage Signs of recent hemor-hage Class Ila (High risk) Non ble%ding visible vessel Class 1lb (Intermediate risk) Adherent clot Class I2c (Low risk) Flat pigmented spot Lesions without acute ble%ding Class I11 (Low risk) Clean ulcer base Bowel Obstruction 00:24:52 Cardinal Features : Non passage of flatus Distention & faeces (Obstipation). Abdominal pain. Vomiting. Investigations : 1. X-ray abdomen erect & supine : Initial Ix. Air fluid levels (>3) 2. CECT : IOC in adults. 3. USG : IOC in children. X-ray Features : 1. Erect x- ray : >3 air fluid levels. 2. Supine x-ray : Site of obstruction Features Feathery ap+earance. Jejunum Valvulae conniventes (Concertina effect). Concertina effect Ileum Featureless (Lo(ps of wangenste%n). Large bowel Incomplete haustrations. Management of Bowel Obstrution : 1. NPO 4. Ryle’s tube insertion. 2. 1V fluids 5. Sx : Emergency laparotomy. 3. IV antibiotics & painkillers. Incomplete haustrautions Surgery : Distended : Large bowel obstruction. Caecum is visualised 1st Collapsed : Small bowel obstruction. Surgery Revision v4.0 Marrow 8.0 2024  88 Surgery ----- Active space ----- Intus#usception : Telescoping of one bowel lo(p into another. (Intussuscipiens : Receiving lo(p, Intussusceptum : Lo(p going inside). Types : Primary Secondary Age group 6 months - 2yrs Adults 2˚ to pathological lead point : Hypertrophy of Polyp (M/c). Trig3er peyer’s patches Diverticulum. Cancer. Ileocolic (M/c). Red cur-ant jelly sto(ls. Features - Sign of dance : Empty RIF (Lump is in lumbar region). Colon Intussuscipiens : Receiving lo(p Intussusceptum : Lo(p going inside Ileum Neck Caecum Investigations : 1. X-ray abdomen : Erect & supine (Initial). Note : IOC. 2. USG : Target/Donut/Pseudokidney sign. In children : USG. 3. Contrast enema : Pincer/claw sign. In adults : CECT. - Diagnostic & therapeutic. - C/I : Perforation, recur-ence or 2˚ to pathological lead point. Target/donut sign Pseudokidney sign Pincer claw sign Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 89 Sigmoid Volvulus : ----- Active space ----- Pre-disposing factors : Long & nar-ow mesentery. Redundant sigmoid. Loaded sigmoid. Commonly se%n in patients : Coffe% bean sign (Dilated large bowel) On antipsychotic meds. With constipation. Rotation : Anticlockwise > Clockwise. Erect X-Ray abdomen D/D coffe% bean sign : Sigmoid volvulus Caecal volvulus Apex Points towards Rt Shoulder. Towards Lt shoulder. Large Collapsed. Dilated. bowel Note : Small bowel dilated. Management : Contrast Enema : Stable, no peritonitis : Unstable, peritonitis Bird’s beak ap+earance Sigmoidoscopic decompression (Flatus tube) Hartmann’s procedure : 1. Resect perforated Definitive surgery : segment. Sigmoidectomy. 2. Proximal colostomy. 3. Distal end closed and kept inside. Intestinal Structure : Causes : 1. Cancer. 2. Post radiotherapy. 3. TB. 4. Crohn’s disease. Mx : Heinke’s stricturoplasty 1. Strictures are close : Resection & anastomosis. 2. Strictures are far apart : Heinke Mikulicz stricturoplasty. Surgery Revision v4.0 Marrow 8.0 2024  90 Surgery ----- Active space ----- Meckel’s Diverticulum : Remnant of vitellointestinal duct. Present along the antimesenteric border. True diverticulum : All layers + Independant blo(d sup+ly : Safe resection possible. Rule of 2 : 2% of population, 2 inches long, 2 fe%t from ileocolic junction. Meckel’s diverticulum Vitellointestinal Duct Abnormalities : Vitelline vessel remnant 1. Completely patent : 2. Fibrous band formation : Leads to volvulus Fecal discharge 3. Patent umbilical end : 4. Ileal end patent : Umbilical cyst/polyp Purulent discharge ± Meckel’s diverticulum. Duodenal Atresia : Common in Down’s syndrome. C/f : Billious vomiting since birth. D/D : CHPS. X-ray : Double bub4le sign. S Mx : Duodenoduodenostomy. D J Jejunal Atresia : X-Ray : Triple bub4le sign. Double bub4le sign Triple bub4le sign (S : Stomach, D : Duodenum, J : Jejunum) Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 91 Adhesive Intestinal Obstruction : ----- Active space ----- M/c cause of small bowel obstruction (Dynamic). Causes : 1. Post surgery (M/c). 2. Non-surgical causes : - Crohn’s disease. - Endometriosis - PID - Cancer - TB IOC : CECT. Mx : Conservative for 48-72 hours Fails Surgery (Adhesiolysis). Superior Mesenteric Artery Syndrome : Normal angle b/w aorta & SMA : 25-45˚. Angle 7 : Likely ap+endicitis Tenderness in right lower quadrant 2 Rebound pain 1 Elevated temperature 1 Leukocytosis 2 Left shift of WBC 1 Possible total 10 Investigations : 1. CECT : IOC in adults. 2. USG : IOC in children. - Blind ending tubular structure. - Probe tenderness. - Periap+endiceal fluid collection. USG Surgery Revision v4.0 Marrow 8.0 2024  94 Surgery ----- Active space ----- Mangement (Appendicectomy) : Do not crush the base. Inflamed base Bury with purse string suture. Gangrenous base : Right hemicolectomy. Ap+endix not inflamed : Rule out meckel’s diverticulum (Distal 2 fe%t of ileum). Appendicectomy 00:52:38 Incisions Used : 1. McBurney’s incision : - Grid iron : Muscle splitting. - Rutherford mor-ison : Muscle cutting. 2. Lanz/skin crease/bikini incision : Better cosmesis. 3. Lower midline abdominal incision : For perforated ap+endix. Note : Gibson’s incision Renal trasplant (Above inguinal ligament) (To identify ureter) Structures Pas#ed : 1. Skin 2. Superficial fascia. 3. External oblique aponeurosis. 4. Muscles 5. Peritoneum Complications : 1. Wound infection (M/c). 2. Ble%ding. 3. Portal pyemia. 4. Stump ap+endicitis (If stump >4mm). Lap. ap+endicectomy Other Conditions Of Appendix 00:55:09 Appendicular Perforation : Omentum dysfunction. Se%n in : - Children - Pregnant females. - Elderly - Immunocompromised patients. - Adhesions Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 2 95 Appendicitis in Pregancy : ----- Active space ----- M/c non obstetrical emergency. ↑ Risk of preterm labor/abortions. C/f : Pain in RIF (Can be higher up also). Ix : USG if uncomfirmed MRI. Mx : Lap. ap+endicectomy in all trimesters. Appendicular Lump : Mx : Ochsner-Sher-en regime (Conservative). Monitor : Mx : Size of lump. NPO. Tenderness. IV fluids Temperature. IV antibiotics. Pulse rate. Analgesics. Outcomes Recovers : Deteriorates (↑Pain, fever & lump size) : Discharge. Suspect abscess. Interval ap+endicectomy Extraperitoneal drainage after 6 we%ks. (Pigtail catheter). Tumours Of Appendix 00:58:13 Neuroendocrine Tumour (NET) of Appendix : M/c tumour of ap+endix (AKA carcinoid of ap+endix). M/c site : Tip of ap+endix. C/f : Pain & ap+endicitis. May be detected incidentally. Mx : 1. Close to the base & >2 cm : Right hemicolectomy. 2. Close to the tip & 25 g/L). 6. Low output fistula (500 mL/day. Management : + Spontaneous closure Conservative Mx. - SNAP protocol Skin care, sepsis control. Nutrition. Anatomical delineation (Imaging). Plan&ed surgery. Prognostic grouping : I II III Degre( of complexity of fistula Low Intermediate High Mortality Low 10 - 25% >25% Early surgical Late surgical Rx goals Spontaneous closure closure closure Surgery Revision v4.0 Marrow 8.0 2024  98 Surgery ----- Active space ----- Short Bowel Syndrome 00:06:21 Definition : Left (SMA > IMA). Diverticulitis. Colorectal cancers. Diverticulitis : Clinical features : Left lower quadrant pain. Diarrhea. Fever. Diverticulitis with abscess Raised TLC. Hinchey staging system : Based on CECT (IOC). Stage Features Management I Colonic inflammation with pericolic abscess Pigtail catheter II Colonic inflammation with pelvic abscess III Purulent peritonitis Laparotomy + Hartman& IV Fecal peritonitis procedure Note : Barium enema/colonoscopy is avoided d/t ↑ risk of perforation. Angiodysplasia 00:11:32 Features : 2nd m/c cause of lower GI ble(d. Dilated arterioles +. M/c site : Caecum. Clinical features : Se(n in elderly (5th - 6th decade). Heyde syndrome : Angiodysplasia + Aortic stenosis. Angiodysplasia Management : Investigation : Colonoscopy. Capsule endoscopy. Treatment : Coagulation/cauterisation. Capsule endoscopy Surgery Revision v4.0 Marrow 8.0 2024  100 Surgery ----- Active space ----- Inflammatory Bowel Disease 00:12:28 Crohn’s disease Ulcerative colitis 20-40 years Age Bimodal peak 25 - 40 years 70 years Sex F>M M>F Smoking ↑ Risk Protective Gene NOD 2/CARD 15 - Any portion : Lips to anus Skip lesion + Rectum Pancolitis Backwash ileitis Anal involvement is common Continuous lesion Relative rectal sparing Anal involvement uncommon Features Transmural involvement : ↑ Risk of toxic megacolon - Strictures Mucosal/Submucosal - Colovesical/colovaginal fistulae involvement Pseudopolyps Creeping fat Non-caseating granuloma Mimics acute appendicitis Blo%dy diarrhea Clinical features Abdominal pain + diarrhea Toxic megacolon Diagnosis Biopsy Radiological sign String sign of Kantor : Toxic megacolon (Diameter >6 cm) Terminal ileum stricture Also seen in TB ↑ Risk of perforation Medical Mx Steroids + S-ASA derivatives Conservative resection Total proctocolectomy + ileoanal pouch Surgical Mx (↑Resection Short bowel syndrome) anastomosis (IAPA) Extraintestinal Manifestations : Indications for Sx : 1. Erythema nodosum. 1. Not responding to medical mx. 2. Primary sclerosing cholangitis. 2. Steroid toxicity. 3. Episcleritis, uveitis. 3. Complications of IBD. 4. Ankylosing spondylitis (A/w HLA B27). 4. Extraintestinal manifestations. Note : Conditions which do not improve on surgery. Primary sclerosing cholangitis. Ankylosing spondylitis. Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 3 101 Colonic Polyps 00:17:57 ----- Active space ----- Types : 1. Inflammatory : Ulcerative colitis Pseudopolyps. 2. Hamartomatous : Seen in Peutz Jegher syndrome. Types : - Single juvenile polyp : Not premalignant. - Juvenile polyposis : ↑Risk of cancer. 3. Adenomatous polyp : ↑Risk of cancer. Inflammatory pseudopolyps Peutz Jegher’s Syndrome : Gene : STK 11 (chr 19). M/c location : Jejunum. Increased risk of : - Pancreatic cancer (100x). - Duodenal cancer. - Thyroid cancer. - Colonic cancer. Perioral melanosis Clinical features : M/c presentation : Intus&usception. Pathognomonic finding : Perioral melanosis. HPE : Arborising pattern. Arborising pattern Adenoma Carcinoma Sequence : Normal mucosa APC Hyperproliferative Early adenoma K-RAS Intermediate epithelium adenoma DC( (Chr 18) AK53 Late adenoma First hit : APC p53 Last hit : p53 Carcinoma. Surgery Revision v4.0 Marrow 8.0 2024  102 Surgery ----- Active space ----- Haggit Classification : For cancer in a polyp. Ses&ile polyp : Starts at level 4. Pedunculated polyp : Includes levels 0 to 4. Familial Adenomatous Polyposis (FAP) : Autosomal dominant APC gene mutation (Chr 5). Pathognomonic finding : >100 adenomatous polyps (100% risk of cancer). Haggit clas&ification M/c site : Rectum. Surgery : Total proctocolectomy + 1APA. Variant As&ociated with FAP Sebaceous cysts Gardner syndrome Osteomas Desmoid tumour FAP CNS tumours : Turcot’s syndrome - Gliomas - Medul)oblastomas Familial Adenomatous Polyposis (FAP) Screening : Genetic counsel)ing + Testing for 1st degree relatives If mutation + Screening from age 10 yrs : Sigmoidoscopy. MUTYH Associated Polyposis : Similar to FAP. Autosomal reces&ive APC mutation not identified. Multiple colonic polyps. 3-6x risk of cancer. Surveil)ance for duodenal adenomas : 2 year colonoscopies. HNPC# : Hereditary non-polyposis colonic cancer syndrome. Defect in mismatch repair genes (MLH, MSH). Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 3 103 Modified Amsterdam criteria : ----- Active space ----- 1. Rule out FAP. 2. At least 3 relatives af+ected by HNPC( tumours of which at least I should be a first degree relative. 3. 2 consecutive generations af+ected. 4. At least one should develop tumours at Rectosigmoid > Sigmoid. Screening : Starts : 50 years of age. If Family history + : 10 yrs before diagnosis of youngest relative. Modalities : Colonoscopy Sigmoidoscopy FOBT Duration Every 10 years Every 5 years An,ual)y 110 - 140 cm (Rectum Length of scope 60 - 90 cm - to caecum visualised) Virtual colonoscopy : CECT f/b 3D reconstruction. Used for screening. Advantages : - Better extracolonic details. - Better patient compliance. virtual colonoscopy Disadvantage : Mucosal details are not wel) appreciated. Investigations of Choice : Diagnosis : Colonoscopic biopsy. Staging : PET-CT. T & N staging for rectal Ca : MRI with endorectal coil. Apple core deformity Surgery Revision v4.0 Marrow 8.0 2024  104 Surgery ----- Active space ----- Presentation : Right sided CRC Left sided CRC An,ular growth Ulcero-proliferative growth Bleed Altered bowel habits Early onset Iron deficiency anemia Bowel obstruction Apple core deformity (Radiology) Duke’s Staging : Depends on depth of the tumour. A : Mucosa + Submucosa involved. B : Muscle involvement with no LN. Mucosa BI Into muscle layer. Submucosa B2 Beyond muscle layer. A B1 C1 C : Muscle involvement with LN positive. B2 C2 Cl Into muscle layer. C2 Beyond muscle layer. Muscle D : Distant metastasis. Serosa Management : Surgery : Colectomy. A. Right hemicolectomy B. Extended right hemicolectomy Lesion in caeum Half of transverse colon removed Structures removed : - Terminal ileum : 10-12 cm - Ascending colon - 1/3rd of transverse colon C. Transverse colectomy D. Left hemicolectomy Only Traverse colon removed completely Lesion in splenic flexure Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 3 105 Surgery in rectal lesions : ----- Active space ----- Tumour location Procedure Structures removed Low Anterior Resection (LAR) > 5 cm from Rectum + anal verge Part of sigmoid Colo-anal anastamosis (Sphincters spared) Abdomino-Perineal Resection (APR) Rectum < 5 cm from + Anal canal anal verge Permanent end colostomy (Sphincters cut) Part of sigmoid LAR APR Plane of dis&ection for LAR/APR : B/w neurovascular bundle of prostate & Sacrum. Total mesorectal excision : To remove lymph nodes. Complications of surgery : Plane of dis&ection Nerve injured Procedure Clinical features Superior hypogastric High IMA ligation Retrograde ejaculation plexus or it’s branches Division of lateral stalks Erectile dysfunction, Pelvic plexus close to pelvic sidewal) impotence, atonic blad-er Periprostatic plexus Anterior dis&ection Sexual & blad-er dysfunction TaTME : Transanal total mesorectal excision. Type of NOTES procedures. Done in early rectal cancers (T1, T2). Anal Carcinoma : Usual)y SC(. Mx : Nigro’s regime x 1 month (Combined chemoradiation). If residual disease/recurrence + Surgery : APR. TaTME Surgery Revision v4.0 Marrow 8.0 2024  106 Surgery ----- Active space ----- Pilonidal Sinus 00:34:43 Features : Management : Sinus/absces& in natal cleft. Excision Rhomboid/Limberg flap. D/t ingrowing of hair. Bascom’s technique. Seen m/c in hairy men. Kardayakis surgery. AKA jeep driver’s disease. Pilonidal sinus Rhomboid flap Hemorrhoids/Piles 00:35:54 Dilated vascular chan,els Bleeding from sinusoids. M/C cause of bleeding P/R. 1° hemorrhoids location : 3,7, 11 o’ clock. Clinical Features : Painles& bleeding P/R. Constipation. Painful if : External hemorrhoids - External (Below dentate line). - Thrombosed hemorrhoids/Meleney’s 5 day self healing lesion : Felt on DRE. Investigation : IOC : Proctoscopy. Proctoscopy Thrombosed piles Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 3 107 Grades & Management of Piles : ----- Active space ----- Grade Description Management 1. High fibre diet + ↑ fluid intake I Only bleeds; no prolapse 2. Laxatives 3. Sitz bath I. Prolapse but spontaneously reduces Grade I Mx + Banding/Sclerotherapy I.I Prolapse ; Have to be pushed inside 1. Hemorrhoidectomy : - Open : Mil)igan morgan - Closed : Ferguson IV Remains prolapsed 2. Stapled hemorrhoidopexy : TOC 3. DGHAL (Doppler guided hemorrhoidal artery ligation) Open hemorrhoidectomy : Banding (Barron’s band) Hemorrhoid resection wound left open Complications of Hemorrhoid Surgery : 1. Urinary retention (M/c). 2. Reactionary hemorrhage. 3. Pain. 4. Stenosis. 5. Incontinence. 6. Recurrence. Stapler hemorrhoidopexy Anal Fissure 00:40:07 Breach in epithelium, M/c site : Posterior midline. Clinical Features : 1. Painful bleeding P/R. 2. Constipation. 3. Skin/Sentinel tag + (Chronic anal fis&ure : >4 weeks). Chronic anal fis&ure Surgery Revision v4.0 Marrow 8.0 2024  108 Surgery ----- Active space ----- Management : 3. Local xylocaine, C(B cream. IOC : External inspection (DRE is C/I). 4. Surgery : If medical mx fails. Rx : - Lateral anal sphincterotomy. 1. Lifestyle changes. - Anal advancement flap. 2. Laxative. Rectal Prolapse 00:41:30 Types : Partial thicknes& Ful) thicknes&/complete Mucosal prolapse Al) layers prolapse Common in children Common in adults D/t incomplete sacral curve D/t weak pelvic flo%r Partial prolapse Complete prolapse Management : Partial thicknes& prolapse : First episode : Digital repositioning. Recurrent : - Thiersch wiring. - Sclerotherapy. Complete thicknes& : Perineal procedures Abdominal procedures Easy to perform Dif+icult to perform Les& complications ↑↑ complications High recurrence rate Least recurrence rate 1. Thiersch repair : Purse string sutures 1. Ripstein rectopexy 2. Delorme’s repair : Plication of prolapse 2. Weil rectopexy 3. Altemier : Perineal rectosigmoidectomy 3. Goldman Frykberg : Resection rectopexy Surgery Revision v4.0 Marrow 8.0 2024  Gastrointestinal Surgery : Part 3 109 ----- Active space ----- Thiersch wiring Delorme’s repair Rectopexy Anorectal Malformations 00:44:20 Level of anomaly Male Female High Rectovesical fistula Rectovaginal fistula Low Anal stenosis Anal agenesis Miscel)aneous - Persistent cloacal anomaly A/w other malformations : VACTRL. Invertogram : Done 24 hours after birth. Patient is inverted Metal)ic marker is placed at anal opening X-ray taken Distance b/w gas bub/le & marker measured : - 2 cm : High anomaly. Invertogram Note : MRI is IOC. Mx : Surgery to bring the rectum down. Anorectal Abscess & Fistula 00:46:31 Forms close to the dentate line Source of infection : Anal glands. Perianal Abscess : C/f : Pain & fever. Mx : Incision & drainage. Complication : Perianal fistulae. Perianal absces& Surgery Revision v4.0 Marrow 8.0 2024  110 Surgery ----- Active space ----- Perianal Fistula : Complication of improperly managed perianal absces&. Clinical features : Pus discharge P/R. Go%dsal)’s rule : Imaginary line drawn through the anal verge. Fistulae anterior to the line Straight tracts. Fistulae posterior to the line Curved tract. Exception : Long anterior fistula (>3 cm). Go%dsal)’s rule Park’s clas&ification : Watercan perineum : IOC : MR fistulogram. Multiple perianal fistulae. Causes : Crohn’s disease. Trauma. TB. Cancer. Immunocompromised patient. Types of fistulae (M/c) Sphincter High Management : Low 1. Low fistulae : - Fistulectomy/Fistulotomy. Based on internal opening : Above anorectal ring : High. - LIFT (Ligation of fistulous tract). Below anorectal ring : Low. - VAFT (Video as&isted fistula therapy). 2. High fistulae : Seton’s procedure (↓Chance of incontinence). Surgery Revision v4.0 Marrow 8.0 2024