Professional Documents
Culture Documents
Chief Editor
Michael Cotton
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The cover illustration attempts to show (with some artistic licence) the maldistribution of surgeons around the world, depicted with the famous Gall-Peters
projection which better demonstrates land mass than the more traditional Mercator projection.
So, here you are, one of our readers, faced with the difficult problem of knowing what you do to help a surgical patient in all these fields, and unable to refer him to
an expert. Reading from the top left in a clockwise direction you may need to be: a plastic surgeon, a neurosurgeon, a thoracic surgeon, a GI surgeon, an ENT
surgeon, a vascular surgeon, a paediatric surgeon, an obstetrician and gynaecologist, a urologist, a proctologist, an orthopaedic surgeon, a hand surgeon,
a maxillofacial surgeon, and an ophthalmic surgeon.
This drawing does not include your role as a trauma surgeon, a dental surgeon, a leprosy surgeon, an HIV specialist, an oncologist, an
anaesthetist, and an 'intensivist', in addition to doing everything else you have to do in medicine, paediatrics, psychiatry, and management!
We hope these manuals will help you in some of these varied and exacting tasks.
Remember though the famous wise words of the London surgeon, Sir Astley Cooper:
“A surgeon should have an eagle’s eye, a lady’s hands and a lion’s heart”.
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Primary Surgery
Volume One: Non-Trauma (Second edition)
Editors
Copy Editor.
MINA LAHLAL, MD, Mag.a (Intl. development)
Tropeninstitut & Department of Development Studies, University of Vienna, Austria,
Visiting Lecturer, CapaCare Surgical Training Programme, Masanga Hospital, Sierra Leone,
Former Emergency Medical Services Programme Team, WHO Barcelona, Spain.
Illustrations Editors.
THOMAS EGLSEDER, MD, Facharzt Allgemeinchirurgie, Klinikum Ludwigsburg, Germany.
BÄRBEL BINDING, MD, Former Facharzt Allgemeinchirurgie, Missionsärztliche Klinik Wurzburg, Germany.
ARTHUR E. COTTON, BSc Hons, BMBS, St Thomas’s Hospital, London, UK.
FELIX RIESE, Technische Hochschule Aachen, Germany.
JULIUS ECKE, Medizinische & Wissenschaftliche Illustration, Germany.
(with grateful acknowledgement to the huge work of previous illustrators whose work has given the book its unmistakeable look and feel)
mikeytha@gmail.com
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FOREWORD
When Michael Cotton invited me to write the Foreword to this second and significantly changed edition of
Primary Surgery, I was delighted, and I have three reasons.
First, I greatly respected Michael’s work as a front line surgeon and a most dedicated teacher of surgery
during his many years in Bulawayo, Zimbabwe. I was often asked by colleagues in training where they
should go to learn operative surgery in Africa; Michael was always the one who came to mind first,
because I knew that he would take the trouble to teach sound, careful and relevant surgery. I knew also that
his colleagues would be working with a man of resolute integrity. This book is the expression of all his work
as a surgeon at the front line; it was a further delight when I found that he had recruited Olive Kobusingye to
be his assistant editor. I have been with Olive on take-in evening ward rounds at Mulago Hospital. Kampala;
I witnessed team work, clear thinking and the practice of excellent clinical surgery. Thus this book has
editors who have been proved as teachers and surgeons.
My second reason for delight is that the book will be a real help to those who have to practise surgery at the
front line. For too long such colleagues, whether surgical clinical officers or medical officers, have not had a
book which was written for them, to enable them to treat rural patients, the injured and those who are unable
to meet the costs of travel to, and accommodation at, a regional or national teaching hospital. I believe that if
the book’s sound common sense and clear practice are followed, the victims of injury will be treated early
and acute emergencies will be dealt with before they progress and complications develop. Patients will thus
be able to get back to work and families will not suffer socially and economically.
Finally, I am certain that, where good life-saving and worker-restoring surgery is done, people who may have
been afraid to bring their family member to hospital will lose that fear. Good surgery will be a great advocate
and foundation for the public health of a community, now assured that disease and injury which previously
could not be treated is not only treated but treated successfully. Surgery will no longer be forgotten by the
administrators and those who are responsible for providing a nation’s health service; it will take its rightful
place in health care. This book, properly used, will help to accomplish this and will be blessed by many
whose surgical needs have been met by the skills which it has helped to develop. I wish it well as I
confidently expect its readers to enjoy successful and fulfilling primary surgical practice.
Eldryd Parry, OBE, Visiting Professor & Honorary Fellow, London School of Hygiene and Tropical Medicine.
Chairman, Tropical Health Education Trust.
Formerly Professor & Dean of Medicine, Accra, Ghana; Addis Abeba, Ethiopia; and Ibadan, Nigeria.
DEDICATION
This book is dedicated to the world’s poor, so that when they need surgical help, they may get it, and it may
be done well.
ACKNOWLDGEMENT
Financial support for the initial collating of material for this edition was gratefully received from:
Asche Chiesi GmbH, Gasstrasse 6, 22761 Hamburg, Germany,
Deutsche Gesellschaft für Tropenchirurgie e.V. (German Society for Tropical Surgery), Erlangerstr 101, 07747 Jena, Germany.
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You must be humble; surgery is a craft that makes use of the scientific method of Popperian falsification.
The art of surgery consists of judgment and the beauty of an operation well done, done gently, with respect
for living tissue, for every cell, with reverence for form and function, carried out with compassion, always
remembering that the only justification for invading the body of another individual is the intent to restore
homeostasis.
Imre JP Loefler, Surgery in the Post-Colonial World (Rahima Dawood Oration).
E & Centr Afr J Surg 2002; 7(1): 53-8.
No person is so perfect in knowledge and experience that error in opinion or action is impossible.
In the art of surgery, error is more likely to occur than in almost any other line of human endeavour;
and it is in this field that it should be most carefully guarded against, since incorrect judgement,
improper technique, and a lack of knowledge of surgical safeguards may result in a serious handicap for the
rest of the life of the patient, or may even result in the sacrifice of that life. For the surgeon, perfection in
diagnostic skill is of equal, if not more, importance than operative skill.
Max Thorek, Surgical Errors and Safeguards in Surgery, JP Lipincott, USA. 1960
Any doctor who has worked in a developing country will not easily forget the widespread and pathetic
evidence of surgical neglect in the villages. Huge hernias and hydrocoeles, unsightly lumps on the faces of
women and children, and the compound fractures infected with maggots bear testimony to the failure of so
many countries to provide even a basic level of surgical care for their people.
Samiran Nundy, How might we improve surgical services for rural populations in developing countries?,
BMJ 1984; 39(10): 71-2.
Patients should be treated as close to their homes as possible in the smallest, cheapest, most humbly staffed,
and most simply equipped unit that is capable of looking after them adequately.
Maurice King, Medical Care in Developing Countries, Symposium from Makerere, Uganda. OUP 1967.
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Chapter 8 Pus in the hands and feet 139 Chapter 13 The stomach and duodenum 243
8.1 The infected hand. 13.1 Peptic ulcers.
8.2 Subcutaneous hand infection. 13.2 Oesophagogastroduodenoscopy (OGD).
8.3 Apical finger space infection. 13.3 Perforated gastric or duodenal ulcers.
8.4 Paronychia. 13.4 Bleeding from the upper gastrointestinal tract.
8.5 Finger pulp space infection. 13.5 Surgery for a bleeding peptic ulcer.
8.6 Infection on the volar surface of the middle or proximal phalanx. 13.6 Hypertrophic pyloric stenosis
8.7 Web space infection. 13.7 Bleeding gastro-oesophageal varices.
8.8 Superficial palmar space infection. 13.8 Gastric outlet obstruction.
8.9 Middle palmar space infection. 13.9 Gastrostomy.
8.10 Thenar space infection. 13.10 Gastric carcinoma.
8.11 Dorsal hand and finger infection. 13.11 Gastric stricture.
8.12 Flexor tendon sheath infection. 13.12 Gastric foreign bodies.
8.13 Ulnar bursa infection. 13.13 Gastric volvulus.
8.14 Radial bursa infection.
8.15 Septic arthritis of the finger.
8.16 Difficulties with hand infection.
8.17 Pus in the foot. Chapter 14 Bowel inflammation & perforation 269
14.1 Appendicitis.
Chapter 9 Pus in the pleura, pericardium and lung 149 14.2 Inflammatory bowel disease.
14.3 Typhoid & small bowel perforation
9.1 Pus in the pleural cavities: empyema. 14.4 Necrotizing enteritis (Pigbel, Darmbrand)
9.2 Pus in the pericardium. 14.5 Amoebiasis: surgical aspects
9.3 Pus in the lung.
Chapter 10 Pus in the abdomen 155 Chapter 15 Gall-bladder, pancreas, liver and spleen 285
10.1 Peritonitis. 15.1 Introduction.
10.2 Subphrenic abscess. 15.2 Biliary colic.
10.3 Pelvic abscess. 15.3 Acute cholecystitis.
15.4 Empyema of the gallbladder
15.5 Cholangitis.
Chapter 11 Methods for abdominal surgery 174 15.6 Cholangitis caused by ascaris.
15.7 Other causes of cholangitis.
11.1 Before a major operation. 15.8 Cholecystectomy.
11.2 Laparotomy. 15.9 Obstructive (cholestatic) jaundice.
11.3 Resecting & anastomosing bowel: end-to-end anastomosis. 15.10 Liver abscess
11.4 End-to-side & side-to-side anastomosis. 15.11 Hepatoma (Hepatocellular carcinoma).
11.5 Stomas. 15.12 Hydatid disease.
11.6 Fashioning & closing stomas. 15.13 Pancreatitis.
11.7 Feeding jejunostomy. 15.14 Pancreatic pseudocyst.
11.8 Draining & closing the abdomen. 15.15 Pancreatic abscess.
11.9 After an abdominal operation. 15.16 Pancreas carcinoma.
11.10 Non-respiratory postoperative problems. 15.17 Surgery of the spleen.
11.11 Respiratory postoperative problems. 15.18 Splenic abscess.
11.12 Respiratory physiotherapy.
11.13 Abdominal wound infection.
11.14 Burst abdomen (Abdominal dehiscence). Chapter 16 Abdominal tuberculosis 313
11.15 Intestinal fistula.
16.1 Introduction
16.2 Ascitic type
Chapter 12 Intestinal obstruction 210 16.3 Plastic peritonitic type
16.4 Glandular type
12.1 The acute abdomen. 16.5. Tuberculosis of liver, spleen or pancreas.
12.2 Causes of intestinal obstruction. 16.6 Small & large bowel tuberculosis.
12.3 The diagnosis of intestinal obstruction. 16.7 Urological tuberculosis
12.4 The management of intestinal obstruction.
12.5 Ascaris obstruction.
12.6 Obstruction by bands & adhesions.
12.7 Intussusception.
Chapter 17 Lymph nodes & salivary glands 321
12.8 Small bowel volvulus.
12.9 Sigmoid volvulus. 17.1 Lymphadenopathy in HIV disease.
12.10 Reversing Hartmann's operation. 17.2 Fine needle aspiration.
12.11 Colorectal carcinoma. 17.3 Lymph node biopsy.
12.12 Caecal volvulus. 17.4 Tuberculous lymphadenitis.
12.13 Chagas megacolon 17.5 Salivary gland enlargement.
12.14 Mesenteric thrombosis 17.6 Lymphomas.
12.15 Other causes of intestinal obstruction. 17.7 Salivary gland tumours.
12.16 Ileus and obstruction following abdominal surgery. 17.8 Block dissection of inguinal lymph nodes.
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Chapter 27 Urology 557 Chapter 29 The ear, nose, throat and bronchus 643
27.1 Equipment for urology. 29.1 Introduction.
27.2 Catheters & how to pass them. 29.2 Deafness.
27.3 Cystoscopy. 29.3 Otitis externa.
27.4 Haematuria. 29.4 Otitis media.
27.5 Bladder carcinoma. 29.5 Acute mastoiditis.
27.6 Retention of urine, 29.6 Foreign bodies in the ear.
27.7 Emergency (closed/blind) suprapubic cystostomy. 29.7 Epistaxis (Nose bleeding).
27.8 Open suprabupic cystostomy. 29.8 Rhinosinusitis.
27.9 Urethral strictures. 29.9 Nasal obstruction.
27.10 Impassable urethral strictures. 29.10 Nasal polyps.
27.11 Urethral fistula. 29.11 Foreign bodies in the nose.
27.12 Extravasation of urine. 29.12 Tonsillitis.
27.13 Urinary tract stones. 29.13 Naso-pharyngo-laryngoscopy.
27.14 Nephrostomy. 29.14 Bronchoscopy: inhaled foreign bodies.
27.15 Ureteric stones. 29.15 Tracheostomy & cricothyroidotomy.
29.16 Nasopharyngeal & maxillary antral carcinoma.
27.16 Bladder stones in adults.
29.17 Laryngeal carcinoma.
27.17 Bladder stones in children.
29.18 Leishmaniasis affecting nose & lips.
27.18 Urethral stones in children.
29.19 Bronchial carcinoma.
27.19 Prostatic enlargement.
29.20 Other problems in the ear, nose, & throat.
27.20 Open prostatectomy.
27.21 Bladder neck problems.
27.22 Prostate carcinoma.
Chapter 30 The oesophagus 678
27.23 Epididymo-orchitis.
30.1 Foreign bodies in the throat.
27.24 Hydrocoeles in adults.
30.2 Oesophagoscopy.
27.25 Testicular torsion.
30.3 Corrosive oesophagitis & oesophageal strictures.
27.26 Orchidectomy.
30.4 Oesophageal candidiasis
27.27 Undescended or maldescended testis.
30.5 Oesophageal carcinoma.
27.28 Testicular tumours.
30.6 Achalasia.
27.29 Circumcision.
30.7 Oesophageal rupture.
27.30 Phimosis & paraphimosis.
27.31 Meatal stricture.
27.32 Priapism. Chapter 31 The teeth and the mouth 688
27.33 Penile carcinoma.
27.34 Penoscrotal elephantiasis. 31.1 Introduction.
27.35 Kidney tumours. 31.2 Gum disease.
27.36 Schistosomiasis in the urinary tract. 31.3 Extracting teeth.
27.37 Other urological problems. 31.4 Impacted 3rd molar (‘wisdom’ tooth).
31.5 Cancrum oris (Gangrenous stomatitis, Noma).
31.6 Jaw swellings.
31.7 Cleft lip & palate.
Chapter 28 The eye 609 31.8 Oral tumours
31.9 Other dental & oral problems.
28.1 The general method for the eye.
28.2 Operating on an eye. Chapter 32 Orthopaedics 704
28.3 The red painful eye.
28.4 Loss of vision in a white eye. 32.1 Muscle & joint contractures.
28.5 Anterior uveitis: iritis, iridocyclitis 32.2 Managing leprosy paralysis.
& posterior uveitis: choroiditis. 32.3 Tuberculosis of bones & joints.
28.6 Glaucoma. 32.4 Tuberculosis of the spine.
28.7 Onchocerciasis (River blindness). 32.5 Tuberculous paraplegia.
28.8 Refractive errors: difficulties reading & presbyopia. 32.6 Back pain & lumbar disc lesions.
28.9 Disease of the neuromuscular system: squints, amblyopia, diplopia. 32.7 Managing chronic poliomyelitis.
28.10 Diseases of the eyelids & nasolachrymal apparatus. 32.8 Contractures of the hip & knee.
28.11 Proptosis (Exophthalmos). 32.9 Equinus deformity of the ankle.
28.12 Tarsal (Meibomian) cysts (Chalazions). 32.10 Club foot (talipes equinovarus).
28.13 Entropion. 32.11 Care of the neuropathic foot.
28.14 Destructive methods for the eye. 32.12 Foot ulcers.
28.15 Conjunctival carcinoma. 32.13 Tibialis posterior transfer for foot drop.
28.16 Retinoblastoma. 32.14 Painful hip or a limp in a child.
28.17 The eye in leprosy. 32.15 Stenosing tenosynovitis.
28.18 Other eye problems. 32.16 Ganglions.
32.17 Carpal tunnel syndrome.
32.18 The hands in leprosy
32.19 In-growing toenail.
32.20 Tumours of bone.
32.21 Other orthopaedic problems.
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1
Preface
The first edition of this work by Maurice King appeared in 1990 and has established itself as the gold standard of do-it-yourself
guides to surgery in the up-country hospital. Some 50000 hours of work went into compiling the mass of expert contributions from
many varied and far-flung individuals, all enthusiasts with a first hand indigenous experience of surgery in poor-resource
environments. The need for such a book has been amply justified, and 25 years on, its usefulness is in no way diminished.
Indeed, there is even greater urgency for such appropriate basic surgical guidelines to be disseminated in parts of the world where
people's access to surgery has been difficult or well-nigh impossible. To this end, it is envisaged that these manuals will be
translated into French, Spanish, Portuguese, Russian and Chinese, and also produced electronically as Compact Discs. Publication
on a freely accessible web-site will allow more readers access throughout the world.
Also, more is included on pathologies seen in different parts of the world, viz. Chagas’ disease in South America, Hydatid disease
in Asia, Schistosomiasis in Egypt, and so on. There will remain gaps, as different hospital environments will always differ hugely:
suggestions for alterations and inclusions will always be gratefully received, and incorporated in future editions, which can now be
updated electronically much more easily than heretofore.
The single most dramatic change in the practice of surgery in much of the developing world, and in Africa in particular, has been
the rampant inexorable spread of HIV disease since the early 1980's; this has seen the appearance of new pathologies, and the
requirement that new strategies are developed not only to combat its spread, but to deal with its effects. By the new Millennium,
antiretroviral medication was still seriously beyond the scope of most Government Health systems, but this is changing.
Whilst the advent of therapies to combat HIV effectively may still remain out of reach for very many, it will offer hope to the
young and those yet unborn that this scourge may be controlled, if only by encouraging victims of the disease to be tested.
Until recently, so much obfuscation around the disease, and slavish following of individualistic ideologies, has prevented much
community openness concerning this epidemic; it is fervently hoped that with cheaper and successful antiretroviral treatment,
the exceptionalization of HIV may disappear.
Much therefore of the changes since the First Edition have concentrated on the impact of HIV disease; however, other changes are
noted: for example, the inclusion of ultrasound and flexible endoscopy, which, though the equipment is expensive (it might be
sourced through donor agencies), it is highly cost-effective in diagnostic yield. Further, thyroid surgery is no longer excluded, as
its performance is considered no more complex than much else described. The inclusion of grading of difficulty of operations,
as mooted in the First Edition, has been carried out: this scale is inevitably idiosyncratic and is offered simply as a guideline,
especially for surgical technicians. Furthermore various procedures, which are in danger of being lost to the experience of Western
style practitioners and their trainees but are eminently useful in poor-resource settings, have been described in some detail.
It is rare that a book tells its reader what not to do, and what to do when things go wrong! This is such a book, whose aim,
essentially, is to encourage surgery in the districts and remote areas, if necessary by non-specialist, even non-medical, practitioners.
The realization that surgery is not an expensive luxury but a cost-effective intervention is slowly dawning on Health planners;
however, to remain viable, such surgery must remain relevant and relatively low-cost. It is estimated that 80% of surgery necessary
can be covered by 15 essential procedures. If even only these are mastered, the surgical contribution offered will be substantial.
The editors’ view is that laparoscopic surgery is not at this stage a generally viable adjunct, and is therefore not described.
Where special arrangements have been made, and a surgeon with appropriate skills is available, the benefits should not of course
be denied patients in rural environments. Nonetheless, the greater danger is that surgery is not done simply because of the
unavailability of highly trained individuals or of high-technology equipment, presumed essential, and this must on all counts be
avoided. Appropriate technology has been described, and inventions made known through the practical insights of many in poor-
resource settings has also been included. This must be further encouraged; indeed the principles thus discovered should be exported
to the so-called knowledgeable rich world, which groans under the ever-increasing cost and bureaucratic complexity of delivering
high-technology medicine.
It is the fervent hope that this second edition will bring relief and benefit through surgery to millions to whom it might otherwise be
denied. The fact that some 2 billion people in the world do not have access to any surgery must be seen as a scandal, and this book
will do its part in correcting this tragedy.
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These are just some statistics of the surgery that needs doing
and is not done. It is estimated that <3.5% of all surgical
interventions done worldwide are done in low-income
countries. Since most of these procedures will be minor
ones, it is probable that <½million major operations are done
ONE OF OUR READERS. You may have had very little surgical per annum in the these countries.
experience and yet have to operate on severely ill patients. In an emergency
you may even have to operate by the light of a hurricane lantern. The light All this unmet need means that there are many unnecessary
will attract insects, and these will fall into the wound, but even so they are deaths from strangulated hernias and obstetric disasters,
unlikely to influence the patient's recovery. However, a LED head torch will
be preferable in such situations, and ketamine anaesthesia is virtually always as well as from vesico-vaginal fistulae (VVF) and from
feasible! Kindly contributed by WHO. foetal cerebral injury or anoxia at birth. They illustrate the
fact that hospitals are only coping with a fraction of the
burden of surgical disease in the communities around them.
The result is that millions of people, whom surgery might
help, get no help. Too many people still die from obstructed
labour or obstructed bowel, or are disabled by untreated
osteomyelitis, or burns contractures, much as they were in
the industrial world a hundred years ago.
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3
If we wait till services are available to prevent the killing 1.2 The surgical scene
diseases of childhood, the simple surgical services described
here will not become available for a very long time. The countries of the third world and the surgical scene
They can do much to improve the quality of life of the poor. within them differ widely. Ethiopia and Paraguay,
for example, are about as different as two countries could be.
Although much of this manual has a rural orientation, Typically, the people of low-income countries are poor,
44% of the people of the developing world are now living in hungry, and rural, although they are rapidly migrating to the
towns, so the surgical care of the urban poor is almost towns. The population of sub-Saharan Africa is increasing at
equally important. As at 2010, 9 nations in Subsaharan an inexorable 3% annually, although in some countries there
Africa (Angola, Botswana, Cameroun, Congo, Gabon, was a negative growth rate due to deaths from HIV disease.
Gambia, Ghana, Liberia, Nigeria) have >50% of their Meanwhile its per capita food production and its already
population living in towns. There were no such countries in meagre gross national product even if increasing remains
Africa in 1950. Practically all South American and Far hugely unevenly distributed, whilst costs on the military and
Eastern nations have a majority of people urbanized. socially dislocating wars multiply. It is obscene that the
There is therefore an urgent need for ‘district hospitals’ in richest 1% own half the world’s wealth.
towns, leaving specialized care to the central institutions. One feature developing countries do have in common is that
Furthermore trauma presents an increasing burden of much of the surgery should be done in ‘district hospitals’.
morbidity and mortality in the developing world, and as the These typically have between 60 and 200 beds and are
success of its management depends mainly on early rapid staffed by 2-4 doctors, assisted by nurses and auxiliaries.
appropriate surgical care, this onus falls on the district Fortunately, the 'one-doctor hospital', which was common
hospital in the first place. until recently, is now unusual. Each hospital typically serves
about 150-250,000 people living in an area which may be as
Surgery has an importance in the public mind that medicine large as 3,000 square miles.
does not have. It is also the most technically demanding of
the tasks of a district hospital doctor or clinical officer, Over the world as a whole these hospitals range from the
and is thus a good measure of the quality of his medical excellent to the indescribable. At one end they provide care
education. If this has not been adequate, either because it which anyone would be fortunate to have, at the other the
never was adequate in the medical school, or because the few patients brave (or foolish) enough to enter them lie
quality of its teaching has fallen, he will be very loath to do largely untended. Nonetheless these hospitals are the local
much surgery, and may do none. This is why many rural focus of health care in the community and have an important
hospitals, and several district hospitals in some countries do place as such, as well as being a major employer of labour.
little surgery. When this happens, patients soon realize that it How much your hospital is valued by the Government can be
is no use going to such hospitals, with the result that they measured by whether the Minister of Health or his accolades
soon have empty beds. So if you see a hospital with empty would be willing to be treated at your institution, or whether
beds, one of the first questions to ask yourself is: “What is they will use scarce resources for treatment in a richer
the quality of the surgery here?” There is thus a qualitative country with ‘better’ facilities.
aspect to the unmet need for surgical care as well as a
quantitative one. If you work in a hospital in the middle or at the lower end of
this spectrum, expect to find your wards overcrowded, with
The constraints on the provision of surgical care are more than one patient in a bed. 'Clean' and infected cases
formidable, but some have succeeded in increasing their may not be separated, so that a patient with an open fracture
work-load and their operations tally despite rising costs and may lie next to one with a perforated typhoid ulcer.
scarce manpower resources. Your maternity ward is likely to be particularly
overcrowded, and resist all your attempts to decongest it.
Cultural reasons may make it impossible to restrict the
number of visitors to the wards. Defects in their construction
will make keeping them clean and tidy a major task.
Your equipment will be limited and poorly serviced.
When it does break down, it may take years to replace.
Trees may be so scarce that your staff have to go a long way
to collect firewood.
If your hospital is at sea level on the equator, expect to
operate at 300C in 95% humidity, your clothes wet,
and everything which can go rusty or mouldy doing so.
Only insects enjoy such conditions, and you will find plenty
of them.
3
4
4
5
(4);The capacity to withstand prolonged periods of cultural If you subsequently move to work in the hospitals of the
and maybe financial isolation. If your morale is high, affluent world, you may well miss the sense of purpose and
so soon will be that of your staff also. Your patients will be achievement that you found when treating patients in low
grateful for anything you can do for them, and it is likely resource settings. Your experience, and your practical
they will not yet have learnt to litigate against you. knowledge may not be highly esteemed, or at worst ignored.
You will be shocked by the wastage of resources, and the
If you serve your hospital and the community round it for lack of a clinical acumen, that you have tuned carefully over
>5yrs, you will earn a unique place in its affections. much time and painful experience, that seems to count for
Just to prepare you, we describe the kind of situation you little in the corridors of modern high-technology hospitals.
may have to cope with.
However, no-one will be able to take away the pride that you
have done what so many of your colleagues wished they had
done, and the gratitude of so many of your patients, who,
without your help, would have suffered long or died.
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6
The method of a good leader is to observe, listen, learn, So you will have to do your best in all these fields
discuss, decide, communicate, organize, encourage, facilitate simultaneously, as well as being 20 surgeons in one!
and participate. It is necessary to have a critique of your To help you we have collected from among the
activity: this is audit. Be sure to set goals, evaluate them, get armamentarium of diverse experts:
feedback, co-ordinate efforts of others, recognize (1);Some easier methods which you could use. Fortunately,
achievement and accept responsibility. Most problems will many of them, despite the fact that they are normally only
have as their root causes: poor leadership, poor relationships, part of an expert's expertise, are not too difficult.
poor pay, poor morale and working conditions, poor For example, the position of safety in a hand injury is within
administration, and poor supervision. How you handle a the competence of any doctor or technician.
crisis is the best test of your managerial skills; try to think (2);Those methods, either easy or difficult, which you will
beforehand what might go wrong, however, to avoid such a have to use to save a patient's life.
crisis. (3);Those difficult, disability-preventing but non-urgent
methods, for which you should refer a patient, but may not
Ordering supplies in advance and organizing repairs are most be able to, such as sequestrectomy for osteomyelitis (7.6).
important. Keeping good records is essential, both of
managerial decisions and patients. Do not forget aspects of Many countries do not even have enough general duty
hygiene, the use of toilets, disposal of garbage, the problems doctors to do all the surgery that needs doing, let alone
of overcrowding and relatives’ accommodation within specialists. Typically there is only one doctor for 50,000
hospital premises, and the problem of excessive noise! people, and only 4% of a severely depleted Gross National
Product is spent on Health Services. Many countries in the
Inevitably you will have to hold meetings, usually as world have recognized that essential surgery should be done
chairperson; set clear objectives and outcomes, set an by specially trained medical assistants (clinical officers),
agenda, keep a strict eye on time, and allow everyone to and several have trained them to do this. Such surgical
have their say, but keep folks to the point and avoid letting technicians are the backbone of surgical delivery in several
the subject drift. Afterwards make sure you get feedback. countries.
You will inevitably have to write death certificates, and How nice it was to see how well the Assistant Medical Officer (AMO) was
medical reports, and do much other paperwork. managing his tasks; he seemed to be well in control. He had done several
Caesarean Sections, 2 laparotomies for intussusception, some
Get a secretary to help you, and limit this sort of activity to a hydrocoelectomies, and fracture reductions. He was treating 3 cases of
particular short period in the day. Take care when disclosing fractured femur with skeletal traction in a very satisfactory way.
medical information: it may be confidential. His management of burns did not give cause for criticism. He had not had
sufficient experience of hernia operations, so we operated on 5 collected
Education is the key: daily morning reports, bedside cases together, after which he wishes to do them himself. To go to Kiomboi
teaching, grand rounds (especially for visitors), morbidity was an inspiration for our AMO training program. (Isaakson,G. Report of
visit to Kilamanjaro Medical Centre.)
and mortality (M&M) meetings and rehearsing critical care
practices should be the norm. Clinical audit is healthy: look We quote it to emphasize that, not only must much surgery
at, for example, rates of wound infection, success of skin be done by non-specialists, but that it is often excellently
grafts, incidence of HIV+ve patients, mobility scores for done by surgical technicians. Perhaps there is no such
femoral fractures, delays getting equipment repaired etc. teaching program in your country, and yet you are hopelessly
Remember, though, that M&M should not be an occasion to overworked. Try to train an auxiliary to do the simpler
apportion blame: it is a way to examine how you can avoid operations, such as hernias, Caesarean Sections and
exploratory laparotomies? Write out a simple-to-follow
errors of omission or commission, or poor judgement or poor
scheme so that they can follow a regular work-path.
technique. This will relieve your burden, and ensure the work carries on
when you are not there!
For you to keep up to date, do not miss out on your own
education: try to encourage specialists to visit your hospital, Remember that there may be a large turn-over of staff:
subscribe to journals (especially Tropical Doctor), establish don’t resent this but be welcoming of new faces & new
distance learning (by e-mail if possible), and promote a ideas!
hospital library. However, beware of spending excessive
time at workshops, which may leave your hospital stranded Beware ‘burn out’, where you get so exhausted and irritable,
and be little educational use to you. Try to visit your rural you cannot function properly. Take a break, leave the place
clinics and other hospitals in your district on a regular basis. and go on a well-deserved holiday, so you can come back
refreshed and revitalized (and bring some vital supplies
back)!
6
7
1.4 Your surgical work This was a consecutive list of surgical cases seen over 3wks in a 50-bed
mission hospital in Mandritsara, Madagascar:
Of all your hospital admissions, 10-15% will probably be (i) a 9yr old girl with osteomyelitis of the tibia
surgical, but because operating is time consuming, and as (ii) 2 Caesarean sections for failure to progress
(iii) a 50yr old lady with intestinal obstruction & carcinomatosis
some patients remain in bed for a long time, surgery may (iv) a 24yr old lady with an ectopic gestation
take 30% of your time, and fill half your beds. How much (v) an 18yr old girl with gas gangrene of the uterus
you will do will depend on how good you are. Patients will (vi) a 48yr old man with an unresectable cologastric mass
travel hundreds of kilometres to a doctor with a good (vii) a 58yr old man with a pertrochanteric femoral fracture
(viii) a 46yr old woman with a large fibroid uterus
surgical reputation. A bad one will soon do little surgery. (ix) a 37yr old man with Fournier’s gangrene of the scrotum
(x) a 36yr old man with necrotizing fasciitis of the whole right leg
Look carefully at the ages and sexes of the patients in your (xi) a 16yr old girl with septic arthritis of the left shoulder
wards. When modern medicine first reaches a community, (xii) a 15yr old boy with a urethral fistula
(xiii) a 35yr old G9 P5 woman with pelvic impaction of the fetal head
the first patients to present are usually the men, followed by (xiv) a 45yr old lady with pericardial tamponade
the women and children. Only when medicine is well (xv) a 9yr old girl with 5 distal ileal typhoid perforations
established, will you see a proportionate number of older (xvi) an 8 month child with a huge 25cm sized hydronephrosis
women. You will see few hypochondriacs, but some may (xvii) a 93yr old man with a right inguinoscrotal hernia
(xviii)a 31yr old man with a plexiform shoulder neurofibroma
just come to see you because of your novelty value, (xix) a 56yr old lady with 3days of adhesive small bowel obstruction
and there are likely to be comparatively few repeat visits to (xx) a 17yr old girl with retained placenta for over 24hrs.
the outpatient department because travel is so difficult.
You will see many of the diseases that are common in the Fig 1-3 Table of surgical admissions in a rural hospital.
industrial world, but in different proportions, a major
difference being that so many of them present late (1.6). Always think whether what you can do to a patient will
probably benefit him; if you cannot refer him, or the distance
'Western diseases' such as aortic aneurysm, carcinoma of the is too great for him to reach the referral hospital alive,
colon, gallstones and varicose veins may not be very your choices are much clearer. Decide whether his problem
common at all in rural practice, but are diseases arriving in is urgent (and therefore needs your intervention) or whether
the cities. Urethral strictures, pelvic infections, fibroids and it can be alleviated by an operation within your scope
hernias are usually common, as are some diseases that are (even if something else has to be done later), or whether it
almost extinct in the industrial world: acute haematogenous can wait for the specialist.
osteomyelitis, for example. Try to get a specialist to visit you to teach and advise:
he may well enjoy a trip away from the daily grind!
You will probably see tuberculosis of the chest, lymph KALPANA (46yrs) presented with mild abdominal pain for several days,
nodes, abdomen, and bones, many manifestations of HIV severe for 4days, and diarrhoea with two loose stools tinged with blood
disease, amoebiasis and other 'tropical' illness. Sepsis is daily for a week. She had a tender, fluctuant mass in her right lower
frequent. quadrant, and a marked leucocytosis. At laparotomy she had a patchy
necrosis of her caecum with a localized perforation. A right hemicolectomy
was done for suspected necrotizing amoebic colitis (14.5). The operation
But you may seldom see carcinoma of the bronchus, or the was a nightmare. Her colon came to pieces in the surgeon's hands and there
thromboembolic complications of surgery that are so was gross faecal contamination. She died. LESSONS (1) Expect a different
common in the West; you may probably never see spectrum of disease from that you might be used to where a fluctuant mass
in the right lower quadrant may be most likely to be an appendix abscess.
diverticulitis. (2) Avoid doing a right hemicolectomy for amoebiasis if you can.
No branch of surgery will differ more starkly from that in the
industrial world than orthopaedics, where contractures and The late Imre J.P. Loefler, one of our editors, in a wide-
deformities are commonplace. ranging lecture on the failure of the medical profession to
deliver surgical care in much of the developing world, stated:
You may be presented with many kinds of operation to do, “You must be humble; surgery is a craft that makes use of
but 50% of your workload is likely to be in Obstetrics and the scientific method of Popperian falsification. The art of
Gynaecology. The rest will be divided almost equally surgery consists of judgment and the beauty of an operation
between sepsis and trauma, the nature of which will depend well done, done gently, with respect for living tissue,
on where your hospital is situated. for every cell, with reverence for form and function, carried
N.B. Trauma is discussed in Volume 2. out with compassion, always remembering that the only
justification for invading the body of another individual is
Unfortunately many times you will not be able to refer a the intent to restore homeostasis.”
patient (1.6). Never refer someone just to get him off your Loefler IJP. Surgery in the Post-Colonial World (Rahima Dawood Oration).
hands! Always think what would, in the current E & Centr Afr J Surg 2002;7(1):53-8.
circumstances (not in the ideal world) be the best for your
patient.
7
8
Remember, it is not only possible, but usually mandatory, You are unlikely to be able to send patients for extensive
to perform surgery without every modern convenience. series of investigations before you start treatment.
Such surgery is by no means necessarily worse than that In fact you should rely more and more on your clinical skills.
done in a high-technology centre with every available Many patients will arrive with classic presentations or
gadget. advanced disease, and the diagnosis may be obvious.
However, we wish to present a guide on how to deal
BHEKUMUZI (10yrs) was lying in a District Hospital with an obviously
logically and effectively with patients without sophisticated
angulated fracture of the left forearm sustained when climbing a tree to fetch
fruit. When a visiting doctor came to do a surgical round, he asked when he technology. Do not fail to treat a patient simply because you
was admitted and was told, “Three days ago, just after it happened.” do not have the means you may be used to!
The reason given why the fracture had not been reduced was that no
radiograph could be taken because the Xray machine was not working!
Expect to find that the patient has other diseases also.
LESSON: It may seem obvious that you don’t need a radiograph to tell you
that an obviously angulated fracture needs reduction. Think whether you Studies in Nepal, for example, showed only 15% of
really need a laboratory to correct potassium loss in diarrhea, or an operations were done in otherwise healthy patients;
abdominal radiograph for a gross sigmoid volvulus, or a CT scan for a head in Zimbabwe over 30% of operations were done on patients
injury.
with HIV. So expect your surgical patients to be poor,
malnourished, immunosuppressed, anaemic, malarious,
1.5 Your patients tuberculous, or worm-ridden, or all of these things.
These illnesses make a patient weak, wasted and a poor
In many of the villages of the developing world, the burdens operative risk. Anaemia increases the risks of surgery, and in
of chronic disadvantage, poverty, ignorance, and insanitation some communities the average haemoglobin may be only
are the background to life. A surgical disease on top of this 8g/dl. Some patients may still be walking around with 4g/dl
may be the last straw. or even lower. Apart from little breathlessness on the hills of
Nepal, one 12yr old girl with a Hb of only 2g/dl had no other
As a result, patients often present late. If yours is a really complaints. So try to prepare your patients for surgery before
disadvantaged community, tapping a hydrocoele may yield you operate, especially if the cause is readily treatable. But
litres rather than mls of fluid. An elephantoid scrotum may beware the dangers of blood transfusion (5.3).
have progressed so far that it hangs to the ground (27.34).
If a patient has a urethral stricture, he may leave it until he Pain and disability are unlikely to rate highly when there is
has multiple fistulae or massive extravasation (27.11). rice or maize to be planted, or when there are festivities and
If he has carcinoma of the penis (27.33), he may wait until holidays. Although the local economy may be poor,
much of it has been eaten away. Most carcinomas of the certain obligations may be compelling.
breast (24.4) and cervix (23.8) present too late for any hope
of cure. Some cultural objections may exist, to orchidectomy,
for example, and may be so firm that a patient is unlikely to
Too often, patients only present when complications have agree. Mastectomy or colostomy may be similarly abhorrent.
made their lives unbearable. When even the struggle to stay
alive may be a losing battle, the fact that surgical disease is
normally treatable is irrelevant.
8
9
Death is the great enemy of doctors and evidence of our Although 'referral systems' exist in all health services,
failure. But a patient may have faced up to his own mortality the difficulties put in a patient's way are often
long before you have, and may not always share your view. insurmountable. Unfortunately, for many patients referral is
He may have learnt to live with death since childhood, a myth. In many resource-poor countries the possibilities for
and both his own attitude to it and that of his closest relatives referral appear to have got worse during the last decades
may be very accepting. Never lie to a patient when you know rather than better. Too often, there is just no petrol for the
he is dying: he probably knows it also, and realizes you hospital's ambulance to take a patient to a referral hospital,
know it too! or no money to buy it; furthermore the roads may be
impassable; he may not have money to pay the referral
One of the greatest mistakes you can make is to offer a hospital fees, or the bribes necessary to gain admission, and
useless operation, which will use up much of his own he may be very reluctant to travel so far away from home.
resources and those of the hospital in an unsuccessful Alas, in many countries the future does not seem any more
attempt to produce a cure. Theodor Billroth, a pioneer of hopeful.
surgery, famously commented, “To operate without having a
chance of success is to prostitute the beautiful art and science Only too often a patient reaches a referral hospital with great
of surgery.” In some cultures it is important for a patient to difficulty, only to return no better then he went.
be buried at home, so consider sending a terminally ill Because there are so many uncertainties, assess the chances
patient home early while he can still travel. for each patient individually. Try to find out what happens to
each of the patients you send. Just what cases is it useful to
refer, how, when, and to whom? If there are referral services,
be sure to use them, both to refer patients properly and to
1.6 Referral is mostly a myth learn from yourself.
A patient with a surgical disease has first to refer himself to In the pages that follow we assume that you cannot refer
you, and if you cannot care for him, you must consider the patient. There may be procedures you do not feel
referring him to someone else. Referral onwards from a confident to do; obviously if you do have the opportunity for
community health worker (CHW) normally takes place at all referral, use such help. Consider carefully if the patient may
the five steps (1-5). Although surgery is done in other parts end up worse off than if you had not intervened.
of this system, we are concerned with the district However, do not back out of a life-saving procedure through
(or mission) hospital, and the critical referral steps from false modesty. This volume exists to help you in just such a
C to D and from D to E. situation.
Do not overburden the referral hospital with minor cases;
take the opportunity to spend time there to
learn surgical procedures if you need more
experience.
The important factor is the degree of urgency
that exists: balance this against the feasibility
of referral.
9
10
There are however certain cases which referral hospitals Unfortunately, the provincial surgeon had left the previous day to attend a
planning meeting at the Ministry of Health. He would not be back for 2days.
should accept without question, and district hospitals should
The provincial surgeon returned and saw him, but decided that the training
know what they are. Such, for example, is the management had not prepared him for posterior exploration of the humerus, plating the
of intestinal fistulae (11.15). fracture and perhaps secondary suture of the radial nerve. Also, he had no
6/0 monofilament. So Patson was given a bus warrant, and a note to the
orthopaedic surgeon in the teaching hospital in the capital city.
Remember, referral hospitals also have their problems:
Unfortunately, he had no money, no food, and no clean clothes for the
(1) They may be overcrowded with simple cases that you journey, so he went home. The Land Rover had been partly dismantled by
could care for in your district hospital. thieves, but his partner had towed the wreck back to the village, and hired a
(2) When the time comes to discharge a referred patient who lad to help him with the fishing. The family were already deeply in debt.
They debated whether he should go 800 km to the capital, but the limp wrist
cannot go home unaided, they may be unable to send him
decided them. He started on the long journey with a pack of food, a few
there because they cannot contact the rural relatives. clean clothes, and a bus warrant, but very little money.
(3) Their system of communicating information may be very Four days later he arrived at the orthopaedic clinic on a Friday. He had no
longwinded, so you may not get proper feedback unless you appointment, and the surgeon to whom the note was addressed had held the
clinic on the previous day. The harassed sister, busy with another clinic,
yourself enquire: that is why direct contact is so useful!
found that he had no relatives in the city, and no money, so she sent him to
the orthopaedic ward in the hope that they might have a bed for him over the
One of the purposes of these manuals is to make sure that weekend. They did.
any surgery that can be done in a district hospital is done On Monday the surgeon saw him. The wound had healed and he was fit for
surgery, and the necessary screws, plates, adhesive drapes, and sutures were
there, so that referral hospitals can fulfil their proper
in stock. But there was a three months’ waiting list, so he had to wait 8days,
function, and life-saving surgery is not deferred till after a even for operation as a semi-emergency. A silent cheer went up from the
long journey to the referral centre. Another purpose is to hospital staphylococci, as they began to colonize the skin of this provincial
train cadres (not necessarily doctors) to acquire special skills patient.
His radial nerve was freed from compression in its spiral groove, and the
to deliver surgical services relevant to situations.
fractured humerus was successfully plated. Two weeks later he returned to
the provincial hospital with suggestions for physiotherapy (a 2day journey
REFERRAL: IS IT WORTHWHILE? for each session) and instructions to return in 1yr for removal of the plate.
He was lucky. He was one of the minority for whom the referral system
'worked'. The radial nerve palsy recovered. A friend paid for nearly 4wks in
The chances of being able to refer a patient vary greatly,
a teaching hospital, and 1600km in transport. He was in debt, and the family
and are apt to change. They depend on the answers to these were hungry, but he did not have to sell the boat, or the remains of the Land
questions: Rover. It could have been much worse.
(1) Does he have a disease for which the referral hospital has
TOPNO (41yrs) fractured his ankle in a bus accident. The very competent
no effective treatment (e.g. hepatoma or advanced HIV
doctor who saw him had learnt that difficult ankle fractures should be
disease) or equipment (e.g. advanced osteoarthrosis of the referred. He could manipulate fractures, but he thought that an expert would
hip needing hip replacement)? do better, so he sent the patient with a letter to the referral hospital 70km
(2) Does he have a condition (e.g. cleft lip & palate) best left away. After a long journey, the patient arrived too late at the fracture clinic.
He was able to reach the next fracture clinic in time, only to find that the
till a later date?
surgeon was away at a conference. So he hung around hopefully for some
(3) Does he have a condition which will kill him before he days, but in the end he was advised to return to the original hospital.
gets there (e.g. ruptured spleen) or be untreatable by the time Meanwhile, he had had no treatment except the original 'first aid' plaster.
he gets there (gastroschisis)? When he eventually returned to the doctor who first saw him, the fracture
had partly united in a very bad position. It was now too late to manipulate
(4) Will he be able to get there and look after himself when
him, so he now has a stiff painful ankle and is waiting to have it fused.
there? What about his family? LESSON A patient may be better in your hands, if you learn those
(5);Will he be sure of getting any better treatment than procedures that you can reasonably do, in your own set-up.
yours? Try to contact the surgeon for advice before sending Jellis JE. Chairman’s Address, Proc Assoc Surg E Africa 1981;4 53-6
the patient, especially if distances are long and the case is not
an emergency. ASSESS EACH PATIENT'S CHANCES OF
EFFECTIVE REFERRAL
PATSON (49yrs) was in a Land Rover when it rolled over in deep sand,
causing an open fracture of the right humerus and injuring the radial nerve. Make sure you know the specialist’s timetable, and his
He was still able to walk, so he eventually reached a district hospital, where contact details including mobile phone numbers. You can
the wound was carefully toileted, and left open for delayed primary suture.
often use the messaging system on mobile phones better than
The radial nerve injury was recognized, the arm was put in a collar-and-cuff
sling, the wrist in a cock-up splint, and he was asked to return in 48hrs. The the voice; with newer mobile phones, you can send pictures
wound being clean, it was closed. So far he had received ideal treatment. of a radiograph, histology slide, or even a patient’s lesion.
It was decided to refer him to the provincial hospital 40 km away, across a Beware, though, of possible leaks of confidentiality.
river and a flood plain, 8mins by air, a day by boat, or 2days by Land Rover.
There was no radio, and the telephone was not working, so there was no
Can the patient get himself to the referral centre? In some
way of telling the provincial surgeon that he was coming. He was able to get
a seat on a barge and was in the provincial capital 24hrs later. It was dark districts, for example, the roads and airstrips are closed for
but he was able to find a relative with whom he could stay the night. The weeks at a time during the rainy season.
next day he sat in the outpatient queue and handed the slip to the medical Is he prepared to leave the family and the fields or the job?
assistant.
10
11
Has he or the hospital got money for transport and for We have tried to serve all your needs.
lodging when he gets there? Often, neither of them have. Although learning something from a book is not for many as
If he does arrive, will he arrive on the right day, find the way good as learning it first hand from a good teacher, the very
to the right clinic, wait in the right queue and be seen and raison d’être of this text is to provide relevant information in
admitted? Will there be an empty bed? Will the surgeon you a situation where you have no such teacher! These books,
send him to actually be there when he arrives, or will he though, are of no use if they are kept unused on the
have gone on holiday, or to a conference in America? bookshelf!
Investigate him first if you can, and state the procedure that
you think he needs. If a biopsy is necessary, do it, and refer As books are expensive, we have endeavoured to make this
him with the report. Often this takes time to obtain or text available electronically as a compact disc, and on the
may have to be sent to the referral hospital anyway. internet, which we hope will further disseminate the
You might then send the patient with the biopsy specimen accumulated wisdom gathered herein.
already taken. If referral is urgent, do not wait for the report,
but give sufficient details so the report can be traced. It has not always been easy to distinguish the tasks which are
obviously impossible for you (oesophageal atresia for
Inform the surgeon that the patient is coming. Make sure that example), from those which may be possible (duodenal or
the patient knows exactly what to do, and where to go when jejunoileal atresia). We have had to balance benefit,
he arrives. Send a careful letter with him, including all risk and urgency. This has led us to include methods for
necessary information. removing the prostate, for example, but not a meningioma.
If there are any particularly good referral facilities, such as We have tried to grade the difficulty of operations described.
those for artificial limbs, for example, be sure to use them. They are included in this edition. If you can refer the more
difficult cases and the patient is likely to obtain a better
Finally, do not refer patients unnecessarily. No surgeon likes result if you do so, this is obviously preferable.
to be sent plantar warts. We have stressed, though, that some operations are only for
the careful, caring operator. These include Girdlestone's
arthroplasty (7-21), closure of a Hartmann’s procedure
(12-15), Roux-en-Y anastomosis (15-12), and closure of a
1.7 The limits of this system of surgery meningomyelocoele (33-15).
Detail, especially in surgery is important, but you can get Although the common conditions may comprise perhaps
bogged down in details. The quotation, “Le bon Dieu est 60% of your work, the rest will include many rarer ones.
dans le detail” (God is in the details), attributed to Gustave In aggregate, the rarities are common. So we have tried to
Flaubert, the French writer (1820-1880), must be balanced describe as many of the comparative rarities as we can, in the
by the German proverb, “Der Teufel steckt im Detail” hope that you will find about 98% of the conditions you
(The devil hides in the details)! could hope to treat surgically described here. The edges of
this large collection of appropriate methods are inevitably
In view of the common impossibility of referral, we have blurred, and it has not been easy to know which rare,
tried to describe everything that you, our readers as a whole, or which difficult procedures we should include.
might have to do; both the emergency procedures and the For example, you will find much on HIV-related pathology
less urgent elective cases. (5.6), and there is even mention of cystic hygroma (33.14).
As you will see in the next section, you individually, should We shall probably be criticized for including
not necessarily do everything we describe. We take for oesophagoscopy (30.2) and bronchoscopy (29.14), and some
granted that personal tuition from an expert is the best way cancer chemotherapy. But it is better to include slightly too
to learn anything. But, what if there is no expert? much rather than slightly too little - there is no obligation for
A manual is surely better than nothing. you to do things you do not feel able to do, but a crisis may
force your hand! Thyroidectomy (25.7) is our tour de force,
Somehow, we have had to find a balance, so we have and the great detail with which we have described it should
considered each procedure on its merits. Our task has been enable our more experienced and caring readers to do it.
made no easier by the wide range of the abilities of our Some methods, such as methods of haemostasis,
readers. You may range from being a highly trained surgeon, are classical, in that no textbook of surgery would be
doing unfamiliar operations for the first time, to an complete without them. Inevitably, some parts of the 'system'
inexperienced technician doing your first job. are tidier than others.
11
12
We have excluded all procedures which appear too Would his operation be better done elsewhere? On the whole
sophisticated, but the range of facilities available is always we think that for every doctor who operates when he should
very wide. In some cases we may have made false not, there are many more who do not operate when they
assumptions. We have often assumed that you have an X-ray should. So one of our aims has been to get more surgery
facility, and ultrasound for example. done, on the correct indications! The mature surgeon is one
who knows when not to operate! On the other hand, if you
Uncertain sterilizing procedures, and limited nursing care are always too cautious, you will never learn and some of
have also guided our selection. your patients will never benefit. Remember to keep records
(2.12).
Although we write mostly for hospitals which are short of
both money and skill, there are some, such as those run by So beware of what Max Thorek's describes as furor
mines and plantations, or supported generously by outside operandi, the furious urge to operate, and ask yourself these
agencies, where money is less scarce. These might be able to questions before you do so:
procure even comparatively expensive drugs for cancer
chemotherapy, for example. For them all the equipment we What will happen if you do not operate? If a patient is
list (even bronchoscopes and oesophagoscopes) should not likely to die or become disabled if he is not operated on
be a problem. However, beware the notion that expensive quickly, you will have to operate. We have therefore
methods are necessarily the best! included all the more practical emergency operations,
whether difficult or not. For example, you must drill
Overall: immediately for acute osteomyelitis, but a patient who needs
(1) We have tried to describe a system of practice which a sequestrectomy for chronic osteomyelitis can wait.
includes all the basics, but is ahead of the practice of many
district hospitals, so that even comparatively advanced ones How difficult is the operation?
have something to aim for. At least three factors determine this:
(2) We have tried to cover most of the range of the 'general (1) your technical knowledge,
surgeon' working in the districts. (2) your experience,
(3) We have tried to describe this system in complete detail, (3) your skill. We can provide you with the knowledge, and
and in doing so would agree with both the quotations with bring you some of the experience of other people, but only
which this section starts. practice will improve your manual skill. A score is given for
(4) We have in our mind's eye a concept of 'quality' at the your guidance. Grades 1.1-5 describe simple procedures that
district hospital level; even simple things can and should be you will definitely have to master. Grades 2.1-5 describe
done well. straightforward operations without serious difficulties or
(5) We have tried to give guidance when things go wrong. complications that would not pose much of a problem for
basic surgical trainees. Grade 3 represents more difficult
This last is most important. Many texts tell you what you operations, with increasing complexity up to 3.5.
should do (in the author’s view); few explain what to do with
complications. If you can correct these, you will often avoid Those procedures of even greater difficulty may be
a catastrophe and gain much satisfaction. You will also build mentioned in passing but not described, as they are thought
a base of great wisdom for the future. to be unsuitable for the situations pertaining where this book
will be useful.
Whether or not you should operate on a given patient will be How safe is the operation? What disasters may happen?
the most important question you will have to answer. Little untoward can go wrong with draining most abscesses,
Put yourself in the patient’s place. What would you like to or manipulating most fractures, but disaster lurks if you
happen if you were the patient? Several factors will decide to close an intestinal fistula, dilate a difficult urethral
influence your decision. We have already discussed one of stricture or do a block dissection of the groin.
them: can you refer him?
12
13
Do you have the instruments, materials, & staff needed? WRITE THESE RULES UP IN YOUR THEATRE:
Even if you do not, you may be able to improvise.
Check that the electricity is working, the blood can be cross- RULES ABOUT DECIDING WHEN TO OPERATE:
matched, the necessary staff are present. Do not be over- (1).You must be certain of the indication to operate, even if
ambitious initially with staff whose expertise you do not it is only exploratory.
know; assess the capability of the hospital to handle certain (2).When life is in danger, take risks and act fast.
procedures. Try to build on your experience, and teach the (3).If a case is hopeless, be prepared to say: “No!”
staff (and yourself) accordingly. Check the instruments, (4).Do not do difficult elective surgery, especially if the
and equipment before you start. Discuss the case with your expected outcome is likely to be of limited value to the
anaesthetist colleague (if any). Is he experienced enough to patient.
administer the GA you require? Is there an alternative? (5).Take trouble to make sure the time is correct to operate,
and all the preparations for surgery are in place.
Are you yourself inclined to operate too readily, or not
readily enough? RULES BEFORE OPERATING: Inform the theatre of
your operation list well in advance, if possible. Book your
Cultural attitudes to operating vary. In Indonesia, for children, clean cases and diabetics first.
example, the common failing is to be too timid, and not to (1).Go over the history, examination and investigations
operate when necessary. The reverse is true in some parts of yourself to confirm it is the right patient: ask him his name
Africa, where inexperienced operators are much too bold. yourself! Confirm the correct diagnosis, and that the need for
So be aware of your own personal and cultural bias and try surgery still exists.
to correct for it. Do not operate out of bravado! (2).If there is a lump, make sure you can feel it. Mark it.
Make sure the bladder is empty.
Is the reason for operation unclear? (3).Ask the patient what operation he expects to be done and
If the indication is vague, wait! Do not be dragooned into explain the nature of this operation, its purpose and
operating by enthusiastic nursing staff or insistent relatives. consequence to the patient: this is informed consent.
Treat the lowliest patient the same as an important politician. You need not scare him or confuse him with medical jargon,
but do not keep him ignorant and make sure he and the
What is the known or probable HIV status of the relatives understand. Use diagrams, stories or even cartoons.
patient? (4).Mark the side to be operated upon with indelible ink.
Take a social and sexual history. Look for tell-tale signs of (5).Make sure the patient bathes the night before surgery,
immune deficiency (5.6). and that especially the operative area has been cleaned.
N.B. You should try to move toward routine HIV-testing Trim his nails, clean the umbilicus, scrub the feet,
especially if antiretroviral treatment is available. remove studs and jewelry. (There is no need to remove all
nail varnish or bangles and threads of religious or cultural
What is the general condition of the patient like? significance, but take down an elaborate hairstyle which may
(1) Check the Hb level (and sickle test if this is common in prevent extension of the neck.) Never use blunt razors to
your area), and the level of malnutrition and dehydration. shave the skin: do minimal shaving. Remove any loose or
(2) Assess the respiratory reserve (11.13). false teeth.
(3) Measure the Peak Expiratory Flow if you can. (6) Check for any allergies.
(4);Can you improve the hydration or nutrition (7).Check that the patient is starved for 4hrs (less for babies),
pre-operatively? but warm, well-hydrated and fit for a GA, fluid-loaded for a
Assess the risks of complications. Remember you will cut, spinal anaesthetic, and that diabetes, hypertension, asthma,
saw, burn, bruise, traumatize and violate your patient, epilepsy, and coagulation are controlled. Do not starve
exposing his tissues to the cold and hostile external patients for long periods waiting for theatre!
environment, spilling his blood and body fluids but the Make carbohydrate drinks available up to 2hrs pre-op to
patient’s own healing mechanisms need to repair the avoid hypoglycaemia. Remember deep vein thrombosis and
damage. You can only assist this process. antibiotic prophylaxis if indicated.
Decision. If you have difficulty knowing what to do and can (8).Check that blood is cross-matched if required, and blood
contacto anyone who might know, do not hesitate to do so. results available.
Try to invite a surgeon to your hospital for a period to give (9).Make sure especially that suction, laryngoscopes,
you instruction first-hand. airways, ambu-bags, masks, endotracheal and nasogastric
tubes, stethoscope and diathermy are available. Make sure
Have this book available in theatre. the patient comes to theatre with the notes, investigation
results and radiographs, and properly signed consent for the
proper procedure (with the correct side, if any, noted).
(10).Familiarize yourself with the operation to be performed
if you are uncertain of any details.
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1.10 Creating the surgical machine ALL FOR A PIECE OF CHALK. There was once a professor of surgery
who found to the astonishment that the operating list had been cancelled.
When he asked why his junior assistant replied, "Because there is no chalk
with which to list the cases". The professor was furious and dismissed the
houseman on the spot. The District Medical Superintendent pleaded with
him, “... such a nice boy...”; even the Minister pleaded, but the professor
insisted that he could not have such a person as his junior. So he continued
to clerk his own cases. Finally, weeks later the repentant houseman came to
him and said, "About that chalk, Sir, I think I made a mistake..."
LESSON Failure to improvise, where this is at all possible, is never an
adequate reason for not doing something.
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Rationalize the use of drugs, especially antibiotics. Look at Try to twin your hospital with an institution you know in a
your establishment figures. You may find that your hospital richer part of the world: the benefits of such contacts are not
has got fat and that you should let it get a bit leaner by not just economical!
recruiting after natural staff wastage. You may find that you
have to return to the staffing ratios and technologies (such as Your greatest asset is the pathology arriving at your door:
making your own plaster bandages) of earlier years. use it! Even simple, but carefully carried out, research is
For example, you will probably find that most patients with valuable and will attract funding to your institution from
pneumonia can he treated without a radiograph and so can outside agencies.
most extension fractures of the wrist. Economize with
sutures, IV fluids, lubricant jelly, stationery and so on. Valuable contributions to the surgical care of the poor have
Use IV drugs only when you have to; remember to use the however been made in South America. In Colombia, it was
rectal route (PR) if the oral route is impossible. found that 75% of all the operations were simple enough to
be done on outpatients with a single anaesthetist supervising
Hospital meetings may often be critical. They will ensure the 2 patients simultaneously in the same theatre, mostly using
co-operation of the leaders of all sections of the hospital, local and epidural methods, and adequately supported by
who will transmit the sense of urgency to everyone else. assistants. Operating theatres were only used for 40% of
They will also help to create an awareness of the economic working hours, surgeons only did 120 operations per year
implications of a decision, to establish priorities, and to and 'physicians' only 18.
ensure the continuation and extension of your economy
drive. Follow up your decisions; someone must check that In most hospitals, services are limited less by resources than
the fire is extinguished once the water is hot, or that the right by motivation. So expect to be able to do much more,
weight of the right cabbages has been supplied. even with what little you think you have. The rest of this
Make sure that the staff know how much money is running section shows what can be done, even when resources seem
through their hands, and that the viability of the hospital to be already stretched to their limit. If you think that
depends on how they use dressing materials, gas, and checking the stores is not your responsibility, remember that
equipment. A public chart showing hospital income and it is critically important for the financial viability of the
expenditure monthly will give employees, and potential hospital, on which your whole surgical endeavor depends.
donors, an understanding of your situation.
ECONOMICAL SURGERY
Money coming in is no less important than money going out.
So try to keep your beds full. Work out a policy to reduce STAFF. You may unfortunately have no control here,
costs to the patient, and to make your services affordable to but your influence is great. If possible try to reduce staff to
as many people as you can. Think about what they can pay the bare minimum by not replacing unnecessary personnel,
and be prepared to lower some charges. However, you may and make sure they do a full day's work. Keep existing staff
be able to offer special treatment, for example in a private busy with additional duties. Junior staff are often willing to
ward, to paying patients, especially if they have a medical have more responsible jobs such as filing and typing, or even
insurance. preparing IV fluids.
Such patients may prefer to come to your hospital for more Try to lay off consistently dishonest and inefficient staff.
individual attention than a large teaching hospital in the city. Encourage punctuality, tidiness and cleanliness.
Consider income-generating projects: a restaurant at the Employ inexpensive ungraded staff where you can,
hospital, a vegetable garden, a dairy, a maintenance service, to relieve more expensive staff of routine tasks. Employ
a garage, a hair-dressing saloon etc. multipurpose workers, such as a laboratory technician who
can take radiographs. Employ married couples where both
You may find it financially more reliable and less stressful to partners are gainfully employed. Do not forget training
lease such activities out to a local entrepreneur. Engage your programmes, and encourage success by certificates and
long-stay patients in making handicrafts or using their skills ceremonies. Take advice across the board: anyone may have
for the hospital (e.g. carpentry, electrical work, sewing). a good idea! This is a strong motivator for staff as they feel
Persuade the major players in the community to invest in the involved.
hospital, e.g. the bank or post office; a branch at the hospital
will be very popular with staff and a big time saver. SAVINGS ON CONSUMABLE MATERIALS
This requires marketing and data collection: make a survey Dressings. If necessary, you can treat most wounds without
of local demands, and needs. One hospital in India had dressings. Clean closed surgical wounds do not need them.
considerable success producing CD’s of elective operations Use gauze and cotton wool economically. Do not make
and selling them to the patients concerned! dressings larger than is necessary. Re-sterilize all dressings
which have not been soiled.
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Avoid using strapping, but if you do use it, use narrow strips Use nylon syringes, such as the French KIGLISS pattern,
and do not allow it to be used anywhere except on the human which you can sterilize indefinitely, and which have a rubber
body. ring to seal the plunger which you can purchase separately.
Hold dressings on with bandages, socks, caps, bras, Do not use disposable urine bags; instead, use bottles and
tight vests, pants etc. tubing from old intravenous sets. Re-use endotracheal tubes
after thorough washing and cleaning with ‘Cidex’ (2.5).
Wash gauze sponges, immerse them in water to remove
stains, dry them and re-sterilize them. If necessary cut up an Catheters. Use simple Jacques catheters if they are less
old polyurethane foam mattress or cushion into small squares expensive than Foley catheters; if you want to leave them in
and use these as swabs and sponges. They absorb blood well. situ, secure them with strapping. Consider carefully if the
Cut up and sterilize old linen. Sterile toilet paper can be used catheter is necessary anyway.
as an alternative to swabs for some purposes.
IV fluids. Make your own for 7% of the price of the
Make up laparotomy pads. Use a sewing machine to join commercial ones. Where possible, use rectal rather than IV
enough pieces of gauze 20x25cm together to make a 5mm fluids. These are not suitable for rehydrating patients,
layer; attach a tape to one end, and when you operate attach but they may be adequate for maintenance. If IV fluids are
a large haemostat to the tape and leave this hanging out of scarce for postoperative patients who have had major
the wound. Laparotomy pads are a more convenient and gastrointesinal or other surgery, insert a nasogastric tube for
economical way of washing and reusing gauze than using it drainage and a naso-jejunal tube for feeding. In this way you
as swabs, and can replace them for some purposes. will greatly reduce your need for IV fluid.
Keep an open wound wet with water. Keeping a wound dry Oxygen is only necessary for such indications as pulmonary
uses many more dressings than treating it wet. The water oedema, asthma, shock, or coma, but not for moribund
need not be sterile, and need not contain salt (except where patients. If you use it for patients with no hope of survival,
sodium loss is important as in burns). Use large quantities of relatives may come to believe that when you switch it off,
water: soak, wash, shower or spray the wounds! it killed them! Get hold of oxygen concentrators:
the economy is well worth the initial expense.
If a wound is suitably sited to be immersed, as with the
arm, leg, or buttocks, immerse it in water for 3hrs bd. Drugs. Use cheaper drugs instead of expensive ones.
Put a leg in a bucket, an arm in a long arm bath, and let a For curettage of the uterus use pethidine with diazepam
patient with a buttock wound sit in a hip bath. instead of ketamine; use aminophylline instead of
salbutamol, aspirin instead of paracetamol, nitrofurantoin
If a wound is not suitably sited for immersion, keep it wet instead of ampicillin for urinary tract infections, and
all day. morphine instead of pethidine for many applications.
N.B. dressings in these situations only serve to protect the Look carefully at the prices you pay for drugs. One supplier
environment. may be 100 times cheaper than another, but beware
counterfeit products! Always consider if antibiotics are
Disinfectants. Do not fill gallipots to the brim. really necessary: they are often over-used! Do not practice
Use cotton wool, not gauze for scrubbing the skin. poly-pharmacy!
Do not use disinfectant for the preliminary 'scrub' to remove
dirt; use soap and water. One gallipot of disinfectant will Sutures. Where possible, use surgical suture material bought
then be enough to prepare the skin. You can use it all day: in bulk on reels, or use nylon fishing line (4.6).
it is self-sterilizing. Only use atraumatic sutures when they are absolutely
necessary. With more expensive suture materials, use
Disposable items. Avoid these and replace them by continuous sutures rather than interrupted ones.
permanent equipment. If you buy plastic equipment which is The application of warm moist gauze packs (especially if
intended to be thrown away, choose the kind which you can soaked in dilute adrenaline) to a bleeding surface will
autoclave or boil. Recycle everything you possibly can, drastically reduce the number of bleeding vessels that you
and try to throw nothing away. need to tie. Use sewing cotton for simple ligatures.
Buy the kind of gloves you can re-sterilize 3-4 times.
Re-use clean sterile gloves as disposable gloves. Scrubbing up. Use ordinary soap not special fluids, if the
Re-use clean disposable gloves for general cleaning work. first costs less.
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SAVING KITCHEN SUPPLIES Solar lighting is practical, virtually maintenance and cost
Find the cheapest supplier and buy at the right season. free and its initial installation is becoming less expensive.
Find out if buying in the market may be better. Solar heating, by allowing the sun to warm black pipes is
Watch tenders carefully, change suppliers when necessary, very effective for producing hot water.
and insist on good quality. Do not let them supply you with Solar refrigerators are available, but their initial cost is high.
old, rotten, or small potatoes. Buy boneless meat, especially Invest in invertors to convert solar 12v to 240v, but beware
offal (liver or heart). Adjust the number of meals cooked to that you do not overuse your batteries. Use solar or hand-
the bed state. Provide high protein diets only on genuine cranked batteries.
indications. Reduce waste. Fill plates moderately and vary
helpings according to the appetites of both patients and staff. OTHER SAVINGS
Keep your own livestock to feed on waste and run your own
vegetable garden if possible. Use the space fully on all case sheets, use paper on both
sides. Make your own forms with a stencil. Minimize the use
ENERGY SAVINGS of paper for internal correspondence. Use scrap paper for
messages.
Washing. Use the timers to set minimum times for washing Do not use so much detergent that it causes foaming in the
and spin drying carefully. Avoid tumble dryers unless the laundry and when scrubbing floors.
climate is very wet; they use much electricity. Register and charge for private phone calls. Send letters with
your hospital transport if possible. Use e-mail or electronic
Petrol or diesel. Diesel vehicles may be cheaper to run but messaging if you can.
need more careful maintenance. Use the smallest economical
vehicle for a given job and avoid unnecessary trips. Control all items that could be used in private homes,
Keep logbooks and use vehicles for hospital journeys only. including torch batteries, soap, matches, pens, toilet paper,
Drive at economical speeds and use moderate engine female sanitary pads, food and medicines. Be firm on
revolutions in all gears. Use public transport wherever discipline when it comes to theft. Remember theft probably
possible. Encourage a style of driving that is considerate for accounts for your greatest ‘expenditure’: inventories and
the vehicle, especially when carrying heavy loads on bad security are mandatory. Proper accounting systems are also
roads. essential: otherwise money will just ‘disappear’!
Also, do not delegate ordering of stock or equipment to a
Gas. Put lids on pots. Reduce the flames when the pot has junior; not only will you get the wrong things but you will be
boiled. Use pressure cookers. Control cooking times. conned into buying expensive varieties of cheap things.
You may be able to insert a system that utilizes gas from Beware offers of ‘new’ equipment from unknown dealers:
compost or sewage, which is very cost-effective, although it is probably stolen or cheaply repaired and will not last.
expensive to install. Practice regular maintenance. Keep an eye open for
breakages and organize repairs early. Establish a climate of
Electricity. Switch off lights when unnecessary (e.g. in accountability. Remember to order stock with sufficient time
daylight!) Use fluorescent tubes instead of bulbs. Heating is to allow for delivery and delays: do not wait till the last Xray
much more expensive than lighting, so make sure it is used film is in the hospital before ordering new supplies!
where really necessary. Make sure you have universal Otherwise you will be forced to improvise with expensive
connectors so you don’t waste time and expense on adaptors. items because the cheaper ones have run out (e.g. using
LED lights (e.g. on a headband) are extremely effective and 3-way catheters when ordinary ones are actually needed).
use minimal power, so are useful if you have to rely on
Solar energy.
Air Conditioning. In hot humid climates, a cool air 1.12 Primary care imaging
environment makes life and work much more comfortable.
Electrically driven air conditioners are expensive and Radiology uses X-rays which provide much useful
frequently break down, and heat up surrounding areas information, particularly about bones but ultrasound (38.2)
outside the room they are cooling down! If you insert a can replace radiographs for very many indications, especially
system of PVC pipes 3m below ground, where the earth in obstetrics except for X-ray pelvimetry. Think carefully if a
temperature is virtually constant, and blow air through these radiograph is likely to give you essential information.
pipes with a simple fan, you can cool the room temperature Remember quite sophisticated interventional radiographs can
by about 10ºC and reduce humidity by 40%. be taken with simple means (38.1).
This system also avoids the dust that regularly contaminates
electrical air-conditioners. THE PATIENTS ARE OURSELVES
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Fig. 1-8 THE BRS X-RAY SYSTEM was developed by WHO to make
essential cost-effective radiology available safely and reliably all over 1.13 How to use these manuals
the world. If you want one of these machines, order one made to WHO
specifications. Note the screen protecting the operator.
Kindly contributed by Philip Palmer.
You will notice that after 5 chapters on 'the basics' there are
WHO has made a great advance in the X-ray departments of the world's
district hospitals by developing the BRS (Basic Radiological System).
5 on draining pus. Then come chapters on the abdomen and
The BRS machine shown (1-8) is made by several manufacturers to WHO hernias, followed by obstetrics, gynaecology, and the breast.
specifications. If you are thinking of buying an X-ray machine, this is the After this there is the surgery of special areas (thyroid,
one to get. If you do not have electricity all day, you can run it on a battery proctology, urology, etc.) then finally terminal care and
which you charge when you turn your generator on. It is so simple that a
radiographic assistant can easily work it, but if you have a radiographer who
imaging.
has been trained to use a more sophisticated machine, he may not like this
one because it does not give him enough freedom to adjust the settings. After dealing with general principles of trauma management,
The BRS machine is based on the assumptions that: (1) A good chest Volume 2 deals with various regions in turn.
radiograph needs a short exposure, and a substantial distance between the
patient and the tube. (2) A radiograph of the lumbar spine will be one of the
heavier exposures required. It has therefore been designed to produce at In writing these manuals we have tried to make both
least 80mA at 18kV, not one or the other, but both simultaneously. It has a language and the typography work for you. You will notice
fixed tube-to-film distance of 140cm, which gives satisfactory chest films that we use the imperative, avoid the passive voice, and refer
and is the ideal distance for most other investigations. The tube is fixed so
that it can use an accurately focused grid of high quality. The tube and the
to ‘the patient’ and then mostly to ‘him’, which does in fact
film are always accurately focused on one another and cannot be angled usually mean both ‘him and her’. Alas, English, unlike
independently. This makes it easy to position the patient and makes routine French, has no personal pronoun which includes both sexes
views exactly repeatable. The supporting arm of the tube and the film can be and we have refused to use the grammatically incorrect
rotated through at least 270º, so that horizontal and vertical projections are
easy, and angled views are possible. Erect views of the skull, sinuses,
‘them’. Our use of ‘he’ or ‘him’ to include both sexes
shoulders, or abdomen are as easy as routine views of the chest. improves clarity, and shortens the text, but we owe our
A radiographer's manual is available; so is a manual of radiography to go apologies to our lady readers!
with the machine. We have used 7 degrees of approximate commonness:
very common, common, not uncommon, uncommon,
ECONOMY IS ESSENTIAL TO SURGERY unusual, rare and very rare. This is based on experience of
the authors and may not apply exactly in your situation.
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A SUGGESTED INITIAL READING LIST Do not let things you cannot do, because you do not have the
Start by reading the whole of this chapter. In those which necessary equipment or drugs, prevent you from doing the
follow, read only the introductory passages, and merely things you can do.
glance at the detailed didactic instructions which follow.
Whenever you refer a patient, try to learn from the person
Read these carefully later when you need them to guide you you refer him to. If possible, be there when he is examined.
in a specific situation. Start with the common things first. In the same way, if someone refers a patient to you,
he should be there so that you can teach him.
Read particularly the first section of each chapter and the
following: the major theatre (2.1), aseptic theatre technique What methods are your staff using? For example, if medical
(2.3), autoclaving (2.4), antibiotics in surgery (2.7 to 9), assistants treat fractures in your hospital, study the methods
the control of bleeding (3.1,2), bloodless limb operations they use and encourage them to use those described here.
(3.4), the instruments (4.1-5), suture materials, sutures and If they might find this manual useful, see that they have a
needles (4.6 to 8), drains (4.9), instrument sets (4.12), copy and go through it with them.
'pus' (6.1 to 24), pyomyositis (7.1), osteomyelitis (7.3),
septic arthritis, especially the positions of rest and function If a patient dies and you are not sure of the diagnosis,
(7.16), hand infections (8.1), empyemas (9.1), try to get permission for a post-mortem examination.
peritonitis (10.1), abdominal surgery (11.1 to 15), the acute
abdomen and intestinal obstruction (12.1 to 16), Make good use of the endpapers and charts you find in these
appendicitis, (14.1), inguinal and femoral hernias (18.1 to 8), manuals:
and PID (23.1). WHO Safety Check List (1.8), Endoscopy form (13-10),
Partogram (21-2), Fundal height chart (22-15), Baby head
THE MAIN ANATOMICAL DRAWINGS are the circumference chart (33-17), & Foetal growth centiles
following: mandibular region (6-7), parotid (6-8), (38-6,7,8).
mouth (6-9), anorectum (6-13, 26-1), anterior thigh (7-18), Where convenient, photocopy them and stick them up on the
hand tendon sheaths(8-4,7), pleurae (9-1), peritoneal cavity wall, or have them printed.
(10-5), anterior abdominal wall (11-1), broncho-pulmonary
segments (11-23), biliary tract (15-3), inguinal region IF YOU ARE A SURGICAL TEACHER, try to integrate
(18-3,4), uterine blood vessels (22-14, 35-20), relations of these manuals into your teaching, and base your examination
the ureter (23-20), ligaments of the pelvis (23-21), questions on them. Aim, less that the students should know
eye (28-1), auditory pathways (29-2), carotid artery (29-7), these manuals, than that they should know their way around
tonsil (29-10), tibialis posterior (32-29), ventricular system them, and be prepared to use them.
(33-18).
There are also the following transverse sections: In-patient hospital records often provide life-saving
forearm (7-8), thigh (7-9, 35-18), calf (7-11), hand (8-1), information which cannot be found elsewhere; they are a
ankle (32-18), wrist (32-35). medico-legal obligation, and should contain all the important
details of patients. There is no real need for nurses and
IF YOU ARE A GENERAL DUTY MEDICAL OFFICER, doctors to keep separate records. Both could write in the
do not be ashamed to refer to these manuals. A patient will same set of notes! A proper hospital filing system is
be more grateful for being correctly treated than for being essential; notes are best stored by number (not name,
wrongly treated because you could not remember something as patients may use different names on occasions) using the
and had to guess! For example, you cannot possibly last two digits, thus:
remember all the steps in the general method for a spinal
injury, or a hand injury, so why not refer to them in front of a ……236000, 237000, 238000….259100, 269100,
patient until you have examined so many patients that the 278100….243200, 252200, 255200….etc…..209800,
necessary clinical routines become automatic? 243800, 246800etc…..256001, 264001, 265001….201002,
If his condition is difficult to diagnose, ask him to wait until 222002, 265002….etc
the end of the clinic, and then use the routines we give here
to try to reach a diagnosis. A patient’s ID number could be used if necessary.
Keep these manuals in the theatre. If a procedure is long or Patients’ social details should indicate: Name, Date of Birth,
difficult, sit in an armchair and study it in peace, before you Address, Next-of-kin, and mobile phone number.
try to do it. Then study it again after you have done it.
Do not expect to be able to do everything we describe If you can get your hospital records digitalized, so much the
immediately. Progressively extend your practice, little by better, but remember that your hospital ‘memory’ will need
little. constantly to be upgraded!
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Straightforward physical cleanliness is important. Do not have more shelves than you need, but keep the
Sophisticated methods are unnecessary. Sluicing the floor things you need daily nearby; use trolleys where you can.
between cases, washing the walls weekly and When shelves are needed, set them 50mm away from the
mobile equipment daily will ensure a high enough wall on metal rods, so that they can be lifted away for ease
standard without using antiseptics on the theatre itself. of cleaning. All shelves should be at least 1m high so that
The floor is important. trolleys can be pushed under them. The glove shelf should
The most dangerous sources of infection are pus and be at least 1·2m high, so that you can keep your hands
excreta from the patients, which must be cleared away higher than your elbows to prevent water running back
between every operation, and must not be allowed to down over your now dry hands. The anaesthetist needs a
contaminate the theatre. To make this easier, it should lockable cupboard, a trolley, a worktop near the patient's
have a terrazzo floor, but a smooth concrete finish is head.
almost as good and much cheaper. To make it easier to
wash down, it should have a 1:1000 slope towards an open Electric sockets should be 1·5m above the floor to
channel along the foot of the wall at the unsterile end of minimize the danger of igniting explosive gases,
the theatre. This channel should have a plugged outlet and damage from moving beds and trolleys. Make sure
leading directly outside to an open gulley. Fit a sparge pipe your electric sockets are uniform, and you have equipment
to the wall at the sterile end 150mm above the floor, working with the hospital voltage. You can easily overload
so that the whole floor can be flooded by turning a tap. the system if you have lights, a sterilizer, suction
A little dust on trolley wheels or shoes, or from open machines, lights, fans, diathermy all working at the same
windows, is less dangerous than is generally believed, time. Make sure you have an emergency power source.
but remember hair, fibres and fluff tends to get caught in A foot suction pump, and hand-torches are useful in a
wheels and need to be periodically removed. crisis.
The walls of the theatre should be smooth, but they need
not be tiled. A sand and cement backwash application Basic requirements are:
painted with one coat of emulsion and two coats of
OPERATING TABLE, simple pattern. The minimum requirements of an
eggshell gloss is adequate. Gloss paint is satisfactory for
operating table are that: (1) you must be able to tilt the patient's head
the walls, and the fewer the doors, sills, ledges, crevices, down rapidly for the Trendelenburg position, and if he vomits.
mouldings, architraves, and window boards, the better. (2) you should be able to adjust its height. This table does these things at
The main point is that the walls must be washable a fraction of the cost of the standard hydraulic ones, which need careful
maintenance, and are useless when their hydraulic seals perish.
preferably up to 3m.
However, if a simple general purpose hydraulic table is well maintained,
Every time a door is opened, dust from the floor is whirled it lasts a long time. A really sophisticated one can cost as much as the
into the room. There is no need for a door between the entire building of the theatre. A dirty table is a menace, so make sure
changing rooms and the theatre. A door is only needed yours is kept clean.
If the head of your table does not tilt head down, get one that does.
between the sluice and sterilizing room, if these rooms will
Meanwhile, in an emergency, you can put a low stool under the bar at its
be used when the theatre is not. foot. If it does not tilt from side to side, make a wooden wedge to fit
under the mattress. If it does not have a kidney bridge and you need one,
The ceiling should be at least 3.5m high and the roof use folded plastic covered pillows.
Locally made 'Chogoria' supports (19-3) are a useful addition to a
timbers solid enough to support an operating light.
standard table. They are made of 2 suitably bent pieces of pipe which fit
It should also have a pair of 2m fluorescent tubes, into the holes for ordinary stirrups and keep the patient's hips widely
or LED lights. abducted, and the hips and knees moderately flexed, so that the lower
The ambient level of illumination should be high, so make legs are horizontal. The legs rest on boards attached to these pipes.
These supports are more comfortable than stirrups and are particularly
the windows big enough. They may enable most
useful for such operations as tubal ligation.
operations to be done by daylight. A suitably placed ALTERNATIVE OPERATING TABLE, Seward minor or equivalent.
mobile mirror to catch the bright sunlight is very useful. This is slightly more versatile and considerably more expensive than the
There should be a window of 5m2 at the head and the foot table above.
MATTRESS, for operating table, with three or more mackintosh covers.
ends, facing north and south shaded by a roof overhang of
A dirty mattress is a potentially serious source of infection. So swab the
at least 800mm. Even better are windows on three sides. cover after each patient, and replace it regularly.
Fit ordinary low windows, and frost only the panes below ARM BOARDS (2), for operating table, locally made. These are simply
eye level, so that the staff can look out (which improves pieces of hardwood about 20x120x1000mm, which you push under the
mattress to rest the patient's arm.
morale), but that anyone looking in can only see their
STOOLS (2), operating, adjustable for height, local manufacture.
heads, not the patient. If you do much operating, a chair with a padded seat, wheels, and a back
greatly reduces fatigue.
In the tropics avoid windows in the roof. You may need LIGHT, operating theatre, simple pattern, preferably with sockets to take
bayonet or screw fitting domestic pattern light bulbs, in addition to
fans to reduce the temperature, but remember they can
special bulbs. Most operating theatre lights take bulbs which are
blow dirt and dust into wounds! Electrical air conditioning irreplaceable locally, and may cost US$70 each, so find out what bulbs
is notorious for collecting dust and transmitting bacteria: your light takes, and try to keep at least three spares. Record their
it should not be a high priority: use an alternative (1.11). specification and catalogue number somewhere on the lamp casing.
When new lights are ordered, they should have fittings that can,
Make sure the theatre still remains warm enough:
if necessary, take ordinary domestic bulbs. An LED operating or head
hypothermia due to exposure still occurs in tropical light is a very useful help or alternative.
regions, especially at night. It is comfort of the patient,
who is practically naked, not of the surgeon, that is
important.
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CLOCK, wall, electric, with second hand. This is essential, you must
have a proper awareness of time, especially when you apply a tourniquet
(3-6), and without a clock you can readily forget it. The instructions
given here for controlling bleeding by applying pressure sometimes tell
you to wait 5mins by the clock.
INSTRUMENT CABINET glass door, sides and shelves,
1300x600x400mm, local manufacture.
RADIOGRAPH VIEWING BOX, standard pattern, local manufacture.
INSTRUMENT TROLLEYS (4) without guard rail, with two stainless
steel shelves, antistatic rubber castors, (a) 600x450mm, and
(b) 900x450mm. Glass shelves ultimately break, so stainless steel ones
are better. A larger table will make it easier to lay up for larger cases,
especially orthopaedic ones.
STAND, solution, with antistatic rubber-tyred castors, complete with two
350mm stainless steel bowls, side by side. Put water in one bowl, and use
the other for spare instruments and the sucker. The bowls can be
sterilized in the autoclave or in a boiling water sterilizer.
DRIP STANDS, telescopic. Or, less satisfactorily, use long wire hooks
suspended from the ceiling near the head of the table. Hooks for drips
sticking out from the wall are useful above some beds in the wards.
SUCTION PUMP, operating theatre, electric with two 1lunbreakable
plastic bottles and tubing. These are always breaking down, so the model
Fig. 2-2 A SIMPLE THEATRE AND ITS TABLE. chosen must be easy to service and spares should be available.
A, this is about the smallest practical theatre possible. B, simple If you are going to depend on an electric sucker, make sure it can actually
pattern operating table described. suck before the operation starts. A sucker which makes a noise may not
A, adapted from Mein P, Jorgensen T, Design from Medical Building, necessarily suck.
AMREF, Nairobi, 1975 with kind permission SUCTION PUMP, foot operated, with two wide mouthed 1lunbreakable
plastic bottles, rubber bungs and metal tubes.
SPOTLIGHTS (2), free standing on the floor, 'Anglepoise' type, to take This is an automobile pump with the valves in it arranged to suck instead
ordinary domestic pattern bulbs. Also, high efficiency internally of pumping. Both the surgeon and the anaesthetist need a sucker,
reflecting bulbs (5) to give a parallel beam. These are necessary, so you need 2 at least. A hospital workshop may be able to make one of
both as a standby to the main theatre lamp, and to illuminate positions these suckers by altering the valves of a truck tyre pump.
that the main theatre light cannot reach. A normal spotlight can direct an A foot sucker is much more reliable and more easily repaired than an
undesirable amount of heat into the wound, so, if possible, get LED lights electric one. If you use an electric sucker, make sure you have a foot
which produce little heat. These are more expensive initially, but have a sucker also.
longer life. You can improvise a spotlight by removing the headlight of a SUCTION TUBES, metal, Poole’s abdominal, wide bore, with guard.
car, especially the sealed beam type, and attaching it to a drip stand in the The standard laryngeal suction, the Yankauer type, is used by the
theatre. Connect it with a long lead to the battery of a car outside. anaesthetist at almost every operation, but not so useful for the surgeon.
Or use a slide projector held by an assistant. If the level of illumination is A small Gilles suction tube is useful for fine operations.
not enough, especially for eye surgery, you can increase the contrast by Connect it through a piece of sterilized rubber tube to one of the suction
blacking out the theatre. pumps.
SOLAR PANEL, charger, and battery. A single solar panel will collect a (If you do not have a suction tube, suck using the rubber end on its own,
useful quantity of electricity and enable you to light two wards in the but beware of damaging bowel if the suction pressure is high.)
evenings. DIATHERMY. Bipolar diathermy is only useful for fine surgery;
BATTERY CHARGER for the common sizes of rechargeable dry otherwise a simple unipolar diathermy is sufficient.
batteries, and five rechargeable batteries of each size. This will enable
you to recharge batteries for your torches and laryngoscopes etc.
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MONITORING EQUIPMENT. A pulse oximeter is very useful; GOGGLES, wrap-around, industrial. These should be used when drilling
a continuous ECG monitor is valuable but less essential. Expensive or splashes are expected.
continuous blood pressure recording equipment is desirable but GOWNS, cotton. These should go right round the wearer and cover the
unnecessary, and if faulty may give a false sense of security. back. They should have long enough sleeves to reach the surgeon’s
SUITS, theatre, cotton, with short sleeved shirt, and long trousers, wrists. Before sterilisation they must always be folded so that the inner
assorted sizes, local manufacture. The purpose of these is to make sure surface on the wearer is exposed to the outside in the drum.
that nobody enters the theatre in ordinary clothes, or in clothes worn GLOVES, operating, sizes 6 to 8. Remember that gloves are designed to
elsewhere in the hospital. Everyone entering a theatre should put on a protect the surgeon as much as the patient. The type of gloves you buy is
theatre suit in the changing room, having taken off their outside clothes. critically important, and so is the relative number of the various sizes.
These suits should be laundered, and if possible ironed, but need not It is useful if they can be re-sterilized, when not soiled by their first use.
normally be sterilized each time they are used, unless they have been Most females wear size 6 to 7 and most males size 7 to 8. Pack each pair
used for septic cases. You should discourage the habit of staff who have in a cloth or paper envelope, one glove on each side with its cuff turned
been out of theatre in their theatre suits, coming back without changing. outwards. Gloves are more useful to protect you and the next patient,
than the patient you are actually operating on. Long arm-length gloves
are useful for septic or bloody laparotomy cases.
GLOVES industrial. These are useful for picking up hot objects, cleaning
floors and surfaces and used on the correct indications will save many
pairs of surgical gloves.
N.B. Avoid glove powder, especially starch or talc because it causes
granulomas particularly in the abdomen, and also is prone to produce
allergic reactions. Never use it when preparing equipment for
auto-transfusion.
SOAP, hexachlorophene, carbolic. If necessary, the cheapest soap that
does not irritate the skin will do. A liquid soap dispenser may prove not
only more efficient but more economical. Spirit disinfectants between
clean cases is effective and saves on soap.
BRUSHES, nylon, nesting, autoclaveable. Autoclave several of these
each operating day and store them between cases in a bowl of antiseptic
solution. They will last longer if you merely keep them clean and
immerse them in an antiseptic solution.
TOWELS, cotton, green, theatre. (a) Hand towels 25cm square.
(b) Theatre drapes 100x75 cm. (c) Abdominal sheets. An abdominal sheet
covers a patient completely from head to foot and has a slit in it through
which the operation is done. The upper end acts as a guard which keeps
the patient's head and the anaesthetist out of the operative field.
GASES. Cylinders need to be re-filled; if this is not possible, for a reliable
Oxygen supply, an Oxygen-concentrator, which extracts the gas from the
air, is very useful. Note that oxygen cylinders are black with a white top,
whereas Nitrous Oxide cylinders are completely black.
ANAESTHESIA DELIVERY SYSTEM. A ‘draw-over’ low pressure system
which is leak tolerant and uses air is far more reliable than a sophisticated
Boyle’s machine. Make sure equipment for airway management
(ambu-bag, mask, Guedel airways, ET tubes, laryngoscope with working
batteries and bulbs, and stethoscope) is always available.
HEATER to warm the theatre when it is cold (especially at night), and to
warm IV fluids and lavage fluid. Even in tropical climates, patients
(especially babies) can become hypothermic!
Fig. 2-4 SOME SURGICAL LAYOUTS. Other supplies: (1) Pyjamas and pyjama trousers. (2) Dresses.
This incorporates the theatre in 2-2 in progressively more developed (3) Macintosh drapes, 75x100cm. (4) Squeegees. (5) Bucket and mop.
settings. A, the absolute minimum. The changing is done in the
sterilizing room. B, similar but has an anteroom and staff changing N.B. Make sure extra staff can be found &called in case of
room. C, the arrangement recommended, which is x2-3 the cost of A. complications or emergencies.
(1) sluice. (2) scrub up. (3) sterilizing room large enough to prepare
sterile items for the rest of the hospital. (4) theatre table.
(5) anteroom. (6) changing room with shower and toilet.
(7) cupboard. D, further addition of (8), a minor (clean) theatre.
Adapted from Mein P, Jorgensen T. 'Design from Medical Buildings'
2.2 The minor theatre
AMREF, Nairobi, 1975 with kind permission.
CLOGS, assorted sizes. Rubber boots are outmoded; sandals are less easy A minor theatre for septic cases will help to maintain the
to keep clean and as they are open, provide inadequate protection. sterility of the major theatre. Use it for draining all
Use them only at the barrier between the theatre and the rest of the abscesses, and for the closed reduction of fractures.
hospital. It will need a simple operating table which tips, and a
APRONS, mackintosh, assorted sizes, local manufacture. These protect
the suits and are worn under a theatre gown. If they are merely hung up in second set of basic anaesthetic equipment, including
the changing room after use, they become progressively more especially a sucker and the equipment for resuscitation.
contaminated and more dangerous. So make sure that they are at least It will also need at least two minor sets (4.12), three
washed and regularly swabbed down with an antiseptic solution, and are incision and drainage sets. If possible the minor theatre
always swabbed after septic cases. Keep two for special clean cases only.
CAPS, cotton. Put on a cap before you enter the theatre, and make sure it should have its own instruments and not be supplied from
completely covers your hair (scalp & beard)! the main one.
MASKS, theatre. The use of these is controversial: if the surgeon has a Do not use this minor theatre for general anaesthesia (GA)
bad cold, he should better not operate. Most masks do not prevent cases.
passage of air-borne bacteria, and cotton muslin masks are useless.
They do protect against blood splashes, and should be used to cover a N.B. Remember there is really no such thing as minor
surgeon’s beard! surgery for the patient!
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ENTERING THE THEATRE. Anyone entering the theatre Rub your hands and forearms to 5cm above your elbows
must change, in the changing room, into clogs and into a thoroughly. Wash your forearms and your hands.
theatre pyjamas or dress. This is important also when Then take a sterile brush and put soap on it. Scrub your
someone has left the theatre (in theatre attire) for the wards nails (2-5C), thoroughly for the first case in the day.
or casualty (accident & emergency) department, N.B. Make sure all surgical staff keep their fingernails
and returns. (Many hospital routines concentrate on short, and have long hair tucked away!
putting on overshoes, gowns etc. on leaving the theatre; Rinse the suds from your hands while holding them high,
more important is to change again on re-entering.) so the water runs off your elbows (2-5E).
You must insist that theatre clothing is not just worn over Turn off the taps with your elbows, if this is possible
ordinary outside clothes. Clogs are better than boots, (2-5D); otherwise ask someone else to do it. Blot your
which become sweaty and smelly. Tennis shoes are hands dry on one corner of a sterile towel (2-5F),
an alternative to clogs but get soaked by fluids. taken from the gown pack without contaminating the gown
However, you can likewise soak them to clean them! itself. Then dry your forearms, using a different (dry) part
of the sterile towel.
There is no proof that masks are helpful, except in
protecting the surgeon (or nurse) from splashes. A sneeze If you can get disinfecting spirit for the hands, you only
passes through all masks; a person with a bad respiratory need wash with soap initially or after septic cases;
infection should not be in theatre at all! Masks are an it is easy to become slack with any method.
unnecessary expense.
GOWNING. Hold the gown away from your body,
POSITIONING THE PATIENT high enough to be well above the floor (2-5G).
Allow it to drop open, put your arms into the arm holes
Do this carefully before you scrub, so that you do not have while keeping your arms extended. Then flex your elbows
to disturb him by altering the drapes or lights during the and abduct your arms. Wait for the circulating nurse to
operation. Make sure IV lines, catheter, nasogastric tube help you. She will grasp the inner sides of the gown at
are in place and functioning. Check that there is sufficient each shoulder and pull them over your shoulders, and tie it
room for you, the anaesthetist, the scrub sister and an at the back (2-5H). Do not touch the outside of your gown
assistant (or two). till you have sterile gloves on.
If you use diathermy, place the earth plate in contact GLOVING. Try to avoid using glove powder even if you
with the skin of the buttock or leg before draping. are using re-sterilized gloves. Be careful to touch only the
Make sure it has been tested, e.g. on a bar of soap. inner surface of the gloves. Grasp the palmar aspect of the
turned down cuff of a glove, and pull it on to your opposite
Pay close attention to pressure points, particularly in hand (2-6A).Leave its cuff for the moment. Put the fingers
emaciated patients, and when legs are put in lithotomy of your already gloved hand under the inverted cuff of the
position. other glove, and pull it on to your bare hand (2-6B).
Holding the sleeves of your gown tightly folded against
If a patient is in the lithotomy position, make sure he is your body, pull the glove over the wrist. Then do the same
pulled down sufficiently so that the perineum is then quite for the other hand.
free from the end of the bed. Make sure the legs do not fall N.B. If you do use powder, always wash it off your
out of the stirrups! gloved hands with sterile water to remove it completely.
If a patient is prone, make sure the abdomen is free to Now help the next person who has gowned on with the
move with respiration. Fold the arms under a pillow on gloves.
which the head, turned to one side, is resting. (If you wear 2 pairs of gloves, you may prefer to put the
first pair on before gowning. The 1st pair could be one that
If a patient is in the lateral position, make sure he is has been re-sterilized.)
cushioned and supported, and there is a pillow between the
knees. You may prefer to ask the already scrubbed, gowned &
gloved theatre nurse to hold open the gloves, with the cuffs
Make sure the theatre lights are directed correctly once everted, for you to slip your hands inside. This is easier
you have pumped the theatre table to an agreeable height. and a safer method, but relies on the scrub nurse’s gloves
being sterile!
SCRUBBING UP. Remove any jewelry. Open a gown
pack without touching the inside of the pack. Check that it MAKE SURE YOU HAVE FOLLOWED THE
is properly autoclaved. Adjust the taps to deliver water at a CAUTIONS LISTED (1.8)
comfortable temperature. In most tropical countries only a
cold water tap is necessary. Wet your hands, apply a little It is a good idea if using local anaesthetic to infiltrate
soap or detergent, and work up a good lather. before scrubbing, in order to allow it time to take effect.
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THE OPERATION SITE Clip them at their intersections. If the towels are in danger
of falling off, secure the towels with a stitch. Do not clip
Make sure the patient has bathed before the operation and the skin with clips as this may cause skin necrosis.
the operation site is clean. Remove any jewelry or skin For an abdominal operation, cover the whole abdomen
piercing. with an abdominal sheet with a narrow quadrangular hole
Check the side to be operated upon. Make sure it is in its centre.
marked with a permanent marker. If not, confirm the side Remember to complete the draping at the beginning of the
with the anaesthetist and scrub nurse. operation if more than one operation site is needed,
Put a septic limb to be amputated in a plastic bag already e.g. for skin grafting. Make sure the perineum is securely
on the ward and seal the bag with wide tapes onto the leg. covered, and that drapes round limbs are secured snugly
In the theatre cover the bag with sterile towels. with clips or bandages. You can cover a hand or foot by
Take the amputated limb out of the theatre before putting on an extra large sterile glove and inverting it over
recovering the towels. the extremity.
Check the position of the patient on the table yourself. If the patient is awake (e.g. with spinal anaesthesia)
put drapes across two drip stands to separate the head from
SHAVING. The operation site should be socially clean the operative field. If important areas near the surgeon
before the operation, and you may have to check this. become contaminated, remove them and cover the patient
There is usually no absolute need to shave a patient. with fresh sterile towels.
If you shave or clip the hair, do so on the morning of the
operation, or as part of the operation, and limit this to a SUCTION TUBING & DIATHERMY. Secure these to the
narrow zone (2-5cm) around the planned incision. drapes securely with towel clips, so they do not fall off
Make sure you remove the cut off hair (this can be done during the operation.
with an adhesive tape and washing); otherwise the hair
will end up in the wound. SWABS AND PACKS. Use 10cm gauze squares on
If you do the shaving a day or two before, minute sponge-holding forceps ('swabs on sticks'). You will also
abrasions in the skin will become infected and the risk of need abdominal packs. Make sure these are counted and
wound infection will increase. Betadine shampoo checked at the end of each operation, and then disposed of
especially of the head and groin is particularly useful after quickly in the sluice.
shaving.
CLEANING THE THEATRE. Remove clutter. Wash the
SKIN PREPARATION. Do this as soon as the patient is floor and clean the table and accessories after each
anaesthetized. Use an alcoholic-based solution, preferably operation. Clean the theatre thoroughly after each day's
iodine, if possible: check for the patient’s sensitivity. list, and completely every week. Fumigate after a septic
Take a sterile swab on a holder, start in the middle of the procedure with formalin.
operation site, and work outwards. Be sure to prepare a
wide enough area of skin, including any additional areas CLEANING INSTRUMENTS. Use an old nail-brush.
needed for example in skin-grafting. In an abdominal Open hinged instruments fully, scrub them, and take
operation this should extend from the patient's nipple line special care to clean their jaws and serrations.
to below the groin. Beware of sharps!
N.B. Make sure the alcohol-based solution dries
because of potential burn hazard if you use diathermy. DIFFICULTIES WITH ASEPTIC METHODS
Avoid spillage under towels, and seepage under a If you have no gloves or very few gloves, scrub up and
tourniquet where it may remain in contact with skin for a then rinse your hands and arms in alcoholic chlorhexidine
long time and cause irritation. (2.5). The alcohol will dehydrate your skin. You can
N.B. There is no justification for using skin preparation reduce this by adding 1% glycerol to the solution.
twice. Unfortunately, although antiseptics may help to protect the
patient, they are not effective in protecting you from HIV
CATHETERIZATION. For major abdominal and pelvic (5.3) so use a ‘no-touch’ technique, using instruments
operations, catheterize the bladder using an aseptic between you and the patient. Limit your operating to
technique (27.2) before draping. Do not catheterize emergencies.
routinely for other abdominal procedures. Change your
(outer) gloves: these can then be re-sterilized. N.B. If you tear or contaminate a glove during an
operation, remove it. Grasp its cuff from the outside, and
DRAPING. Wait until the patient is anaesthetized. Aim to pull it down over your palm. Alternatively, if it is not
leave the operation site alone exposed and all other parts soiled, put on another sterile glove on top over it,
covered. Place the first towel across the lower end of the in the same way as described above.
operation site. Place another across its nearer edge.
Apply a towel clip at their intersection, under the folds of If you have no drapes or gowns or very few of them,
the drapes. Place another towel across the opposite edge of use plastic sheets and aprons and soak them in an
the site, and finally one across its upper edge. antiseptic solution (2.5).
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Steam is generated in, or admitted to, a jacket round DRESSING BOXES, stainless steel, with hinged lid and perforated
sliding shutters at front and back, 250x200x150mm. Use these for
the chamber, rather than in the chamber itself.
sterilizing gloves and dressings.
This jacket keeps the walls of the chamber hot, which TRAYS, dressing, without lids, stainless steel, 275x320x50mm.
prevents condensation and helps to dry the load. Use these to prepare sterile sets for the wards. Boil a tray and the
Steam enters the chamber through a pipe at the top and instruments, lay a sterile towel on the tray, put the instruments on it and
fold it over them. Better, autoclave the tray.
displaces the air it contains. Air, condensate, and excess
steam escape through a pipe at the bottom. This pipe has a
thermometer in it to record the temperature in the bottom
of the autoclave.
In some autoclaves a water pump, which works on the
same principle as an ordinary laboratory water pump,
sucks out some of the steam afterwards (post-vacuum).
There is also a means of admitting sterile air to break the
vacuum at the end of the cycle.
The drain at the bottom of the chamber should have a
'near-to-steam trap', which will allow the discharge of
condensate and air, and will close automatically when they
have been discharged, and the trap meets live steam,
thus avoiding the need to close valve 13 (2-7) manually,
which could spoil sterilization.
The thermometer records the temperature in the chamber
drain, which is the coolest part of the autoclave.
When this reaches the operating temperature, the timing of
sterilization can begin.
More sophisticated autoclaves have better pumps,
a recording thermometer, a thermocouple to measure the
temperature of the load, and an automatic control system.
Inadequate sterilization is an important cause of wound
sepsis in poorly maintained theatres.
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CAUTION! Let the air and the steam escape freely until
STERILIZER, boiling water, electric: (a) 'Bowl sterilizer',
there is no more air in the autoclave, this usually takes
450x350x380mm, with counterbalanced lid, 6 kW, with six spare
elements, state voltage. (b) Instrument sterilizer, 350x160x120mm, about 10mins. To test this lead a rubber tube from the
1·2kW, with 6 spare elements, state voltage. One of these is for trays and discharge tap into a bucket of water. When air no longer
bowls, and the other for instruments. Keep them both in the preparation bubbles to the surface, there is no more air. After some
room. Never try to sterilize anything contaminated with faeces with
trials you will learn how long to allow for this to happen.
boiling water in a sterilizer - it does not destroy spores.
FORCEPS, (2) sterilizer, Cheatle's, 267mm, Close the discharge tap. Let the temperature rise until it
FORCEPS (2) sterilizer, Cheatle's extra large, 279mm, complete with reaches 121ºC. The safety valve will open and allow steam
can of appropriate size for antiseptic fluid. These are useful for bowls to escape. It should come out with a pure hissing sound
and utensils, and will also pick up small objects.
rather than gurgling indicating the presence of air.
FORCEPS, bowl sterilizing, Harrison's double jawed, complete with can
of appropriate size for antiseptic fluid. Autoclave these and Cheatle's Now start to measure the holding period and continue this
forceps and their cans after each day's use, then fill them with fresh for 15mins. Then, turn off the heater and allow the
antiseptic fluid. autoclave to cool, until the pressure gauge records zero
pressure. Do not open the autoclave whilst the pressure is
Many hospitals do not have piped steam supplies. still high: you might be badly burnt! Then open the
If so, use a vertical autoclave. Your electricity supply may discharge tap and allow air to enter the autoclave.
be unreliable; think about using an alternative such as gas. Remove the load.
There are many pitfalls. Start by inspecting your CAUTION! If anything in the load has paper or cloth
equipment and taking an interest in it. Read the maker's wrappings, do not allow them to touch anything unsterile,
instructions carefully, and make sure that: until they have dried, because microbes can penetrate wet
(1);it has been properly fitted and tested. For example, paper.
if a water ejector pump is fitted, it is likely to need a water
pressure of 1·5kg/cm². JACKETED AUTOCLAVE (2-7B)
(2);all the staff who use it understand how it works,
and how to use it effectively. They must realize the Keep the jacket full of steam at 121ºC throughout the
importance of packing the drums loosely, the need to working day. Drain the chamber to remove any water that
discharge the air, and the correct holding time. may gather in it. Load the heated chamber, close the lid,
and open valve (13).
STERILIZING WITH MOIST HEAT
BOILING WATER STERILIZING. Open valve (14). When the temperature
on thermometer (12) has reached the sterilizing
Make sure that every article for sterilization is cleaned temperature (usually 121ºC), the holding time can start.
thoroughly to remove dried blood, pus or secretions before Close valve (13). If it is letting much steam through,
it is sterilized. Remove instruments from boiling water the temperature will not reach 121ºC, until it is closed.
with long-handled Cheatle's forceps which have been in So close it as soon as no further air and condensate come
saponated cresol ('Lysol') up to their handles. If you are out of the chamber. If you still do not get the temperature
not wearing sterile gloves, make sure you let the you need (usually 121ºC), open valve (13) for a minute or
instruments dry. If you use them wet, bacteria from your two and try again (a near-to-steam trap does this
hands may flow down from your fingers in drops of water. automatically). When the temperature has been reached,
start timing.
PACKING ANY AUTOCLAVE CAUTION! Do not infer the temperature from the
reading of the pressure gauge. This may give you an
Sterilization is impaired by anything which hinders the inaccurate indication of its temperature and is a common
removal of air, so arrange the contents loosely; cause of sterilization failure.
a drum which can only be closed with difficulty is grossly
overpacked. Place the contents so that air can readily be POSTVACUUM (drying). Open valve (20), then valve
displaced downwards: the principles are the same in (18). Leave them open for 15-20mins. Close valve (18)
horizontal and vertical autoclaves. This means packing the then valve (20).
items vertically rather than horizontally. To avoid air
pockets, interleave sheets of mackintosh or jaconet with TO BREAK THE VACUUM. Open valve (16).
some permeable fabric, so that no two surfaces of the
non-permeable material are in contact. TESTING AUTOCLAVES
If you are using Browne's tubes, put a tube in the centre
A SIMPLE AUTOCLAVE (or pressure cooker) (2-7A) of the load, with, if possible, one on the outside to show
that the autoclave has indeed been switched on!
Make sure there is enough water in the bottom of the
autoclave. Insert the drums to be sterilized, and turn on the If you do not have Browne's tubes, put some dry earth in
heater. See that the discharge tap is open, and then screw an envelope, autoclave this and then culture it in a bottle or
down the lid. As the water boils the steam will rise and tube of nutrient broth. Spores may be slow to grow,
carry away the air in the autoclave. so incubate it for a week. If even this is impossible,
put an egg in the middle of a drum to see if it is hard
boiled!
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PARTICULAR PROCEDURES FOR AUTOCLAVING There is an optimum antiseptic for each purpose, so try to
The following figures are guidelines only and vary with use the right one.
the type of autoclave and the size of the load. Disinfectants have serious limitations and only work
They apply to a sterilizing temperature of 121ºC. when the object they are disinfecting is clean:
Empty glassware & unwrapped instruments. they are ineffective in the presence of blood or pus.
Sterilizing time 15mins, drying 10mins. So wash scissors and fine instruments carefully before you
Wrapped instruments, rubber gloves, tubes & store them in an antiseptic solution. If possible, drains and
catheters, and sutures being re-autoclaved. other heavily contaminated pieces of equipment should be
A common regime is 0·7kg/cm² (10psi) for 20mins. boiled or autoclaved after washing and before being
Fabrics & dressings. Sterilizing time: 20mins, immersed in these solutions. Afterwards, wash them well
drying time: 15mins. in sterile water before you use them. Catheters and tubes
Liquids in flasks and bottles. etc. deteriorate in antiseptic solutions and are better
Sterilize bottles according to size & time as follows: autoclaved before use.
mls 100 300 500 1000 3000 Avoid cetrimide: it is mainly a detergent; chlorhexidine is
mins 20 30 35 40 50 better.
Switch off the heat and let the autoclave cool down.
Do not open it until the pressure is zero, as the bottles may
burst.
PREVENTIVE MAINTENANCE
Follow the maker's instructions carefully. Don’t miss out
on this for reasons of false economy or ‘permanent’ need!
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2.5 Disinfectants & antiseptics Aim to sterilize everything coming into contact with the
wound by soaking it for a sufficient time in an antiseptic
solution. Unfortunately:
SKIN. Any alcoholic solution will do. Alcoholic iodine is (1) An antiseptic solution leaves everything wet.
best: use it routinely, except in children, on the scrotum, (2) Sterilization is slow so that you may only be able to do
and in allergic patients. Chlorhexidine 0·5% in spirit is a one operation at a time.
less satisfactory alternative. Apply it to the skin after (3);Wide areas of the body are exposed to the antiseptic,
removing all traces of soap. which causes much exudation from the wound.
Even so, antiseptic surgery is simple, and makes many
WOUNDS. There is no substitute for a scrubbing brush, kinds of operation possible. If necessary, you can combine
plenty of water from a jug, and a thorough surgical toilet. antiseptic and aseptic methods, and sterilize smaller
Chlorhexidine is useful for cleaning the skin round a instruments in a pressure cooker. Chlorhexidine is the
wound. most practical antiseptic, but is far from perfect.
INSTRUMENTS, SUTURE MATERIALS, & DRAINS. ANTISEPTIC SURGERY UNDER ADVERSE CONDITIONS.
The following agents are effective against HIV and HBV, “The only means of access to our hospital at present is by walking over
in addition to the classical pathogens (5.4). the mountains for a week. All supplies have to be carried in by porters
who take two weeks for the journey. For the first 2½yrs, we worked in a
(1) 0·55% ortho-phthalaldehyde. traditional Nepali house with a thatched roof and a floor made of mud
(2) 2% alkaline buffered glutaraldehyde. and cow dung. In it we did over 100 operations by the antiseptic method,
(3) 8% formalin in 70% spirit or as a tablet. without serious mishap. Later, limited space became available, so that
(4);A 0·5% solution of chlorhexidine in 70% spirit with although we enjoyed the advantages of tap water, a concrete floor, a clean
ceiling, and adequate window ventilation, we still had to operate on a
0·5% sodium nitrite. (This is in terms of the active agent.) light outpatient type of table and in the same room in which the
(5) Plain 70% spirit. outpatients received all their medicines, injections, dressings, incisions,
The first 2, ‘Cidex OPA’ and ‘Cidex’, are the best; and dental extractions. We almost always used epidural or local
glutaraldehyde needs to be activated before use but anaesthesia”. Dick JF, Surgery under adverse conditions, Lancet
1966;7469:900.
ortho-phthalaldehyde does not.
10mins is the absolute minimum time in these solutions,
ANTISEPTIC SOLUTIONS.
provided instruments are scrupulously clean, 24hrs is
Use chlorhexidine 5% concentrate to make two solutions:
safer. Ideally, nothing should be considered 'sterilized'
(1);A weak solution of 1/2000 of the active agent in water.
until it has been immersed for 24hrs. Wash all equipment
Use this for soaking towels, etc.
well before using it.
CAUTION! (2);A strong solution for instruments, as described (2.5).
(1);Except for glutaraldehyde (which can be used for Make up small quantities of solutions frequently, make
them up hot, and clean out the containers well between
14-28days depending on the brand) you must prepare these
batches.
solutions freshly every week, and keep them covered to
prevent the alcohol evaporating.
STERILIZING EQUIPMENT AND DRAPES.
(2) A 'wipe' is not nearly as good as a soak!
N.B. Formalin tablets can be vaporized in special Soak everything which will come into contact with the
chambers and used to sterilize endoscopes over 12hrs. wound in one of these solutions for at least 30mins.
Soak sutures and gloves in this solution overnight.
It is irritant to the eyes, and nose, and toxic to the tissues.
Use monofilament (4.6) for ligatures and sutures, and the
It is useful for fumigating the theatre after a septic
minimum number of simple instruments.
procedure.
The most appropriate drape, for a tubal ligation, for
FURNITURE, DOORS; WINDOWS & OTHER example, may be a single solution soaked plastic sheet
long enough, and wide enough, to cover the whole patient,
FIXTURES
with a hole in the middle through which to operate.
5% phenol (carbolic acid) is a satisfactory cleaning agent;
If you have 2 such drapes, one can be in use while the
you can use a 10% solution for very soiled surfaces.
other is being soaked in a flat container of solution.
CAUTION! Do not use syringes and needles soaked in
antiseptic to give a subarachnoid or epidural anaesthetic.
2.6 Antiseptic surgery
WHILE OPERATING, treat the patient's skin with the
solution for at least 2mins before the operation.
This used to be standard practice before aseptic methods
Wash your hands as usual and put on the wet gloves.
made it more or less obsolete. But it may still be useful
Wring out the soaked drapes as dry as you can, and apply
when power supplies have failed or your autoclave breaks,
them as near as possible to the operation site.
or an important operation has to be done in some remote
Clean the patient's skin with the same solution.
place. It has been said that a first-class surgeon can
operate in any theatre in any clothes in any situation.
If there is a danger that he might get cold,
However, even if you are not an expert, do not deny
cover him with a dry blanket in a plastic sheet, and put this
someone life-saving surgery if your autoclave has stopped
between the skin and the wet towels above and below the
functioning!
operation site, where it will not get in the way.
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Swab the trolley with the solution, or put the instruments For prophylaxis use a single dose of antibiotic: this is
on a solution-soaked towel. Keep 2 bowls near the indicated in ‘clean, contaminated’ (category 2) cases such
operating table, one containing water and the other as hysterectomy, Caesarean Section, appendicectomy,
antiseptic solution. cholecystectomy.
When instruments have been used, wash them in water and N.B. Clean uncontaminated wounds (category 1) do not
keep them in the solution until you use them again. benefit from antibiotic prophylaxis.
Shake off the excess solution before you use them. Even with immunocompromised patients you should not
Handle the tissues as little as you can, and try to keep the change this principle.
solution out of the wound as much as possible.
Do not let cleaning solution get into the body cavities. That said, how can you use antibiotics for invasive sepsis
to the best advantage, when your laboratory staff cannot
AFTER OPERATING rinse everything free of blood. culture bacteria, or at least not reliably? You can learn
Rinse the instruments, and put them away. much, however, from a simple Gram stain. Nonetheless,
If the wound is well sutured and is not expected to encourage the laboratory to examine blood cultures, which
discharge, leave it open to the air. are not difficult technically, and, when these are positive,
to isolate the organism responsible for septicaemia in pure
culture.
If you are fortunate, you will be able to plan a logical
2.7 Antibiotics in surgery antibiotic policy for your district, and keep some
antibiotics for hospital use only, in the hope that the arrival
Antibiotics have 2 uses in surgery: of antibiotic-resistant strains from elsewhere in the world
(1) To treat invasive sepsis. will be delayed as long as possible. In such an ideal
(2) In certain circumstances only, and when used in a very situation you might decide, for example, that the clinics
particular way, as prophylaxis to prevent postoperative should use only penicillin and tetracycline, with perhaps a
infection. little ampicillin or trimethoprim; keep streptomycin for
tuberculosis only. This will enable you to use
They are less important than: chloramphenicol with metronidazole as your main surgical
(1) Careful aseptic theatre routines. antibiotics, especially when the gut and the genital tract
(2) A thorough wound toilet. are involved. For other occasions you can use gentamicin,
(3) Delayed primary closure. or a cephalosporin.
(4) Making sure there are no foreign bodies, dead tissue, Unfortunately, you are more likely to work in a situation
excessive blood clots, or faeces in the wound. of antibiotic chaos, in which any antibiotic is obtainable
over the counter without prescription, and where multiply
In preventing sepsis, antibiotics give you no licence to resistant strains, particularly those resistant to
neglect the classical rules of good surgery, especially if chloramphenicol, are common. Be sure to find out what
the patient is diabetic, very old, has HIV and is very ill, are the sensitivities and so the antibiotics of choice for
and so is less able to overcome any bacteria that cause your area. You should get a good idea of which antibiotic,
infection. out of those generally available, to use for which situation.
Antibiotics will represent a very large part of your You may have donations of expensive newer antibiotics:
pharmacy’s budget, so use them wisely and not do not waste them through ignorance of their benefits!
indiscriminately.
So:
(1) Handle the tissues gently; take care to avoid spillage
and contamination of the wound.
(2) Do not leave large pieces of dead tissue in the wound,
such as huge, massively ligated pedicles, or with excessive
use of diathermy.
(3) Do not put tissues or skin under tension.
(4) Make sure there is secure haemostasis.
(5) Divert faeces if they risk contaminating a wound, by
temporary colostomy.
Differentiate from prophylactic use of antibiotics (2.9) Fig. 2-9 ANTIBIOTICS MUST GET TO THE PATIENTS AND
and the treatment of invasive sepsis (e.g. cellulitis, THE DISEASES WHERE THEY CAN DO MOST GOOD.
A poster from Oxfam's 'Rational Health Campaign' to show the
septicaemia). enormous burden many communities bear in misused antibiotics that
are bought in the market-place, or are prescribed by doctors on the
wrong indications for the wrong patients.
Kindly contributed by Oxfam.
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As to the antibiotics to use, you will see from the list of ONLY A FEW HIGH RISK PATIENTS NEED
indications below that, if chloramphenicol is not PROPHYLACTIC ANTIBIOTICS
much used in the community, chloramphenicol with
metronidazole is likely to be the most cost-effective “We may look back on the antibiotic era as a passing
combination. Otherwise, use cefradine (or some other phase, an age in which a great natural resource was
cephalosporin) with metronidazole, which are much better squandered.”
than penicillin and streptomycin.
Always differentiate prophylaxis from treatment.
Using your more expensive antibiotics in life-threatening 2.10 When prevention fails: wound infection
sepsis makes more sense than wasting them in dubious
prophylaxis. If you are treating septicaemia, aim to If a wound discharges pus, the aseptic routines described
continue the antibiotic regime until the illness is under earlier in this chapter have broken down. Although this is
control (usually 5-7days). Once a patient can take drugs not the only cause of a wound infection, it is the most
orally, there is usually no longer any need to give them IV. unnecessary one.
THE DOSE AND THE TIMING ARE CRITICAL: Keep a record of your wound infections. They are most
MAKE SURE THERE ARE ADEQUATE LEVELS likely to occur if:
AT THE TIME OF SURGERY (1);You are operating for some infective condition, such as
acute appendicitis.
PERIOPERATIVE PROPHYLAXIS: INDICATIONS. (2) The operation is long and difficult.
(3);You leave dead tissues, foreign bodies, dirt, or clot, or
(1) Peritonitis (but antibiotic use here is likely to be an excessive number of sutures (especially non-
therapeutic rather than prophylactic) absorbable) in the wound.
(2) Operations likely to contaminate the peritoneal cavity, (4) You create dead tissue by operating clumsily.
especially with spillage from the colon, appendix, (5) You do an unnecessary un-clean procedure at the same
bile duct or stomach. time as the clean surgery.
(3) Operations on the urinary tract when the urine is (6);You close a wound by immediate primary closure,
already contaminated, including bouginage, when delayed primary closure would been have been
cystoscopy, and prostatectomy. wiser.
(4) Hysterectomy. (7);You leave IV cannulae, chest drains or other drains in
(5) Emergency Caesarean section. longer than necessary.
(6) Intracranial explorations.
(7) Open fracture surgery, and amputations. SURGICAL SEPSIS.
(8) Re-opening haematomas. (1) A theatre had extractor fans installed, but the only inlets for fresh air
(9) Splenectomy. were under the doors, so that dust from the corridor was drawn into the
theatre continually. Only when three patients had died of tetanus was the
(10) Dental or oral surgery with known heart valve disease. flow of the fans reversed.
LESSON Keep dust out of the theatre.
CAUTION! (2) In a certain teaching hospital, there were two minor theatres in which
Gentamicin and other aminoglycosides may seriously many septic operations were done. On 2 mornings a week the same
equipment was used for a list of circumcisions. One circumcised child
prolong the action of long-acting (non-depolarizing) acquired erysipelas which spread from the umbilicus to the toes and
relaxants, and may prevent the establishment of killed him.
spontaneous ventilation. Avoid them unless your LESSON Where possible do not do clean cases in a theatre which
anaesthetist is experienced. normally does septic ones.
(3) An eminent professor electively resected an appendix at the same time
N.B. Prophylactic antibiotics will probably not cover as cholecystectomy. The patient developed an anaerobic wound infection
the perioperative risk of respiratory infections. and later a faecal fistula.
Physiotherapy is far more likely to be effective, both pre- LESSON Do not do unnecessary procedures which increase the risk of
and post-operatively. infection.
(4) Hamilton Bailey, subsequently a distinguished surgeon, but then a
registrar in the 1930’s, was deputizing for the chief. Having done an
CONTRAINDICATIONS. Antibiotics are not needed for: elective list which began at 1.30p.m. he insisted on continuing with a
(1);Already well-localized infections. non-stop flood of emergencies which continued rolling in all the evening.
(2);Clean category 1 operations (hernia repair, ovarian At 3 a.m. the following morning, 'dead on the feet', he pricked himself
when operating on a patient with streptococcal peritonitis. Bailey insisted
cystectomy, etc) that the finger be amputated, and survived. The patient died.
(3) Burns (initial treatment) LESSON Accidents, including those which increase the risk of sepsis,
(4) Tracheostomy, intercostal drainage, simple lacerations. hepatitis and HIV transmission, are particularly likely if you are
overtired.
If you are using a tourniquet, time the injection to provide
If >5% of your clean cases become infected, something
the maximum concentration about the time that you
has gone wrong. Prophylactic antibiotics are not the
release it, so that the clot which forms in the wound will be
answer! The chances are that the aseptic technique (2.3)
heavily loaded with drug.
is not being followed, or you are making the errors 3, 4,
and 5 above.
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THE PREVENTION OF WOUND INFECTIONS If you are successful, the wound will heal spontaneously.
AUTOCLAVING. Otherwise, you will have to open around the sinus and
(1);Check that your autoclave does reach 1 kg/cm2 (2.4), extract the foreign material.
that the air is being discharged, and that the holding time is
being maintained. If a growth develops from the wound, this is a pyogenic
(2);Check that the drums are not being overpacked, granuloma (34.4): excise it and check for HIV disease.
that they are labelled after autoclaving, and that the label
includes the date.
If a wound fails to heal, think of diabetes mellitus, Combinations of analgesic drugs and of routes of delivery
HIV (5.6), anaemia, malnutrition, the presence of cancer give the best results. You can provide much pain relief by
or a foreign body. putting large volumes of low concentration long-acting
local anaesthetic (bupivacaine) into the wound at the end
If a sinus develops from a wound, suspect an infected of the operation; do not inject it into the surrounding
buried non-absorbable suture knot (a stitch sinus); sterilize tissues if the wound is infected: you can then just drip it
a crochet needle and use this to try to hook the knot out of into the wound and leave it for 1min to get absorbed.
the wound.
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The sad reality is that in present practice many patients If you know that an operation will give considerable pain,
wake up with pain, shout for help and are shouted at in prescribe regular analgesia for the first 2-3days, not ‘PRN’
turn, until eventually, they are given a large IM dose of (which stands for pro re nata = as required, but often in
opioid. They then go to sleep again. Later, when the practice implies ‘presumably rarely needed’)
analgesic effect wears off, the cycle repeats itself.
This is not only unsatisfactory from the point of view of For MILD PAIN, paracetamol is ideal. It can be given as a
needless suffering but is often the cause of postoperative syrup for children or those who have difficulty
complications: atelectasis, deep vein thrombosis, vomiting, swallowing.
anorexia, constipation, dehydration, urinary retention,
and it also prevents people from getting out of bed. Trans-cutaneous electrical nerve stimulation, and neuro-
acupuncture can give added relief if you have these
For SEVERE PAIN, morphine is preferable to pethidine, facilities.
because it produces less respiratory depression,
less nausea, and is less of a cerebral irritant.
It also lasts longer. (Pethidine needs to be repeatedly given 2.12 Records
3hrly to be effective)
Because these are controlled drugs, nurses will often only Keep meticulous records of operations performed: train the
give them at standard drug dosage times. Challenge your theatre staff to fill in the book immediately and keep these
local regulations if these inhibit patients getting proper records accurately. Bad records are almost as good as no
pain relief. Try to get solutions of oral morphine made records at all! You should have all the following
locally. This should not cost >1c.(US)/mg! Do not use information in the theatre book (which obviously should
injectable opioids SC or IM but always IV, injecting be fairly large, and preferably hard-backed):
slowly: this way relief will be immediate and the dose
received will be less. Small, frequent IV opioids will DATE
prevent pain and it will be possible to switch to the oral or OPERATION NUMBER
rectal route within 24hrs in most cases. Apart from being PATIENT’S NAME
PATIENT’S AGE/SEX
much more effective if given IV, either as boluses or better
PATIENT’S HOSPITAL NUMBER
as an IV infusion, they are safer given this way as you DIAGNOSIS
thereby must watch the patient’s response. OPERATION PERFORMED
EMERGENCY/ELECTIVE
SURGEON
A calculated IV infusion of opioid is not dangerous!
ASSISTANT(S)
(If the IV infusion has accidentally run in fast with all of ANAESTHETIST
its added 10mg of morphine, simply omit the dose with the ANAESTHETIC USED
next litre of IV fluid.) Arrange the infusion in theatre with SCRUB SISTER
TIME STARTED & TIME FINISHED
the co-operation of the anaesthetist.
COMPLICATIONS
In children, tilidine oral drops (x1 per year of age up to 10) HISTOLOGY/PUS SWAB RESULT
is very useful indeed.
Keep your book neat: if necessary fill in details initially in
Ketamine gives good post-operative pain relief; pencil. Keep to the columns drawn in the book.
its hallucinatory effects are diminished by giving diazepam It is important to use the same nomenclature throughout,
before the operation, i.e. with the ketamine. e.g. 12 Feb 2004 for the date (and then not use 12/02/04
or, worse, 02/12/04), and particularly consistency in
Remember that opioids occasionally cause hyperalgesia abbreviations (e.g. I&D for incision & drainage, MUA for
(especially if used for non-malignant causes); but beware manipulation under anaesthetic etc). Try to keep names
of the patient with chronic pain who regularly refuses consistent, using the family name first in CAPITALS and
opioids (he probably needs them) and the patient with then the first (and second) names. The more detail you can
aberrant behaviour who demands them (he does not need put, the better will be your records, and your ability to do
them!) research.
For MODERATE PAIN, the choice is paracematol-with- Under ‘Diagnosis’ be sure to put the correct diagnosis
codeine and/or a non-steroidal anti-inflammatory drug. (which may differ from the pre-operative diagnosis).
The latter have considerable side-effects: peptic ulceration,
renal impairment, and coagulation problems. They can be Under ‘Anaesthetic Used’, you should put at least GA for
given rectally if a patient is not taking in orally. general anaesthetic, Sedation, or LA for local anaesthetic.
The evidence that they are any more effective than You could put Thio/O2/N2O if using thiopentone, oxygen
paracetamol-with-codeine is not convincing, but it is and nitrous oxide, or Ket if using ketamine, but the more
always best to ask the patient which drug he finds best! detail in the records the more diligence is required in
keeping them. Often there are no records at all which is a
disastrous and unacceptable state of affairs.
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You may be able to control massive bleeding from a large Bone wax packed into the bleeding edge of the skull into
vessel by inserting a balloon catheter into its lumen, the diploe, or into the marrow of a bone, will stop the
and inflating the balloon. bleeding if it is not too aggressive.
Alternatively, occasionally you can put a tube shunt
between the widely separated ends of a large important Adrenaline, already added 1:100,000 to lidocaine solution
artery, fixing these in place with tape. or to saline, used to infiltrate the tissues, will minimise
Get proximal control by formally exposing the vessel high capillary and venous bleeding, e.g. during the repair of a
above the bleeding point. This will only be necessary on vesico-vaginal fistula (21.18), in thyroidectomy (25.7) or
unusual and desperate occasions. On rare occasions you cleft lip repair (31.7). You can also use a pack soaked with
may have to tie off the artery despite the consequences of 1mg adrenaline in a bleeding nose (29.7), or on a bleeding
distal ischaemia. tooth socket (31.3).
Never use adrenaline in the penis, or the distal parts of a
limb such as a finger or toe, or in an IV forearm block,
because it may constrict the vessels so much that the part
becomes gangrenous.
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The common mistakes are: Spencer Wells are general purpose haemostats; Crile’s are medium-sized
and more robust than Halsted’s, which are some of the finest and most
(1) To panic when there is severe bleeding.
delicate instruments and must be used with care. Blalock (bulldog)
(2) Not to apply pressure when this is indicated, and not to clamps are non-crushing clamps to stop blood spilling from a vessel
apply it for long enough, or to apply it diffusely through whilst it is being repaired. Mayo’s pins keep forceps together in bunches
more and more rolls of cotton wool and bandage. during sterilizing.
(3);To grasp wildly with a haemostat in a pool of blood,
Spencer Wells, straight, box joint, (a) 200mm, (b) 150mm.
to fail to grasp the bleeding vessel, and perhaps to injure Spencer Wells, curved, box joint,
some important structure. (a) 230mm, (b) 200mm, (c) 150mm, (d) 125mm, curved.
(4) Not to apply the special methods for special sites. Crile's, straight, box joint, 140mm.
(5) To cross-match blood too late. Crile’s curved, box joint,
Halsted's, ultrafine, mosquito, haemostatic, straight, box joint, 120 mm.
Halsted’s, ultrafine, mosquito, haemostatic, curved, box joint, 120mm.
A STORY ABOUT BLEEDING. A young trainee surgeon was excited to
Kocher's, straight, box joint, 200mm.
be able to assist the professor at an operation for a leaking aortic
Kocher’s curved, box joint, 200mm.
aneurysm. Predictably, there was quite a lot of bleeding seen when he
Blalock artery clamps (various sizes)
released the big aortic clamps. In fact he hadn’t seen so much blood in the
abdomen outside of the trauma situation, where there was always frantic
activity to stem the bleeding. When the professor had sutured in the graft,
there was considerable oozing from the suture lines. He simply put in a
big pack and asked the assistant to press gently, but firmly, till he
returned, and went off to have a cup of tea! Petrified, the trainee hardly
dared breathe, let alone move. When the professor came back 10mins
later well refreshed, he re-scrubbed, and removed the pack; the operative
field was perfectly dry.
LESSONS When you control bleeding by pressure or with a pack
sufficient time (≥5mins by the clock) is all important.
HAEMOSTATS
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TO CONTROL BLEEDING FROM A LARGE Heat causes coagulation of blood in vessels; this has been
PEDICLE, such as that of the spleen or uterus, do not try known for centuries. In order for an electric current to
to use a single ligature. Control of the vessels will be safer provide sufficient heat on a small area but without causing
if you take one or more bites of the pedicle and tie them muscle spasm and cardiac dysrhythmia, diathermy uses
separately. radiofrequency currents of 0·5-1·5MHz.
TO CONTROL A DIFFICULT BLEEDING ARTERY,
try to get into the correct tissue plane. First find the artery In monopolar diathermy, there is a high current density
by feeling for pulsation. Push the points of a fine ensured at the point of contact with the active electrode at
haemostat into the connective tissue around it and separate the diathermy probe tip but the current is then dissipated in
them to open up a plane (3-4B). Gradually develop this a large volume of tissue through a large surface area
plane until you can see the artery you are looking for. ‘indifferent’ electrode, usually a plate placed under the
In this way you will avoid tying some important nerve in buttock (3-5A). You must make sure this contact is good
the ligature. and uniform, otherwise a burn may result.
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Make sure the wire connections in the instrument are Do not use diathermy on the groin if the scrotum is not
sound, because poor contacts will increase the heat and so in contact with the rest of the body: you might cause
cause burns. Usually you will pick up a blood vessel with coagulation in the testicular vessels, especially if you lift
dissecting forceps, and touch the forceps with the the scrotum up in your hand.
diathermy tip. As metal is a good conductor of current,
little heat is generated in its passage through the forceps. Do not use diathermy in an amputation for an ischaemic
Make sure though that your gloves have no holes, leg (35.3): you will increase tissue necrosis.
otherwise you may experience an electric shock and burn
when the metal forceps comes in contact with your own Do not use diathermy on large blood vessels:
skin! tie them instead.
In bipolar diathermy, the current passes between two If the patient has a cardiac pacemaker, the diathermy
point electrodes placed across the vessel to be coagulated. current may affect this; so place the indifferent electrode
In this way a very high current density, and so much heat, far away, or use bipolar diathermy.
is produced over a very small volume of tissue, with
virtually no heat generated elsewhere (3-5B). Do not use diathermy in the presence of inflammable
Bipolar diathermy only works with low currents, and is anaesthetic agents, e.g. ether, and take care if you use
therefore most suitable for small blood vessels, and fine spirit-based skin cleansing preparations that the fluid does
surgical procedures. not pool: serious burns may result.
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TOURNIQUETS
INDICATIONS.
(1) Wound toilet in an injured limb, particularly if this has
to be followed by repair of the vessels, nerves,
and tendons.
(2);Any hand operation, other than a very small one.
Hand injuries, and hand sepsis.
(3) The exploration and drainage of bones and joints, when
this is anatomically possible, as in the lower humerus,
the elbow and parts distal, or the lower femur, the knee,
and parts distal.
CONTRAINDICATIONS.
(1) The SS and CS varieties of sickle cell disease, but not Fig. 3-6 TOURNIQUETS.
AS heterozygotes. A, do not use Samway's tourniquet, as you may damage the tissues.
(2) Ischaemia due to arterial disease. B, a pneumatic tourniquet is much the best. C, the Esmarch bandage
is a roll of red rubber. D, site to apply it in the arm. E, site in the leg.
F, use a rubber catheter as a finger tourniquet. G & H, when you
ANAESTHESIA. A tourniquet is painful and a conscious apply a tourniquet, take the time and record it. I, If you want to
patient will not usually tolerate one for >5mins. exsanguinate the arm, raise it and then apply Esmarch bandage,
You will therefore need either GA or regional anaesthesia starting at the hand. J, inflate the pneumatic tourniquet, then
unwind the bandage, starting proximally in the limb. K, you can use
in most cases. an Esmarch bandage as a tourniquet.
HANK (42yrs) was to have a bunion removed. The junior resident was
asked to apply an Esmarch tourniquet. He had never applied one before, N.B. Do not exsanguinate a septic limb or where there
so he just wound the whole bandage round the patient's unpadded leg. 10 is malignancy distally with an Esmarch bandage;
days later at the follow up clinic the patient had a numb foot. you can use a simple tourniquet, though.
LESSON Learn how to apply a tourniquet, before you apply one.
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CAUTION! When you do apply it, apply 2 more winds than are
(1);A tourniquet on the forearm or on the lower leg is necessary to obliterate the pulse. When you have finished,
dangerous, because you may damage the radial nerve at it should feel moderately firm, but not rock hard.
the ulna, or the common peroneal nerve at the neck of the CAUTION!
fibula. (1);Do not apply a tourniquet over too narrow a band of
(2);Tie a tourniquet to the operating table, to prevent muscles.
anyone forgetting it, because the patient cannot later be (2);Do not ever wind on more than five turns after you
lifted off the table without removing it. have obliterated the pulse.
A tourniquet hidden under drapes can easily be forgotten. N.B. Every turn may add 100mm Hg more pressure.
THE SAFE TIMES for an adult of average build are: the TOURNIQUET TIME:
arm 1½hrs, the leg 2hrs. Shorten these times by 60% in a 1½HRS IN THE ARM and 2HRS IN THE LEG;
thin adult or in a child <8yrs. Apply a tourniquet to a 60% LESS FOR THIN ADULTS AND CHILDREN
finger for a few minutes only. The responsibility for
keeping within these times lies with the anaesthetist, EXSANGUINATING A LIMB
who should remind the surgeon every 15mins how long a INDICATIONS.
tourniquet has been applied, and write on a board in the Any operation in which you want a completely bloodless
theatre when it was applied. field, particularly orthopaedic.
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One of the purposes of monitoring a patient immediately If you aspirate large quantities of fresh blood
after an operation is to watch for reactionary haemorrhage, from a nasogastric tube after upper gastro-intestinal
so make sure your staff observe carefully for early signs of surgery, there is probably bleeding from a suture line. This
blood loss, and understand what to do. is unlikely to stop spontaneously. You will probably need
to re-open the abdomen to deal with the problem.
If a wound bleeds, try firm local pressure and packing.
If it bleeds briskly, you may have injured an artery, such as If there is bleeding some days after a laparotomy,
the inferior epigastric. Minor bleeding is probably coming the blood may be coming from a stress ulcer, or from a
from the subcutaneous tissues, and is unlikely to be pre-existing duodenal ulcer unrelated to the previous
serious. pathology. This may threaten life. Treat this as described
(13.4).
If local pressure fails to control bleeding, do not apply
more and more dressings; take the patient back to theatre, If blood is not clotting properly, check the clotting time.
open and, if necessary, enlarge the wound. Take 5ml into a dry glass tube; invert it every 30 seconds,
Irrigate it thoroughly with warm water. You can usually do keeping it at body temperature, and time when it clots.
this under LA. Remove the sutures and tie (3.2) If this takes >8mins, there is a clotting defect.
or coagulate any bleeding vessels that you can see: you Administer 10mhg vitamin K IV. Use whole blood or
may need to put a running suture to control such bleeding. packed cells and FFP to replace the blood loss, to try to
Liga clips may be useful (4.10). replace the clotting factors.
If necessary, remove a pressure bandage or split a cast
lengthways and open it at least 2cm. If you need to Disseminated Intravascular Coagulation (DIC) may
immobilize an open fracture, loosely apply a well develop, especially with retained products of conception.
padded cast. You may need to re-apply the tourniquet, If blood clots in ≤2·5min, it is hypercoagulable: thereafter
but do not forget to remove it! if the clot lyses in 30mins, fibrin degradation has occured
If you have had to re-open a haematoma, add a single Use whole blood, FFP and fibrinogen 4 to 8gif available,
dose of prophylactic antibiotic (2.9) to correct the clotting disorder.
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Apart from these, there may be ABO or Rhesus (Rh) LIFE-THREATENING EMERGENCIES.
incompatibility as well as 26 other types of
cross-reactions, as well as plasma reactions and problems Severe haemorrhage often occurs in unforeseen
related to the blood being still frozen, or overheated. circumstances. It is best to be prepared rather than sorry
A graft-versus-host disease can rarely occur producing an after the event. Try to keep at least 2 units of O-ve blood
ARDS-type lung injury. continuously available in your hospital, because there will
be no problem transfusing this in 99% of your patients.
Stored blood may have K+ of 40-70mM, so multiple If you cannot get O-ve, O+ve will be satisfactory for
transfusion may produce a dangerous hyperkalaemia, 85-95% of cases, so if a patient is in extremis, do not fear
and the citrate used to preserve its liquidity may produce a the risk of 5-15%!
worsening acidosis. However, often more importantly,
as stored blood loses its clotting factors after 24hrs, Fresh blood is often better than stored blood; try to have
coagulation becomes disrupted. Further the citrate soaks reliable persons (tested regularly HIV-ve) in your
up calcium, and this further aggravates bleeding. community available to assist in an emergency with blood
Haemorrhage may even be exacerbated by a consumptive transfusion.
coagulopathy producing DIC. Remember to try to correct clotting disorders, if present.
If your laboratory produces packed red cells (because N.B. Fresh Frozen Plasma can be stored for a long time
other blood products are filtered off), there are no platelets as opposed to blood and should therefore be available via
in the blood. the national/regional blood bank. However, as one unit is
Using whole blood avoids this problem and hold the collected from more than one donor, the risk of HIV,
clotting factors necessary for haemostasis. Stored blood is Hepatitis transmission etc. is that much greater.
just not as good!
PROTOCOL.
Check the blood units individually for compatibility
(name, hospital & batch numbers, group) and expiry date.
Make sure an IV line is patent and flushed with saline.
Warm the blood (do not heat it up!). Check the blood unit
to be used again, and make sure it is signed for. Attach the
blood unit to a blood-giving IV infusion set (with a filter).
Observe the patient ½hrly for pyrexial or other reactions,
and chart infusion volumes.
N.B. Do not stop a transfusion because of a minor
pyrexia especially if the patient is septic anyway.
Administer 10ml (2.2mmol) 10% calcium gluconate IV
with every 4th unit of blood transfused.
N.B. 10ml of 10% calcium chloride IV provides 6.8mmol
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Beware cutting yourself or an assistant when using sharp SCALPEL, solid forged, size #1, 30mm, and size #5, 40mm.
If your disposable blades are exhausted, you can use a solid scalpel and
instruments!
re-sharpen it (4-3), whereas you cannot re-sharpen a disposable blade.
Make sure you have secured the blade tightly on the HANDLE, scalpel, Bard Parker, #4. Get good quality handles, because
handle, because if you lose it in a body cavity it is poor ones may not fit the blades.
difficult, and hazardous to find it again! HANDLE, scalpel, Swann Morton, #5.
BLADES, scalpel, disposable, Bard Parker or Swann
Morton type, stainless steel.
OILSTONE, hard Arkansas pattern, 150x70x30mm.
Use this to sharpen scalpels and scissors. A very blunt
instrument needs a carborundum stone first.
DISSECTOR, MacDonald. A blunt dissector is often
safer than a scalpel. This is a blunt general purpose
dissector, with 1 straight flat end and 1 round curved
end, neither of which are likely to injure anything.
4.3 Scissors
Remember:
(1);Do not use sharp-tipped scissors in
dangerous places, or cut what you cannot
see.
(2);Do not use scissors which are longer than
the haemostats you have, or you may find
yourself cutting a vessel which you cannot
reach to clamp.
(3);Mayo's, McIndoe's, and Metzenbaum's
scissors are intended for cutting tissues,
so do not use them for anything else.
Use other scissors for cutting sutures and
Fig. 4-1 SCALPELS AND HOW TO USE THEM. dressings.
The advantage of a solid forged scalpel is that you can resharpen it. (4);Carefully keep and pack very fine scissors,
It is useful for symphysiotomy (21.7). Take care when you remove a e.g. ophthalmic instruments, separately.
blade: always use an instrument, hold the blade with the sharp side
away from you and never your fingers or plastic forceps!
(5);Beware, when passing scissors to do so holding the
Dispose of sharps in special containers (5.3). closed tips, so that your assistant or scrub nurse can take
them by the handle. Alternatively, place them on a special
tray.
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Note that it is not necessary or even desirable to have all SCISSORS, bandage, angular, Lister, 180mm. These have a blunt knob at
the end of one blade which goes under the bandage to protect the patient.
these sorts of different scissors.
Insert them away from the wound; if they become soiled or wet, clean
Make sure you look after your sharp instruments carefully. and sterilize them before you use them on someone else.
Buy good quality scissors, and do not autoclave them
mixed together with the other instruments. The very best
ones have tungsten carbide inserts, which make their
cutting edges last much longer. These are 4 times more
expensive, but justify their extra cost.
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Non-absorbable Diameter limits Fishing line size by breaking Improvised syringe needle gauge
suture size, (mm) strength (in pounds) and Uses and inner diameter (mm)
U.S.P. (and approximate diameter
metric)
6-0 (0.7) 0.070 - 0.099 N/A Face, blood vessels 30g (0.140) or 31g (0.114)
5-0 (1) 0.100 - 0.149 1 lb (0.12-0.14 mm) Face, neck, blood vessels 28g (0.191) or 29g (0.165)
4-0 (1.5) 0.150 - 0.199 2-4 lb (0.15-0.20 mm) Neck, hands, limbs, 26g (0.241) or 27g (0.216)
tendons, blood vessels
3-0 (2) 0.200 - 0.249 6 lb (0.22-0.26 mm) Limbs, trunk, bowel, blood 23g (0.318); 24g (0.292) or 25g (0.267)
vessels
2-0 (3) 0.300 - 0.339 8-10 lb (0.30-0.33 mm) Trunk, fascia, viscera, 22g (0.394)
blood vessels
0 (3.5) 0.350 - 0.399 12-14 lb (0.32-0.39 mm) 20g (0.584) or 22g (0.394)
1 (4) 0.400 - 0.499 15-20 lb (0.40-0.48 mm) Abdominal wall closure, 20g (0.584)
2 (5) 0.500 - 0.599 25-30 lb (0.50-0.58 mm) fascia, muscle, drain and 18g (0.838)
3, 4 (6) 0.600 - 0.699 N/A line sites, bone 18g (0.838)
5 (7) 0.700 - 0.799 50 lb (0.70-0.77 mm) 18g (0.838)
N.B. The thickness of fishing line is not necessarily
proportional to its breaking strength!
Or, if necessary, you can use ordinary linen or cotton
thread almost anywhere, especially as ties. You can The narrower and deeper the space the smaller and more
likewise buy this cheaply on a reel, and re-sterilize it. curved the needle has to be. If necessary, you can try to
Use 4/0 monofilament as your basic suture material for fine skin bend a half-curved needle into a ⅝ circle. To economize
sutures. on commercially-produced sutures, you can use fishing
SUTURES, catgut, plain, 3/0, in boxes of 12. Plain catgut is soft. wire (4.6).
Use it for suturing the mouth, tongue, and lip.
SUTURES, absorbable, strengths 3/0, 2/0, 0, 1 and 2. A needle can have an eye, or the suture material can be
SUTURES, absorbable long-lasting, atraumatic, (a) 2/0 on half circle
fixed to it to form an atraumatic needle. These are
30mm needles. (b) 2/0 on 5/8 circle 30mm needles. (c) 4/0 on 16mm
curved needle. These sutures have needles swaged on to them. expensive, but they make smaller, neater holes, because
Use them for the bowel, the gall-bladder, and the stomach, held in a the suture material is not doubled through the extra
needle-holder. The smaller needles (c) are for children. thickness of the eye. Use atraumatic needles to suture
SUTURES, prolene, atraumatic, (a) 4/0 on 16mm half circle, round-
bowel, the urinary tract, blood vessels, nerves, the cornea
bodied needles, (b) 8/0 on 3mm 3/8 circle atraumatic needles.
SUTURES, linen, # 1. Use linen for tying vessels. It holds knots well and and the face, especially the eyelids. These commercially
is stronger than cotton. available sutures are much easier to use. It is worthwhile
SUTURES, nylon or virgin silk, 8/0. These are for suturing the cornea. trying to get them through donations. Though they have
WIRE, monofilament, soft stainless steel, (a) 5/0, (b) 0.35mm, (c) 1.0mm,.
commercial expiry dates, their reliability lasts at least
Surgical wire must be soft and malleable because springy wire is difficult
to work with. Autoclave the whole reel. 12-24 months past this date.
(a) Fine 5/0 wire is cheap, and is excellent for the skin, if you can use it
efficiently. Always use a cutting needle for the skin, either a straight,
(b) 0.35mm wire is for wiring the teeth and for hemicerclage.
half-curved or a large curved one held in your hand, or a
(c) Tension 1.0mm wire in a stirrup and use it for exerting traction.
These wires and the equipment to use them are essential. One of the smaller curved one held in a needle holder. Use a cutting
advantages of wire is that, unlike more massive pieces of metal, it does needle for tough fascia. Mayo's needle is a hybrid: it has a
not promote infection, so that you can if necessary put it though infected trocar point and a curved round shank. Use it for big wide
tissues. You can wire tissues in the presence of sepsis; for example, when
vascular pedicles and tough tissues, such as ligaments.
you repair a burst abdomen (11.14).
Fasten wire by passing its ends through any convenient tube, such as that Use round-bodied or taperpoint needles for most other
from a ball pen, and then grasping the ends and twisting them. tissues, because of the danger of needle stick injuries.
Finally, cut the twisted ends of the wire short. This will prevent it from Re-sharpen cutting needles on a stone (4-3).
coiling up in an inconvenient way.
WALL BRACKET, stainless steel, to hold rolls of monofilament (4-6).
Fix this to the wall, and pull lengths of monofilament from it. If you You will want a needle-holder to hold small needles and
cannot get one of these brackets, make it. suture in a confined space. Use a holder with a short
REELS, stainless steel, egg shaped ('eggs'), for holding suture material. handle near the surface, and a long one deeper inside.
Wind monofilament into these, autoclave them and cut off the length of
Use big needles in big holders, and small needles in small
suture material you require.
CRIMPING PLIERS, for bending needles. holders. A large needle can break a fine needle-holder
such as Derf's, so treat it with care. Needle-holders can
have plain jaws, or tungsten carbide inserts which prevent
4.7 Needles & their holders the hard steel of the needles wearing them away.
These cost twice as much, but last more than twice as long.
Needles can be round-bodied, taper-pointed, or they can Quality counts in needle-holders, so get good ones.
have cutting edges. They can be thin or thick, large or Hold the needle at the middle of its curvature at the very
small; straight, J-shaped, or curved into ¼, ⅜, ½, or ⅝ of a tip of the needle holder, and follow the curvature of the
circle. Curved needles are for working in confined spaces. needle when you draw the suture through the tissues.
Use a ⅜ circle needle in a shallow space, and a ⅝ needle in
a deep one.
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Some suture materials undo more easily than others. REEF KNOTS can be tied in several ways.
Non-absorbable multifilament makes the safest knots. The 1st method (4-10) is the surest way of tying a knot and
Knots of braided suture seldom undo, but knots of is the one to use if you want to exert continuous pressure
monofilament undo much more easily. So either use a while you tie. In the 2nd method (4-11) use forceps in your
surgeon's knot or at least 4 hitches when you tie right hand. The 3rd (4-12) is an 'instrument tie' and is
monofilament. For important knots put ≥2 turns on the useful if one end of a suture is short, or if the knot is in a
1st and 2nd hitches. With multifilament a single turn is deep cavity. The short end can be quite short. First, make a
enough on each hitch. loop with the instrument in front of the long end. Grasp the
short end and pull it through this loop. Then pull the first
Practise these knots with string or your shoelaces, until half hitch tight in the plane of the knot. To make the
you can do them quickly, and do them blind. Learn the second half hitch, start with the instrument behind the long
various ways of doing them in the following order. end.
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CAUTION! Keep the tips of the scissors in view, N.B. Add 50% to these values for patients taking
and do not cut unless you can see what you are cutting. corticosteroids or cytotoxic medication.
AN ABERDEEN KNOT (4-13) is a useful method to When you remove a suture, try not to pull any part of the
secure a mass closure of the abdomen (11.8); hold the suture material which has been on the surface through the
suture in a loop and pass successive loops of the suture tissues, or you may contaminate the wound. Clean the
through the 1st loop, c. 4-6 times, and then pass a single skin, cut the suture where it dips under the skin with sterile
strand finally through the loop. Pull this taut, thus taking scissors or a blade. Remember that after 3wks a wound has
the slack off the loop, and creating the knot. You can then only 15% of the strength of normal skin, at 4months 60%,
bury the suture end by taking a bite through adjacent and only full strength at 1yr.
tissue.
TUBE, nasogastric, plastic, Ryle's, with several side holes near the tip,
Ch14, Ch16, Ch18. Transparent plastic tubes are better than rubber ones,
because they are less irritant, they do not collapse, and you can see what
is inside them. Most tubes have markings, the first at 45cm showing that
the tip is about to enter the stomach, and the second that it is in the
antrum.
TUBE, stomach, plastic, adult and child, assorted sizes Ch8-22.
These are critically important for making sure that a patient's stomach is
empty before he is anaesthetized, and for washing it out if he has
swallowed a corrosive (30.3). Adults need tubes of Ch16-22, children
Ch10-14, and infants Ch8-10.
INDICATIONS.
(1);To remove fluid from the stomach before anaesthesia,
so as to reduce the risk of the inhalation.
N.B. The solid food from a recent meal will not come up
Fig. 4-13 AN ABERDEEN KNOT. a small nasogastric tube, so if you want to anaesthetize a
This is a very secure knot, especially useful for securing an patient safely who has recently eaten, or has intestinal
abdominal closure. obstruction, you will have to empty the stomach with a
large nasogastric tube.
REMOVING SUTURES. Leave them until the wound has (2);To decompress the stomach during upper abdominal
healed adequately. Some sutures can be removed on the surgery or in cases of high intestinal obstruction.
2nd day, others not until the 14th. Remember the function (3);To keep the stomach empty after a laparotomy for
of sutures is simply to approximate tissues, not to tie edges acute intestinal obstruction and in cases of pancreatitis.
together! Here is a guide: (4) To feed a patient.
(5) To monitor severe gastric bleeding.
Skin sutures on the face and eyelids 2-3 days
The tongue 4 days For all these reasons, it is good practice to pass a tube
The scrotum 5 days whenever you do an emergency laparotomy. It is, however,
The scalp 6-7 days not necessary with simple cases of appendicitis,
The arm, hand and fingers 7 days cholecystectomy, or elective bowel resection and most
The abdomen: transverse incision 7-9 days gynaecological procedures.
vertical incision 9-11 days
The skin of the back over the shoulders 11-12 days
The skin of the legs 14 days
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(3);Insert the drain through a separate stab incision, SUMP DRAIN, rubber or plastic. In an ordinary drain the holes through
which fluid is sucked frequently block. A sump drain overcomes this
not through a sutured wound.
difficulty by having 2 tubes, an outer one with many holes in it, and an
(4);If a drain is in any danger of falling out, stitch it in as it inner one through which fluid is sucked. Fluid trickles into the outer tube
passes through the skin (4-14L). and is then sucked away down the inner one. Ideally, suction down the
(5);Keep dressings over the drain separate from the main inner tube needs to be applied with a low pressure pump. There should
also be a single hole in the inner tube close to the surface to prevent too
wound, so the former does not contaminate the latter.
high a pressure building up in the sump. There are many kinds, and you
(6) Do not try to drain the whole peritoneum in peritonitis: may be able to improvise one. A sump drain is particularly useful for
it is impossible anyway. Instead, wash out the peritoneal draining large quantities of fluid from fistulae or a large localized abscess
cavity (10.1). in the peritoneal cavity. Alternatively, use a folded catheter. Suck through
one end and let air enter through the other (4-14E).
(7);Finally, be sure to explain to the ward staff why you
have inserted a drain, how they are to manage it, and when
they are to remove it. DRESSINGS
(8) Make sure, if there is more than one drain, that they are If dressings are in short supply, wash the wound with
labelled appropriately with a permanent marking pen. water 2-4hrly and cover it with a dressing towel (1.11).
Gauze will stick to raw wounds, and paraffin gauze is the
TO INTRODUCE AN ABDOMINAL TUBE DRAIN, standard alternative, but is expensive. You can make your
try to fit a wide bore tube tightly in a small hole. own non-stick dressing with liquid paraffin, coconut or red
Make a small incision in the skin. Use a 10mm (Ch30) palm oil.
tube, and cut side holes in the end. Make a small hole in
the tissues and 'railroad' the drain in (4-14G-J), using a LEAVING WOUNDS OPEN POSTOPERATIVELY,
hand to protect the bowel. Try to do this under direct where you can, is a useful economy. Do this if a wound is
vision! Anchor the drain to the skin with a suture. Insert a not going to discharge. If it oozes a little, put a thin
skin stitch, tie a second reef knot distal to the first one and dressing of gauze or whatever you have on it for 24hrs.
then tie the ends of the suture round the drain with a If you do use postoperative wound dressings,
surgeon's knot (4-14L). Finally, tape the drain to the skin. do not routinely change them unless they are wet, soiled,
Connect it to a sterile bottle. or smelly, or you suspect a wound infection because of a
fever.
SUCTION DRAINS are ideal, especially the disposable
plastic kind. More practical are the reusable 'Redivac' LAYERS OF GAUZE AND COTTON WOOL
suction bottle type, which have disposable drainage tubes. will collect the discharges from a wound which is too
shallow to let you insert a rubber drain (4-14A).
SUMP DRAINS are useful if you have a suction pump and Change these dressings frequently. If necessary, place a
you want to drain fluid, such as urine, or pancreatic juice sheet of plastic or waterproof paper between the outermost
which is welling up from the depths of a wound. layer and the patient's clothes.
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Insert the gun into the lumen of the organ to be (3) LINEAR RESECTION/STAPLER DEVICES
anastomosed, and tie it down with a snug purse-string The linear stapler inserts 4 parallel rows of staples and cuts
suture around the rod over the cartridge; put the anvil between the 2 middle rows; the instrument divides into
inside the lumen of the other organ to be anastomosed 2 parts which can be locked together. Place the separate
and tie another purse-string to hold that end snug. jaws of each half of the instrument inside the bowel
Fix the spindle of the anvil onto the rod of the gun, lumina to be anastomosed, making sure that no excess
and screw them together by turning the end of the handle tissue is inadvertently trapped between the jaws.
of the gun, till the desired point is reached (marked on the Slide the cutting handle down the full length of the 2 jaws,
instrument). This traps the tissues to be stapled between and separate them. This should create a perfect
anvil and cartridge. Release the safety catch, and with one anastomosis; any defect must be closed by hand.
firm movement, pull the trigger. This fires the staples You can then close the remaining open ends with another
across the tissue and simultaneously cuts a central portion linear stapler.
of excess tissue away. Release the trigger, and wiggle the Typical use of the linear stapler is in bowel anastomosis,
instrument out with a gentle twisting movement. e.g. in a right hemicolectomy (11.3) or in a gastrectomy
Unscrew the instrument: you should find 2 complete (13.10)
doughnuts of tissue under the head of the anvil if it has
worked properly. An incomplete ring will mean a defect (4) HAEMOSTATIC CLIPS
exists, which you then need to close by hand. This may be
‘Ligaclips’ are useful for closing blood vessels or ducts
very difficult! deep in the pelvis when ties by hand are awkward because
of limited space; apply the clips double with a special
instrument for better safety.
TUBES, rectal, rubber, (a) child's size 8mm (Ch24); (b) adult's size
10mm (Ch30). You can also connect these to a large bore funnel and use
them to give an enema. Introduce them carefully: you can easily perforate
Fig. 4-15 ANASTOMOSIS GUN. the sigmoid colon.
A, safety catch. B, anvil. C, cartridge with staples. D, spindle. CONNECTORS, end-to-end, polypropylene, external diameter
E, screw for approximating anvil and cartridge. F, gauge to measure (a) 4mm, (b) 7mm, (c) 10mm, (d) 15mm, (e) 19mm. Use these to join
adequate approximation. G, firing handle. short lengths of tubing together for suction or drainage etc.
CONNECTORS, plastic 3 way 'Y', assorted sizes.
CLIPS, towel, cross action, 90mm. These are the simplest towel clips.
Typical uses of the anastomosis gun are in colorectal CLIPS, towel, with ratchet, Backhaus. These are more expensive than the
anastomosis (12.10) and oesophageal transection (13.6) towel clips listed above, but they have several other uses, including
holding the sucker tube, and the ribs in chest injuries.
LINEAR CUTTING & STAPLING DEVICES FORCEPS, sponge holding, Rampley, straight, (a) 240mm, box joint.
(b) 120mm. Use these for swabbing, and for ''swab dissection'.
LOUPE, binocular, Bishop Harman, x2 magnification. Perch its 2 lenses
on the very tip of your nose, or wear it over your spectacles. Curl its ear
pieces, so that it fits your face. This is a twentieth the price of a binocular
loupe, and is invaluable for fine operations like repairing nerves,
or arteries, or 'cut-downs', or removing splinters. The disadvantage of a
loupe is that it focuses close to your nose, so use short-handled
instruments.
TROCAR AND CANNULA, straight, with nickel silver or stainless steel
cannula and metal handle, (a) 4mm (Ch12). (b) 8mm (Ch24). (c) 12mm
(CH36). The small size is useful for tapping hydroceles, the middle one
for suprapubic cystotomy, and the largest one for chest drainage.
CANNULA WITH SIDE ARM. Attach suction to the side arm and use it to
aspirate the gall bladder etc. (15.3).
PROBES, malleable, with eye, nickel silver, 150mm, 3 sizes.
Use this to probe perianal fistulae etc.
HERNIA DIRECTOR, Key's. Use this for opening the neck of a hernial
sac.
DIRECTOR, probe-ended, Brodie, 165mm. Use this for exploring
sinuses.
RING CUTTER. Try, before using this, to remove a ring with soap and
Fig. 4-16 LINEAR STAPLING DEVICES used to divide & close string.
bowel. NEEDLES, aneurysm, Dupuytren, (a) needle curving right, (b) needle
curving left. These are curved needles on the end of a handle.
Use them for passing a ligature under something (3-4).
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NEEDLES, aneurysm, small, with blunt point. Keep these in your 'cut (3);If you have enough instruments, particularly
down sets', and use them to pass ligatures under a vein.
haemostats, you can make complete special sets.
CATHETER, metal female.
BRUSH, for cleaning instrument jaws. The jaws and joints of surgical This is the best method, and the one which we follow here,
instruments need brushing regularly. You can also use suede brushes with but it requires many more instruments, and it is very
bronze bristles. important that someone trained puts the right instruments
RAZOR, safety, for preoperative preparation. Shaving a patient
in the sets. If this is not possible, revert to system (1).
preoperatively is not the essential ritual that it was once assumed to be.
You can also adapt a safety razor for skin grafting. Because of the risk of
cross-infection, especially of HIV, these should be disposable. You can do an occasional emergency operation with only
BUCKET, stainless steel, with handles. one general set, but when you have a list of patients to
KIDNEY DISHES, stainless steel, with half curled edges, 4 sizes
operate on, you will need several general sets, if you are
100-300mm.
GALLIPOTS, stainless steel or autoclavable plastic, set of 6 sizes not to wait too long between operations. Boiling a set takes
40-200mm. Use these for lotions, swabs etc. at least 15mins, and autoclaving 30mins. A set costs
JAR, stainless steel with dropover lid, 150x150mm. Use these for spirit between US$750 and US$1000; about 30% is the cost of
swabs.
the haemostats.
JUG, plastic, autoclavable, conical, 3 litre. Stainless steel jugs have
become standard, but plastic ones are satisfactory. If instruments are limited, start by collecting a general set
BIN, soiled. adapted for Caesarean section and laparotomy, and also
JELLY, hydroxymethylcellulose, sterile petroleum jelly. This is a sterile the more important special instruments.
non-greasy jelly for catheters etc.
'BIPP', bismuth iodoform and paraffin paste. This is a mildly antiseptic
self-sterilizing anaesthetic packing material. You can leave it in the nose Once you have all these, try to complete a chest
for a week without significant infection, or much smell (29.6). If you do drainage set, a tracheostomy set, 2 cut down sets,
not have any, smear gauze or bandage with any non-adherent antiseptic and a 2nd laparotomy set. When you have these, your next
ointment.
objective should probably be a minor set for
CARPENTER'S EQUIPMENT (a) Saw. (b) Twist drill. (c) Hammer,
claw head. If you cannot get the surgical equivalent of these, you will such operations as wound repairs and circumcisions.
find these very useful. If you perform many uterine evacuations, 2 or more sets
OTHER MATERIALS include gauze, cotton wool, bandages, adhesive would be useful.
tape, and laparotomy pads (1.11).
A Caesarean Section is only a particular kind of
laparotomy. The set differs mainly in that it includes
2-6 Green-Armytage (or sponge-holding) forceps,
4.12 Instrument sets and the large round-ended Doyen's retractor, which is
specially designed for pelvic operations, replaces
For most operations you will need about 50 general Balfour's. (A wide Deaver or Morris retractor is an
purpose instruments called 'the general set', with a few alternative.)
special ones when necessary. You can handle additions to
the general set in three ways: The sets below mostly start with 6 towel clips and a towel
holder, which you can also use to hold the sucker tube.
(1) You can keep special instruments in the cupboard, and Next come 4 Rampley's sponge-holders, the first 2 of
sterilize them when needed. It is useful for the theatre staff which are used for preparing the patient's skin, after which
that you have cards indicating which instruments you need they can be used to hold towels. The remaining 2 are for
for which operations. If you do not know in advance what 'swabs on sticks', and for swab dissection. Then come
you will need, you can sterilize as many of your basic toothed and plain dissecting forceps, 2 scalpel handles, and
instruments as you can, lay them out on a sterile towelled a heavy and a light needle-holder. There are also 4 pairs of
trolley, and select immediately before each operation what Allis tissue forceps, and various retractors, depending on
you will need. You then cover the trolley with a sterile the set. The expensive items, because of the large number
towel till you are ready for the next operation. Obviously, you need, are the haemostats, straight, curved, big, and
take care not to contaminate the trolley between small, clipped together in groups of 6 on Mayo's pins.
operations. This method has been very successfully used in The more experienced you are, the fewer of these you will
Manama, Zimbabwe, where the sterilizer took the better need. We list 6 of each, which is a generous number for a
part of the day to heat up! beginner. Finally, there is the Pool’s sucker and its tube;
this is a perforated suction tube which does not suck up
(2) You can make incomplete special sets, such as a burr bowel. Do not use haemostats as towel clips!
hole set or an orthopaedic set, with their special
instruments, which you use with the general set when Keep an inventory of equipment and a check list for each
necessary. The advantage of this method is that you will set posted where the set is packed and stored.
have these special instruments ready when needed in a Nice instruments tend to disappear. One aid to keeping
hurry, and you do not waste re-sterilizing instruments not instruments together is to provide them in pairs, or in
required. You can use this method in combination with (1) even- numbered quantities where possible. For example,
and (3); the nurses will find it useful to remember that haemostats
and towel clips should always be in half-dozens.
The theatre is the best place in the hospital for sterilizing
equipment. So try to develop a simple 'central sterile
supply' service which can prepare sets for the wards.
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INSTRUMENT SETS You will want the following sets, some of which ABSCESS SET.
are described elsewhere: a uterine evacuation set (2 if possible), a general 2 Rampley's sponge-holding forceps.
purpose set (preferably 2 sets), a Caesar set, a cut down set, an abscess 4 towel clips.
set, several minor set (for hernias, etc.), an orthopaedic set (for drilling 1 knife handle.
for osteomyelitis, etc.), an intestinal clamp set (for resecting bowel), 1 sinus forceps.
a fine instrument set (for hand surgery), an eye set (28.1), a burr hole set, 1 Mayo's scissors.
a chest drain set, and a tracheostomy set. 1 toothed dissecting forceps.
1 150mm receiver,
SHARP EQUIPMENT needs to be kept separately, because it gets blunt 2 gallipots and some gauze swabs.
if it is autoclaved too often. Keep scissors separate from other 2 towels.
instruments. Keep osteotomes and gouges in a cupboard and put them in
sterilizing fluid 30 minutes before you use them. Autoclave the bone saw UTERINE EVACUATION SET.
when you want it. Keep the bone drill and the twist drills to go with it in a 2 ovum or sponge-holding forceps (without ratchets).
special sterile pack. 1 Sims' vaginal speculum.
1 vaginal speculum (Sims, Auvard’s or Collin’s).
CAUTION! Always re-autoclave the packs and drums regularly. 2 Teal's vulsellum forceps.
A pack which has not been re-sterilized for some time is a risk, especially 1 set of Hegar's dilators.
if it is only covered in towels. You may find termites inside it! Karman suction curettes
Uterine curettes with sharp and blunt ends (several sizes each).
THE CONTENTS OF PARTICULAR INSTRUMENT SETS 1 200mm Kocher's forceps.
1 toothed dissecting forceps.
THE GENERAL SET (including the instruments for laparotomy) Have intra-uterine contraceptive devices (IUDs) available.
6 towel clips.
1 Backhaus towel forceps. ORTHOPAEDIC SET.
4 Rampley's sponge-holders. 6 towel clips.
1 toothed dissecting forceps (Treves). 4 Rampley's sponge holders.
1 plain dissecting forceps (Bonney's). 4 dissecting forceps: (1 heavy toothed 180mm Lane's or Charnley's,
1 #4 & 1 #5 scalpel handle. 1 light Adson's 125mm, 1 plain 180mm, 1 McIndoe's 180mm).
2 needle-holders, a heavy and a light. 6 curved 150mm Spencer Wells haemostats.
2 Allis tissue forceps. 6 curved 200mm Spencer Wells haemostats.
2 Lane's tissue forceps. 1 # 4 & 1 # 5 scalpel handle.
6 200mm curved haemostats (Spencer Wells). 4 220mm light bone levers, Lane's or Trethowen's.
6 120 or 140mm straight haemostats (Halstead's or Crile's). 4 275mm heavy bone levers.
6 120 or 140mm curved haemostats (Halstead's or Crile's). 1 Faraboef's elevator.
2 Kocher's artery forceps. 1 large & 1 small periosteal elevator (for the femur and humerus).
2 Czerny's (or Langenbeck's) retractors. 1 Size C double-ended Volkman's bone scoop.
2 Morris' retractors. 1 350g mallet.
Poole's sucker tube. 1 sequestrum forceps.
1 20cm receiver & 2 gallipots. 1 180mm Read Jensen bone nibbler.
Desirable additions include Lahey's curved gallbladder forceps. 1 bone file or rasp.
1 220mm Liston's bone cutters.
CAESAR SET (US$950). 1 200mm bone hook.
6 towel clips.
1 Backhaus' towel forceps. BURR HOLE SET.
4 Rampley's sponge holders. 1 Hudson's standard perforator 12mm.
1 18cm toothed dissecting forceps. 1 Hudson's set of conical burrs 13mm and 16mm.
1 18cm plain dissecting forceps. Hudson's brace.
2 #4 scalpel handles. 1 West's self-retaining retractor.
2 180mm needle-holders. 1 60mm brain sucker.
2 Allis tissue forceps. 1 Ch14 soft rubber catheter.
6 Green-Armytage forceps. 1 20ml syringe for washing out.
12 150mm straight Spencer Wells haemostats.
6 230mm curved Spencer Wells haemostats. SMALL (Hand) INSTRUMENT SET.
1 Morris retractor. 2 small sponge holding forceps.
1 Doyen's retractor. 1 plain 150mm McIndoe dissecting forceps.
Poole's sucker and tube. 1 plain 100mm Silcock's ophthalmic dissecting forceps.
1 300mm bowl (for blood clot), 1 toothed Adson's 120mm dissecting forceps.
1 200mm receiver & 2 gallipots. 4 165mm Gilles skin hooks.
Desirable additions include a tenaculum, and a self-retaining retractor. 1 light 190mm McIndoe dissecting scissors.
1 light 140mm curved Aufrecht's scissors.
MINOR SET (US$750). 12 curved Crile's mosquito haemostats.
6 towel clips. 1 Bard Parker # 4 scalpel handle.
2 Rampley's sponge holders. 2 114mm Derf needle holders. 2 small 178mm Meydering retractors.
4 Backhaus' towel forceps. 2 114mm Harlow Wood tendon hooks.
1 # 4 & 1 #5 scalpel handle. 1 small curette.
1 toothed dissecting forceps (Treves). 2 assistant's scissors.
1 plain dissecting forceps (Bonney's). 1 fine probe.
4 Allis tissue forceps.
1 West's self-retaining retractor. KIRSCHNER WIRE PACK.
2 Czerny's retractors (or Langenbeck's). 6 wires of each size 0∙75mm, 1∙0mm, 1∙5mm.
12 125mm curved haemostats (Spencer Wells). 1 Pulvertaft's Kirschner wire introducer.
6 200mm curved haemostats (Spencer Wells). 1 pair of Kirschner wire cutters.
1 20cm receiver 7 2 gallipots.
Desirable additions include a dissector and a Volkmann's spoon.
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It was then evident that HIV was spread heterosexually and 5.2 Pathophysiology
that subsequently this mode of spread was to prove
geographically and numerically far greater a threat to The causal agent of AIDS is known to be HIV which has
populations. The rate of spread is linked to the presence of two known types (HIV-1 and HIV-2), belonging to the
co-existent sexually-transmitted diseases, principally of the family of primate lentiviruses (slow viruses), differing by
ulcerating variety. the former having a vpu and the latter a vpx gene, absent in
the other. There is great similarity with the Simian
Studies show that a relatively small pool of infected Immunodeficiency Virus (SIV) strongly suggesting a link
commercial sex-workers could be responsible for 80-90% of between these viruses. HIV-2 is more similar to SIV, and
the initial disease prevalence in a community. HIV-1 has been found genetically to originate from a
Numbers of cases of HIV disease have increased exponentially, chimpanzee species. In conformity with other retroviruses,
and in many sub-Saharan countries doubled every 9-12months. HIV contains a virus capsid whose hallmark is the enzyme,
This trend has been followed in Southeast Asia and the Indian reverse transcriptase. This enables a double-stranded DNA
subcontinent. copy of the original genomic RNA to be made in host cells.
The viral DNA is thus integrated into the lymphocyte
Initial reactions amongst politicians to the scourge of HIV, genome. The glycoprotein (gp120) envelope of HIV binds
which was known to result in inevitable, usually slow and to the glycoprotein (gp41) molecule on the surface of
agonizing death through an end-stage described as Acquired certain thymus-derived T-lymphocytes known as
Immune Deficiency Syndrome (AIDS), was to deny the helper/inducer cells. This molecule called CD4 is also
problem. The overlay of sexual promiscuity, and in the West, found on other cells, such as macrophages, monocytes,
of weird life-styles, served to exceptionalize HIV disease, and even some antibody-producing B-lymphocytes, as well
which has been handled differently from other infectious as in brain cells.
diseases (especially with regard to counselling). Stress was on
confidentiality and anonymity and concerns about abuse of a The helper/inducer T-lymphocytes are the kingpins of the
victim’s civil rights demanded private individual counselling immune response: when stimulated by antigen contact, they
prior to HIV testing. This has resulted in isolation of the divide and produce lymphokines (such as interleukin 2 and
sufferer, contrary to the prior tradition (as in Africa) of interferon) which control the growth and maturation
understanding illness as a community problem to be discussed particularly of cytotoxic/suppressor T-lymphocytes which
fully within the family and then within the village setting. have a CD8 glycoprotein molecule.
Thus the HIV patient has often been secluded and even The ratio of CD4 to CD8 gives a good indication of
victimized in rural society and even within the family itself. immunological capability. Early on in HIV infection, the
Many women preferred not to know their HIV status, fearing CD8 cell number may rise, but there is an inexorable fall in
ostracization, because they have little control over their lives CD4 cell numbers; in the final stages of disease, the CD8
and cannot make plans for the future. With the increased count will also fall.
availability of anti-retroviral medication however,
the exceptionalization of HIV disease has become an Virus replication appears to occur mainly in dividing CD4
anachronism. cells and these cells divide upon stimulation by
In some countries, notably Uganda, the inexorable increase of micro-organism antigens (at least in vitro): thus intercurrent
HIV cases seems to have been reversed, principally through infections may stimulate viral replication. Paradoxically,
strenuous saturated educational coverage, propagated in the in the final stages of the disease, when CD4 counts
main by non-governmental organizations, and by popular fear approach zero, there may be little active viral replication.
of the disease. You can think of the CD4 count as the distance a patient is
from death; the viral load the speed with which he is
The advent of ARV therapy has had a significant impact on travelling there.
HIV disease, even in the late stages. However, this therapy
remains exorbitantly expensive long-term for most people in The extensive genetic variability in HIV isolates and the
developing countries, although WHO is making strenuous inherent difficulty of blocking the CD4-HIV binding make
efforts to make low-cost drugs available. Single-dose vaccine development far from straightforward.
treatments for antenatal women reduce transmission to the
unborn child, after needle-stick injuries, and in rape cases. The Although HIV core antigen can be detected and viral counts
emergence of resistant strains, however, remains a problem. are very useful for monitoring anti-retroviral therapy, these
The development of a vaccine is still at this stage a dream. tests are rarely available in the developing world. The most
Viricidal creams may offer some real hope in reducing widely used ELISA anti-Immunoglobulin antibody test for
transmission. HIV infection will only become +ve 6wks to 9months after
infection, thus producing a ‘window’ period when HIV is
Thus HIV is a fact of life (and death) in the developing world, actually present in serum but not detected.
and surgeons working there must know its implications.
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This has serious clinical significance; change in the test from The risk increases in a violent sexual encounter such as
-ve to +ve is known as seroconversion. The accuracy of the test rape, in the deflowering of a virgin, if ulcerative venereal
and its sensitivity is high; most incorrect results arise from disease is present (up to a factor x10), if non-ulcerative
laboratory or deliberate errors, and if a result is clinically venereal diseases are present, if an intra-uterine
suspicious, you should organize a repeat test, preferably using contraceptive device is in situ and during pregnancy.
a different laboratory or a different technique (viz. radio- It may be 500 times higher in the phase of acute HIV
immunoassay) with better specificity. The Western Blot seroconversion. The risk increases x4-x7 in anoreceptive
method is expensive, however, and is probably not justifiable intercourse, and is further increased when jelly with the
in most situations in the developing world. spermicide, nonoxylon-9, which breaks down the rectal
lining, is used. The risk is also present in oral sex, and with
artificial insemination.
5.3 Transmission & prevention A condom (female as well as male) is protective, and
reducing menstrual bleeding (by use of the combined pill
and depot medroxyprogesterone acetate) will also reduce
The 3 most prolific methods of transmission of HIV in the transmission. Male circumcision also reduces transmission.
developing world are:
(1);by sexual contact, dominantly heterosexual, Restricting sexual activity to a monogamous marriage
(2);from mother to baby, without extra partners remains the only certain way to avoid
(3);by blood products. HIV exposure by this route. Therefore you should advocate
prenuptial HIV testing, and certainly before any pregnancy
Transmission may also occur through is considered.
(4) transplanted tissue,
(5) sharps injuries and splashes. (ii) Vertical transmission of HIV from mother to baby
This may occur between drug users sharing injection needles, varies between 15-45% if there are no interventionist
especially when ‘mainlining’ (injecting) themselves with IV strategies used; estimates are that transmission occurs in
drugs. Viral particles have, however, been detected in seminal ⅓ before delivery, in ⅓ during delivery, and in ⅓ after
fluid, and pre-ejaculate fluid, vaginal and cervical secretions, delivery. It seems possible to reduce transmission to 2-3%
breast milk, tears, urine, and saliva, so caution regarding with the antenatal use of antiretroviral drugs (a single dose
transmission is wise. of nevirapine appear to be sufficient), arranging delivery by
Caesarean section, and avoiding mixing breast feeding with
(i) Sexual contact. bottle feeding of milk substitutes.
As simultaneous sexual promiscuity by men is common, there
can be no clearly defined risk group; nonetheless certain Whilst the adoption of mandatory Caesarean section for
groups have significantly higher prevalence rates than others, HIV-mothers may have theoretical justification,
and therefore a high index of suspicion is justified. the morbidity and mortality inevitable in such a policy in
Such groups are: the developing world outweigh the advantages
army personnel, notwithstanding the costs of screening and surgery.
those travelling widely in their employment, Previous policies of restricting breast-feeding have actually
e.g. truck-drivers, police, and itinerant salespersons, been shown to be harmful, and are not recommended.
attenders at venereal disease clinics, especially when tested
+ve for syphilis, Other practices, however, reduce risks of transmission:
men working away from home, protocols developed to prevent blood exchange from foetus
those with high alcohol intake, (low-pressure) to mother (high-pressure) in potential rhesus
male prisoners (through forced rape), sensitization are applicable up to the moment you clamp the
divorced, separated, or young widowed women, umbilical cord:
young widows and widowers. (1).Treat infections which disrupt the placental barrier,
particularly malaria and toxoplasmosis because these
As, however, the spouses of infected persons are at as great increase transmission of the virus. Malnutrition also allows
risk, the identification by history and direct social questioning increased transplacental viral transmission.
of potential HIV individuals becomes at best difficult and (2).Reduce prolonged labour by use of prostaglandins and
time-consuming. Nonetheless identifying a girl as a virgin is oxytocin. Treat chorio-amnionitis with antibiotics.
helpful in minimizing HIV as a factor in reaching a diagnosis. (3).Avoid external cephalic version and amniocentesis;
clamp the umbilical cord as early as possible.
The estimated risk factor of transmission from a seropositive The longer the baby is protected in labour from direct
man to woman during a single unprotected sexual exposure is contact with the mother’s blood and secretions the better.
c.0∙5-0∙75%, but seropositive woman to man 0·25%. (There is (4).Avoid artificial rupture of membranes and make
a considerable range from 0·1% where the viral load is <1700 episiotomies at the last moment. If membranes are already
copies/ml to 20% where the load is >38500/ml). ruptured, reduce contact time by use of oxytocin.
The risk is zero if viraemia is undetectable.
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N.B. Foetal scalp electrodes and foetal scalp blood Use blood transfusion therefore very sparingly; educate
collections are contra-indicated. anaesthetists concerning the safety of working with
suboptimal Hb levels, and learn the appropriate strategies.
(5).Be very careful with instrumental deliveries, preferably Various strategies can avoid risks:
using rubber cup vacuum extractors to prevent abrasions of the (a) Autologous blood.
foetal head; better avoid them altogether. Washing of the Take 1L of blood from an adult; treat him with maximal
vagina with povidone iodine before instrumental delivery or doses of ferrous sulphate for 2wks; then take a further 1lat
after rupture of membranes is probably a sensible precaution. the same time as transfusing 500ml of the previously
Rinse babies immediately after delivery in warm water. collected blood. In this way you can prepare 1500ml
(6).During Caesarean Section, try to deliver the foetus with (3 units) of blood for elective surgery.
intact membranes; do not use the scalpel to open the whole
thickness of the abdominal wall, lest the baby is cut. (b) Intraoperative haemodilution.
Suctioning of the baby after delivery pushes maternal blood up Take 1lof blood immediately prior to surgery and replace it
its nose and is unnecessary; wiping is usually sufficient. with crystalloid. The fresh and platelet-rich blood is then
immediately available for re-infusion if needed;
Transmission during breast feeding appears to increase if the blood viscosity is also incidentally lowered and this may be
mother seroconverts during this time, if breast feeding is mixed an advantage, especially in vascular surgery.
with other feeds, and if the nipple is cracked or eczematous, or
the baby has mouth ulcers. Abandoning breast feeding implies (c) Peroperative blood salvage (Autotransfusion).
the ready availability of milk substitutes, rarely the case for the Blood from clean traumatic injuries of the chest or
poor in low-income countries, and removes the natural abdomen, or from an ectopic gestation, is ideal for this
transmission of protective immunoglobulin to the baby. treatment; it can be life-saving. Also, it carries no risk of
However, expressed breast milk can be pasteurized (kept at hepatitis or HIV, and it will be perfectly cross-matched.
62·5°C for 30mins, or heated just up to boiling and then Autotransfusion is thus very useful.
cooled) to eliminate HIV, as well as Hepatitis B virus (HBV).
Supply it then in a small cup rather than in bottles with teats as CONTRAINDICATIONS.
these are difficult to sterilize properly. Nutrients and Do not attempt autotransfusion if:
micro-nutrients are preserved but IgA antibody activity is lost, (1).There is an offensive smell when you open the
and diarrhoea is then a frequent problem. Proper attachment of abdomen.
the baby to the breast and preventing nipple damage also (2) The abdomen is grossly contaminated.
reduces the risk. Heat treatment is not possible for colostrum, (3) The blood is obviously haemolysed.
however, because it curdles and there is a high viral load in (4) A woman is more than 14wks pregnant with a ruptured
colostrum. amniotic sac. (Her blood will be contaminated with
Correct Vitamin A deficiency, which increases the risk of amniotic fluid containing large quantities of
transmission. thromboplastin. If you transfuse this, it could theoretically
N.B. Transmission of HIV from seropositive baby to cause disseminated intravascular coagulation (DIC).
surrogate breast-feeding mother has occurred, and vice versa Nonetheless you can use blood in a contaminated peritoneal
from seropositive surrogate mother to baby. cavity on occasion under antibiotic cover without untoward
effect if you are absolutely desperate.
(iii) Transfusion of blood products entails a significant N.B. The presence of fresh clots is not a contraindication
risk (3.6), especially where laboratory testing is unreliable. to autotransfusion.
Because of the window period, apparently safe blood products
may actually be contaminated. In order to reduce this risk, THE VACUUM BOTTLE METHOD is the best.
encourage long-standing donors whose HIV-ve status Buy vacuum bottles, or prepare them by
can be followed over a considerable period of time closing blood-taking bottles containing 150ml 3·8%
(and are therefore unlikely to seroconvert), unlike citrate-dextrose immediately after they have been sterilized,
schoolchildren who may become newly sexually active. before the steam in them has had time to condense.
Discard blood from a new donor deliberately; accept it only if Clamp a taking set, introduce one of its needles into the
he tests -ve on a subsequent visit after nine months. Select abdomen, as if you were doing a 4-quadrant tap, and then
blood donors on a voluntary basis, thus removing a financial put the other needle into the bottle and remove the clamp.
incentive for donation. To fill the bottle insert another sterile needle connected by
way of a heparinized suction catheter to a vacuum pump
The risks from transfusion are cumulative, rising with numbers into the bung. You may be able to collect up to 3lof blood
of units transfused. Furthermore the risk of using products this way. If the vacuum is imperfect, and does not fill the
pooled from many donors is also higher; thus do not use Fresh bottle, apply suction with a vacuum (water) pump
Frozen Plasma and pooled Platelet Concentrate. The use of connected to a sterile needle inserted through the bung.
Factor VIII concentrate is likewise risky but may be essential
in treatment of haemophiliacs requiring surgery; render it safe
by heat treatment.
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Most injuries to health-care workers arise from careless Adopt a hospital sharps-injury policy in order to advise all
handling of sharps: health workers on precautions and action to take after
exposure, depending on facilities available. Discipline staff
Recapping of needle 40% not taking precautions. Introduce a post-exposure
Improper disposal of sharps 32% prophylaxis/treatment policy if you don’t already have one
Contamination in open wound 25% in your hospital. Remember to wash the part injured by a
Other 3% needle-stick immediately, and cleanse it with betadine.
Use the low-cost de Montfort medical waste incinerator.
In the laboratory, heat-treat serum at 56ºC for 30mins
before testing; pipette solutions using a teat not your mouth!
5.4 Sterilization
Wear gloves when cleaning spills. Dilution by washing is
important. If alcohol is used, wipe the surface several times
because alcohol evaporates. Establish the rule,
“You spill it, you clean it.”
Dispose contaminated materials safely; do not put them on
a rubbish tip where they may be scavenged!
Ordinary laundry is effective for cleaning soiled linen after
thorough soaking.
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* Chlorine-releasing solutions are excellent disinfectants. As most erroneous results are from laboratory errors rather
Their power is expressed in ‘available chlorine’: 1% = 10g/l = 10,000 ppm
than deficiencies of the test, repeat surprise results.
(part per million) = 3·33 chlorometric degrees
N.B. Chlorine corrodes iron and stainless steel, so these disinfectants must Repeat confirmation of -ve results likewise for safety,
not be stored in stainless steel containers; equipment is easily corroded and after 3-6 months. Oral tests are now available.
should be rinsed well after disinfecting.
Sodium Hypochlorite solutions (Liquid bleach, Javel) are unstable:
Though the theoretical model of insisting on counselling for
Neat disinfectant (domestos, Chloros, Sterite) contain c.100,000 ppm
Strong hypochlorite solution BP contains >80,000 ppm HIV tests as promoted in the First World is commendable,
Most supermarket brands contain c.50,000 ppm it may not be practical in the developing world situation
Milton contains c.10,000 ppm where resources are few and trained manpower limited.
HIV is inactivated by 5,000 ppm solution in 1 minute, by 50ppm in 10mins;
It has been shown that a short description of the facts of
at this low dilution it is very unstable so must be freshly made, used and
discarded. HIV disease without full discussion of the social
Calcium Hypochlorite (70% available chlorine) and Bleaching Powder implications will lead to fear and despair rather than a
(35% available chlorine) sold as tablets, granules or powder, both decompose positive attitude to the disease; thus limited counselling
gradually if not protected from heat and light.
may be more detrimental than none at all.
Sodium Dichloroisocyanurate 0·5% (NaDCC: 60% available chlorine) and
Tosylchloramide sodium (Chloramine T: 25% available chlorine) sold as
powder or tablets, are comparatively stable. If tests are only done when a patient has been fully
Use solutions of 1,000 ppm for general disinfection of wards, theatres and counselled, many patients will go untested. Furthermore a
laboratory benches.
possible HIV-ve result may thus be denied a patient who is
Clean contaminated surfaces with 5,000 ppm which is left in contact for
30mins before rinsing off. too scared to ask for a test, assuming as many do in areas of
high HIV endemicity, that any severe illness is probably the
Recommended dilutions of chlorine- releasing agents dreaded disease that leads to certain early death.
To put pressure on a patient to make up his mind on
Available Clean Dirty condition
Chlorine condition (e.g. blood spills, whether or not to have a test which may reveal a fatal
(e.g. cleaned soiled equipment) illness is like asking a patient with a pathological fracture
medical whether he wants an X-ray to be done if it might reveal a
equipment) malignancy. Indeed even the counselling becomes
Available 0·1% (1g/l, 0·5% (5g/l,
Chlorinerequired 1000pcm) 5000pcm)
something with a stigma attached for the patient.
Dilution
Sodium 5% 20ml/l 100ml/l In areas of high endemicity, an HIV test may be important
Hypochlorite to exclude HIV infection as a diagnosis, rather than
Solution confirming the presence of the disease, and thus giving a
Calcium 50% 1·4g/l 7·0g/l
Hypochlorite
patient hope when he had long given up ideas of recovering
NaOCC 60% 1·7g/l 8·5g/l from illness.
NaOCC-based 1·5g 1 tablet/l 4 tablets/l
tablets per tablet Where HIV is prevalent, and testing difficult or
Chloramme 25% 20g/l 20g/l impossible, an awareness of the clinical presentation of
RECOMMENDED DILUTIONS OF DISINFECTANTS HIV-related disease is essential. As any body system can
WHO AIDS Series (2), Guidelines on Sterilization and High-Level Disinfection be affected; HIV does not manifest itself usually by a single
Methods effective against HIV. Geneva 1988 identifying pathology. Therefore look for the usual
significant tell-tale signs in patients, especially to give clues
Standard autoclaving at 121ºC at 1 kg cm2 or use of a hot air as to the underlying pathology of the presenting condition.
oven at 170ºC for 2hrs eliminates HIV (as it does the hepatitis HIV has made new diseases common, and changed the
B virus, which is much more easily transmitted). diagnostic spectrum.
Thus place all surgical instruments which tolerate heat, and all
reusable surgical sundries in disinfecting fluid and then clean Certain conditions have a very high association with HIV,
them (someone wearing non-sterile gloves) free of blood or whereas others less so; it is the sum total of the clinical
tissue and then sterilize them by heat. picture that is important. Because HIV affects any system,
always take a meticulous general history and make a full
examination.
5.5 Testing & visual recognition Perhaps the most striking features of untreated HIV patients
recognizable before any medical interview is undertaken
Combo kits are now available which detect IgM as well as IgG, are the following (seen obviously mainly in the face):
and so reduce the window period when a common screening (1) Facial rash, typically seborrhoeic dermatitis,
test may show -ve in the presence of early infection (and high (2) Lymphadenopathy,
risk of transmission owing to high viral loads). (3) Herpes Zoster scarring (5-3),
(4) Parotid swelling (5-12),
(5) Unilateral ptosis (5-14),
(6) Weight loss; hair changes & premature ageing.
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Where you see these features, concentrate the remainder of the Some dermatitis may be secondary to other conditions,
medical history and examination for diagnostic purposes on e.g. HIV-related malnutrition leading to pellagra.
further HIV-related conditions. Although, of course, patients Some malignant skin conditions may show a more
with HIV may have non-HIV-related illness, inherently it is aggressive pattern: this has been reported with malignant
more likely that the illness is indeed HIV-related. For example melanoma. Several skin ailments are common with high
a patient with clear signs of immunosuppression complaining HIV association, with Herpes Zoster having a high
of headache is much more likely to have HIV-related causes of predictive value, and Herpes Simplex on the vulva and
headache than a brain tumour. buttocks; eosinophilic folliculitis has only been seen in
HIV+ve patients, particularly where the CD4 count is
Gradation of severity of symptoms and signs is related to <400/μl.
dropping CD4 counts, but this test is not available in most
hospitals, although you can gauge it by the total lymphocyte
count.
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MOLLUSCUM CONTAGIOSUM
SEBORRHOEIC DERMATOSIS
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Cellulitis (6.22), arising without history of diabetes mellitus or There is chronic staphylococcal carriage with decreasing
trauma, is a common manifestation of HIV; the causative immune competence, and therefore colonization of foreign
organisms remain streptococcus and staphylococcus and the bodies such as catheters is high. The incidence of post-
disease responds to intravenous penicillin or cloxacillin, rest operative wound infections increases dramatically in
and elevation of the affected limb. There is, however, frequent HIV+ve patients, especially if the CD4 count is <200/μl.
skin necrosis requiring debridement and subsequent skin-
grafting. This may occur with pseudomonas aeruginosa Abscess formation, especially de novo, in normally clean
infection where the result is known as ecthyma gangrenosum. anatomical sites should give rise to suspicion of HIV
Facial cellulitis is potentially life-threatening owing to possible disease; in this category are breast abscesses in
spread of organisms to the brain through the cavernous sinus, non-lactating women (6.13), muscle (pyomysositis) (7.1),
and requires aggressive intravenous antibiotic therapy. thyroid (6.12), abdominal wall, penile (6.21) and
retroperitoneal abscesses (6.15). Submandibular and neck
NECROTIZING FASCIITIS abscesses (6.11) are often related to pre-existing
lymphadenopathy and may be tuberculous.
Pressure sores often arise from the combination of inertia,
cachexia and neuropathy in HIV disease.
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Histoplasmosis in Latin America, leishmaniasis in South Oropharyngeal carcinoma is 3 times as common with
America and infection with penicillium marneffei in the HIV disease.
Southeast Asia are increasingly common associations of
lymphadenopathy and hepatosplenomegaly with HIV. Kaposi sarcoma (31.8) lesions on the palate or gums
In children with HIV, BCG immunization produces a (5-11) are manifestations of systemic gastro-intestinal
lymphadenitis. involvement. Non-Hodgkin Lymphoma is also frequently
seen.
D..ORAL DISEASE
KAPOSI SARCOMA ON THE GUMS
Oral candidiasis (5-10) is a very well-known manifestation of
HIV disease, which may present in erythematous,
pseudomembranous, hyperplastic forms or angular stomatitis.
ORAL CANDIDIASIS
E..NASAL DISEASE
F..EAR DISEASE
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G..SALIVARY GLAND ENLARGEMENT (17.5) A small lesion with an irregular surface 2-5mm in diameter
appears on the medial side of the limbus usually, spreading
Parotid enlargement is a typical early sign of HIV disease; onto cornea and underlying sclera. Recurrence after
its cause is varied, including lymphadenopathy (as part of excision is fairly common. Where tumour extends into the
generalized lymphadenopathy), salivary and extraparotid sclera, resulting in necrotizing scleritis, the eye is lost.
lympho-epithelial cyst formation, and lymphocytic infiltration
(due to direct infiltration by CD8 lymphocytes). Kaposi sarcoma appears as a slightly raised pigmented
This may represent a beneficial response to HIV infection, and lesion found on the eyelid, conjunctiva or inside the orbit.
patients with salivary gland enlargement seem to experience This may be isolated or multifocal; recurrence after
slower progression of the disease. Frequently, unilateral parotid treatment is usual.
swelling is followed some time later by swelling of the
contralateral side. Molluscum contagiosum consist of raised umbilicated
lesions; when they affect the eyelids, they may become
PAROTID SWELLING large and numerous; an associated follicular conjunctivitis
may occur due to viral shedding.
Keratitis is a severe, rapidly deteriorating infection involving Spontaneous pneumothorax (36.1) occurs especially in
the cornea caused by either: bacteria, fungi, microsporidia, pneumocystis carinii pneumonia, which accounts for up to
Herpes simplex, or Herpes zoster. The cornea is affected in the 60% of pulmonary infection in HIV disease.
latter through the nasociliary branch of the ophthalmic division This occurs frequently in conjunction with
of the Vth cranial (trigeminal) nerve. Progress occurs to cytomegalovirus. Other infections in the lung are mainly
multiple small dendritic and then geographic ulceration and with bacterial pathogens and mycobacterium: in low-and
frequently to perforation. Healing by scarring may give rise to middle-income countries, tuberculosis is extremely
iris adhesions leading to glaucoma, and inevitably corneal common as a manifestation of HIV disease. Pleural
opacification. Once perforation occurs, however, or if a effusion is a common consequence, and empyema thoracis
staphyloma develops, the eye is lost. (9.1) likewise.
However, not all effusions are due to tuberculosis: they
Bacterial conjunctivitis comes as acute or subacute infection, may be secondary to lymphoma, Kaposi sarcoma, or
either staphylococcal or gonococcal. serious bacterial infection.
Open thoracic surgery is fraught with serious pulmonary
Conjunctival carcinoma (28.15) was soon found as a more complications and is ill-advised.
frequent pathology in Uganda, being first described in
Guadeloupe as probably related to HIV, having been noted as Tuberculous pericarditis and pericardial effusions (9.2)
an oddity much earlier. (This pattern mimics the story of are common.
Kaposi Sarcoma). There appears to be an increased
susceptibility to ultraviolet light in the presence of human
papilloma virus-16 infection.
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Nonetheless you may see HIV-related pathologies frequently; Tuberculous adhesions are often thick and unyielding (and
these include: may be detected as septa on ultrasonography in an ascites-
Primary peritonitis: most common, filled abdomen). A tuberculous mass usually occurs in the
Spontaneous bowel perforation, especially in the distal right iliac fossa but any site may be affected; an intestinal
ileum (usually due to CMV) or colon, stricture occurs in the ileum in 70%, in the jejunum in 15%,
Tuberculous peritonitis (16.1) in the following forms: and in both in 15%.
Multiple peritoneal seedlings with ascites,
Tuberculous mesenteric lymphadenopathy In a few cases, the signs of intestinal obstruction may
(with or without ulceration), mimic a paralytic ileus thought to be related to an HIV-
Ileocaecal tuberculous mass (Tuberculoma), neuropathy.
Tuberculous colitis (mimicking ulcerative colitis),
Tuberculosis of Fallopian tubes and ovary, L..ABDOMINAL MASS
Abdominal wall sinus.
Cryptococcal peritonitis, multiple superficial small white Lymphoma or tuberculoma is likely to be the diagnosis in
nodules seen on the omentum and serosal surfaces, a younger patient; tuberculous abscess of the liver or spleen
Mesenteric thrombosis (12.14), usually a venous infarction, are not rare, but common local conditions should still head
Colitis (in adults), from enteropathic E. coli or CMV, the diagnostic list in HIV+ve patients, especially where,
mimicking amoebic colitis, as in schistosomiasis, HIV appears to have little impact on
Necrotizing enterocolitis (in adults and infants beyond the the disease pattern.
neonatal period;10.4),
Acalculous cholecystitis (caused by cryptosporidium, CMV, Do not assume a right iliac fossa mass to be a walled-off
microsporidia, lymphoma or KS). acute appendix! Whilst the diagnosis of an abdominal mass
follows standard principles, keep HIV-related conditions in
In late stages, the gallbladder may perforate, mind.
but perforations may be multiple and small with inflammatory
exudation.
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Liver abscess (15.10), especially tuberculous, is not Pregnancy worsens the HIV condition if in the late stages;
uncommon. wasting contributes to maternal and perinatal mortality;
puerperal sepsis (22.14) is more common and more severe.
Hepatitis is common: either with hepatitis B or herpes virus, Although Caesarean section reduces the transmission of
cryptococcus, or induced by drugs. Granulomatous hepatitis HIV to child, it is not practical to advocate such a general
occurs with fungal infections or mycobacteria. policy. Introduce practices to reduce transmission (5.3).
Unusual infections, e.g. peritonitis after postpartum tubal
Hepatoma is 7 times as common with HIV disease, but the ligation, or pubic osteomyelitis after spontaneous labour,
effects of Hepatitis virus exposure are probably more are seen.
important.
Puerperal psychosis may be difficult to differentiate from
Acalculous cholecystitis has been discussed previously under HIV-cerebral encephalopathy.
‘Acute abdomen’. Good contraception (and that usually does not mean the
contraceptive pill), is needed in HIV+ve women.
Cholestatic jaundice (15.7) may arise from several types of The contraceptive pill is a bad option because ARV therapy
HIV-related pathology: and antibiotics (especially rifampicin) interfere with their
papillary stenosis, absorption and so they become far less effective (unless
sclerosing cholangitis, 2 pills a day are taken). Fever, vomiting diarrhoea and the
lymphadenopathy in the porta hepatis, especially TB. AIDS dementia syndrome also interfere with effective use.
Cryptosporidium and cytomegalovirus have been implicated; The dangers of IUD’s are overstated, but Depo-Provera is
this is not necessarily a late complication of HIV disease. probably the drug of choice.
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Focal segmental glomerulonecrosis is the commonest cause Do not underestimate the possible complications of elective
of HIV-related renal impairment; renal tuberculosis remains circumcision, especially if you use a LA ring block:
rare but consider it in chronic sterile pyuria. necrotizing fasciitis, abscess and also the risk of
Although common in the HIV population, epididymitis shows haemorrhage, particularly where thrombocytopenia is
no real differences in presentation and treatment with the present, are serious problems. Though these complications
non-HIV population. are quite common with HIV+ve patients, they can also
occur to others.
Tuberculous epididymitis is however more common; Recommendations for circumcision to prevent HIV
the lesion is typically firm. transmission fall in the same category as the use of
condoms: although it may help, it does not get to the root of
HIV-related cystitis may be aggressive and extremely the problem. You must carefully counsel your patient that
debilitating. The predominant symptoms are painful circumcision does not protect him from HIV infection,
urinary frequency, suprapubic pain and haematuria but may just lowers the risk.
(micro- or macro-scopic) without any demonstrable urinary
tract infection. Cystoscopy reveals a highly characteristic Condylomata may be very profuse on the foreskin and
uniformly congested appearance with no ulceration and no may encroach onto the glans penis and into the urethral
significant reduction in bladder capacity. The histological meatus.
appearance is like a non-specific interstitial cystitis without
mast cells, with no cytomegalovirus found. Erectile dysfunction is very common in HIV disease,
and seems to have a multifactorial origin; treatment with
Urinary tract infections occur in c.15-20% of males with sildenafil and related drugs pose huge moral and ethical
advanced HIV disease (CD4 <200/μl), most commonly with issues.
pseudomonas aeruginosa.
All types of sexually transmitted infections are inevitably Q..ANORECTAL DISEASE (26.2)
common in HIV+ve patients, and therefore a combination of
diseases is frequent. You will find a variety of anorectal lesions in HIV+ve
patients, and their severity relates closely to CD4 levels;
Balanitis co-existing with chancroid, condylomata or with in all patients they are common, although they are
malignancy. This may be in the form of squamous carcinoma particularly numerous (c. 30%) in homosexuals, where they
or Kaposi sarcoma. There may be a continuum of histological have a somewhat different pattern. As many practitioners
change from condyloma to squamous carcinoma, suggesting a have a natural reluctance to examining the anal region, they
synergistic interaction between the papilloma virus and HIV. are often referred to as ‘piles’; however haemorrhoids are
Malignancy of the foreskin however remains rare; frankly per se not part of the spectrum of HIV anal pathology.
necrotic ulcerative penile lesions are usually due to chancroid. Many of the lesions are resistant to treatment, and their
Patients may request circumcision (27.29) hoping thereby to aetiology is not known; however, this does not mean that
avoid recurrent penile ulceration; this may then of course occur you can do nothing for patients with these conditions.
on the glans penis itself. The operation of circumcision is not However, do not undertake elective anorectal surgery
without risk: severe necrotizing fasciitis of the penis can occur lightly: many authors have reported poor or absent wound
post-operatively. There appears, at least in certain cases, to be healing often after many months. Distal septic
a microangiopathy associated with balanitis; this may be the complications such as meningitis may also occur.
predisposing factor in the development of necrotizing fasciitis
and it may be exacerbated by increased tension when LA is Idiopathic anorectal ulcer appears first as a mucosal
used in a penile block. You should therefore perform the laceration within the anal canal, and gives rise to symptoms
operation only under GA or using a caudal block. identical to the classical anal fissure, i.e. pain and bleeding
per rectum. However, you will see no anal skin lesion on
Penile abscess (6.21) de novo is diagnostic of HIV infection. gentle parting of the buttocks, because the lesion is internal,
The infection usually spreads from the penis to the scrotum, usually just proximal to the dentate line. Furthermore there
rather than the reverse as in the classical Fournier’s gangrene. is rarely anal sphincter spasm, and often diarrhoea rather
In the absence of urethral stricture or diabetes mellitus, than constipation. Pain is persistent, usually associated with
necrotizing fasciitis of the penoscrotal tissues is likewise some intermittent bleeding per rectum, particularly after
diagnostic of HIV disease. defecation.
Don’t necessarily refuse a request for circumcision in HIV+ve The mucosal defect then deepens and becomes palpable as
patients on traditional or social grounds; there may be a an ulcer with smooth benign-feeling edges. As this ulcer
protective role in HIV transmission in the act of circumcision. deepens further, it may penetrate into the vagina or urethra
The epithelium of the exposed glans penis in the circumcised or appear as a large fistula externally.
male changes from columnar to stratified squamous, and may No single agent has been implicated in this lesion, although
thus be more resistant to ulceration. in some cases cytomegalovirus, chlamydia trachomatis
However, the morbidity and, in some cases, mortality of (26.11), and herpes simplex virus have been found.
circumcision, especially where medical resources are scarce, There is commonly associated infection, with patients
may make this procedure dangerous. reporting pus draining per rectum.
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Superficial breakdown of perianal skin with excoriation Squamous carcinoma (26.7) may be heralded by the
is often associated with chronic diarrhoea; neoplastic change seen in anal intra-epithelial neoplasia
control of loose stools is therefore obviously important. (AIN), or be the result of chronic infestation by
Vesicular excoriation is due to herpes simplex. condylomata, especially if florid, or arise de novo.
Careful examination to exclude fistulae and abscesses is vital. The incidence of HIV-related anal carcinoma is rising and it
is 60 times more common than without HIV disease, but
Fistulae (26.3) in HIV+ve patients are often complex and this may be mostly due to the risks of ano-receptive sexual
multiple. They are frequently high or intersphincteric intercourse.
(intermediate) and are therefore not amenable to simple laying (Lymphoma and Kaposi sarcoma may also be found at
open. In fact, even for low superficial fistulae, the laying open the anus.)
may result in non-healing perianal wounds, especially if CD4
counts are <200/μl. Proctitis: Just as in colitis, the rectum may be affected by a
Many fistulae arise from sepsis, but some as a result of severe inflammatory process; cytomegalovirus, herpes
extension of the idiopathic anal ulcer described above. simplex, chlamydia or enteropathic E. Coli may be the
In these cases, the fistula is wide and may readily admit the cause.
examining finger. Fistulation can occur to the outside skin,
but also to the vagina or bladder. This occurs both in adults and R..VASCULAR DISEASE
small children. If the fistula was not present at birth, it is
pathognomonic of HIV-disease. Any major artery can be involved; the pathology affects
mainly the adventitia with leucocytoclastic vasculitis of
Anal and perianal warts (26.6) are often very extensive; vasa vasorum and periadventitial vessels, proliferation of
their excision or diathermy ablation surprisingly results in rapid slit-like vascular channels, chronic inflammation and
wound healing, presumably due to an epithelial growth factor fibrosis. There is associated medial fibrosis with loss and
in the papilloma virus. Contact tracing in poor-resource fragmentation of muscle and elastic tissue, and similar
environments is a pipe-dream, and therefore recurrence by fragmentation in the internal elastic lamina of the intima,
reinfection is frequent. Moreover, if not all condylomata are with calcification.
removed, and they can extend far up in the anal canal,
they quickly re-establish themselves. Beware when using Arterial occlusion (35.2) or aneurysm formation (35.8)
diathermy on these lesions: HIV may be transmitted by the are the end result; the former is much more common,
smoke, so always wear a mask and aspirate away the fumes. but increasing numbers of aneurysms are seen in HIV+ve
patients.
PERIANAL CONDYLOMATA Arterial occlusion in limbs results obviously in gangrene;
in poor-resource countries, patients rarely present with
claudication, and the deterioration of symptoms is usually
too rapid to allow early presentation. Thus arterial
reconstruction is hardly ever an option; you should also
have serious qualms about using prosthetic material in
HIV+ve patients as the vessels take sutures poorly,
and secondary infection of the graft is a very definite risk,
often with fatal outcome. Results of surgery for
atheromatous disease (i.e. not HIV-related) in HIV+ve
individuals may however be more successful.
Thrombosis may also occur in mesenteric vessels, or
cerebral arteries resulting in a cerebro-vascular accident.
Aneurysms tend to occur in the carotid and superficial
femoral arteries, although any artery may be involved and
multiple lesions are seen. Spontaneous arteriovenous
fistulae also result.
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Transverse myelitis, leucoencephalopathy, progressive All these complications may be correlated to CD4 cell
dementia, and encephalitis, occur through the strong affinity counts and can therefore give an indication of the stage of
of HIV for neuronal cells. advancement of the disease, and also of its regression with
treatment:
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CD4 count WHO Stage In areas of high TB endemicity, you may be able to
>500/μl I diagnose TB by a lymphocytosis on pleural fluid,
200-500/μl II - III pericardial fluid or simply the presence of para-aortic
<200/μl IV lymphadenopathy on ultrasound. Pleural fluid usually has
The T-cell profile changes with drop in levels of CD4 cells and fibrinous strands visible on ultrasound.
rise in CD8, with drop in ratio CD4/CD8 <2; there is a total
drop in T-cells late in the disease. However, a T-cell leukaemia
may occur with rise in numbers.
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It is important to screen sputum also for AAFB (‘open PTB’) If the CD4 count is <50/μl, however, start ARV treatment
in every patient for good infection control, especially in the as tolerated, but avoid nevirapine and substitute efavirenz
community. A chest radiograph may not show classical apical which is much more expensive. Otherwise start ARV
disease, but rather lower lobe infection; there is less cavitation treatment after 2wks of anti-TB therapy.
and a miliary pattern is common (especially when the CD4
count is low). It is important to perform radiography when The main drawback with TB drugs is their side-effects,
treatment is finished, and to file films properly for which are often shared by anti-retroviral drugs:
future cross-reference.
Toxicity TB Drug ARV Drug
Do not start treatment without arranging contact tracing, Neuropathy H d4T, ddC, ddI
especially babies and infants, and notification. Hepatitis & R, H, Z, S NNRTI’s
Special charts are available in many countries. Follow your Rash
regional regime, or otherwise, the WHO approved standard, Nausea Z ddI, AZT, PI’s
using a directly observed treatment scheme (DOTS): Visual loss E -
Intensive Phase: 2months Isoniazid (H), Rifampicin (R), Hearing & S -
Pyrazinamide (Z), & Ethambutol (E), followed by Balance loss
Continuation Phase: 4months HR. (N.B.Names of ARV drugs in 5.8)
(Note, however, that visual loss is usually the result of
Extend this continuation phase to 5months for TB epididymitis, CMV retinitis rather than a side-effect of TB drug therapy)
6months for spinal TB with neurological problems, TB
pericarditis and meningitis, and 9months for renal TB. If a patient is already on ARV treatment when you
(An alternative is 6months of Isoniazid and Ethambutol.) diagnose TB, don’t stop the ARV drugs!
Do not use Ethambutol in children <10yrs.
If patients do not complete their treatment courses, or if
If the patient has had treatment before, initial treatment is many different treatment regimens are used, resistant
probably best in hospital: use longer treatment phases: strains are likely to develop. Multi-resistant TB has
Intensive Phase: 2months Streptomycin (S), plus HRZE, surfaced in some parts of the world: 2months of
followed by 1 month HRZE, and then, streptomycin are then recommended but get specialist help;
Continuation Phase: 4months HRE. the possibilities of untreatable TB, if combined with HIV,
Do not use Streptomycin in pregnancy; or (and Ethambutol) to would be disastrous. For these reasons, prophylactic
children <10yrs. Thiacetazone is no longer routinely used. treatment of HIV+ve patients with isoniazid is only
recommended where tuberculosis is not so prevalent: follow
Dosages are weight-dependant: as the patient improves and he national programme guidelines!
gains weight, so you may need to alter the dosage; these are
daily oral doses:
5.8 Treatment
Weight Isoniazid Rifam- Pyrazin- Etham- Strepto-
(H) picin amide butol mycin The virus multiplies at an alarming rate: within a week of
(R) (Z) (E) (S) seroconversion there are 107-8 RNA copies/ml.
5-9kg 50mg 75mg 250mg - - In 6-12 months the viral load reaches an equilibrium where
11- 100mg 150mg 500mg - - it can usually be maintained by medication for several
20kg years.
21- 200mg 300mg 1000mg 800mg 500mg
33kg ARV therapy has proved remarkably successful, though
34- 300mg 450mg 1500mg 800mg 750mg eradication of viral reservoirs has not been possible. You
50kg should maintain long term treatment, though this is still
expensive; however costs have come down dramatically
>50kg 300mg 600mg 2000mg 1200mg 750mg
through WHO campaigns; so use this resumé if you can.
Unfortunately still only c.50% of people with HIV needing
Fixed dose combinations may be available, and help patient treatment worldwide are getting it.
compliance; twice or thrice-weekly regimens are being
introduced to make DOTS easier, but dosages will then differ. A willingness and commitment to long-term therapy is
essential; consider the financial costs, and the potential
Control neuropathy with Isoniazid with Pyridoxine barriers ahead. Treat co-morbidities, and manage
(Vitamin B6) 50mg tid; prophylactic treatment is 20mg od. psychosocial issues: the drugs are not the whole story!
Most of the problems with HIV treatment occur with A combination of drugs is necessary; otherwise early drug
rifampicin which induces liver enzyme breakdown of ARVs resistance is inevitable, and further treatment practically
making them less effective; generally start anti-retrovirals after impossible.
the intensive 2month phase of TB treatment. Rifabutin is an
alternative to Rifampicin.
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Reduction of viral loads by 70-80% is usually possible with at Recommended initial therapy is one NRTI from Category
least 95% adherence to drug regimes, but about 30% of I, one from Category II, and one NNRTI. Use an extra
patients default treatment. NRTI from Category III if the viral load is <55,000
copies/ml: monitoring of viral load and CD4 counts is
Agents can be divided into: important.
Type Abb. Function Name Abb. Normally treatment was only started if the CD4 count was
<200/μl, though evidence now suggests it may be better to
Nucleoside NRTI Mimic stavudine d4T start when the count is <500/μl. Treatment is necessary
Reverse Cat I normal zidovudine AZT regardless for clinical stages III & IV, co-infection with TB
Transcriptase building or Hepatitis B (include TDF and 3TC or FTC), pregnancy
Inhibitors blocks of (avoid AZT if HB <80g/l) or where the partner is HIV-ve.
HIV-DNA
NRTI didanosine ddI Other combinations are 3 NRTI; 2 NRTI + PI; 2 NRTI +
Cat II lamivudine 3TC 2PI; or NNRTI + PI. Do not use two NRTI’s alone; PI’s are
zalcitabine ddC metabolized by cytochrome P450 which is inhibited by
NRTI abacavir ABC ritonavir.
Cat III This enhances their efficacy if used in combination,
Nucleotide NtRTI as NRTIs tenofovir TDF but adds significant side-effects, especially metabolic.
Reverse emtricitabine FTC Combination drugs are available. Both d4T and ddI are
Transcriptase being phased out because of their toxicity.
Inhibitors Follow nationally agreed guidelines, as with TB therapy.
Non- NNRTI Directly delavirine DLV
Nucleoside inhibit efavirenz EFV Screen patients for anaemia, TB, Hepatitis B and syphilis
Reverse early nevirapine NVP and treat these before starting ARV therapy. Try to get
Transcriptase stages of etravirine ETR renal and liver function tests done. Do not forget to do the
Inhibitors replication pregnancy test in women of reproductive age!
Protease PI Directly amprenavir APV
Inhibitors inbibit last indinavir IDV Treatment for children should also follow nationally
stages of nelfinavir NFV agreed guidelines: use first-line therapy with RTV-boosted
replication ritonavir RTV LPV for babies <3yrs and EFV for those >3yrs, together
saquinavir SQV with 2 NRTIs
atazanavir AZV
lopinavir LPV Sudden discontinuation of all therapy usually results in
darunavir DRV viral rebound within a month with ‘wild-type’ HIV strains;
discontinuation of therapy even when no detectable virus is
Dideoxy- Hydroxy- Promotes Hydroxy-
found for 3yrs almost always results in viral rebound in
nucleotide urea NRTI urea
3months.
reductase activity
This means that if you have severe complications after
inhibitor
abdominal surgery resulting in your patient not being able
to take his medication, all the problems described may
The main drawback of these drugs is their side-effects and emerge. Consider carefully therefore before you undertake
interactions with other drugs (especially TB treatment, which complex elective procedures in the abdomen.
often means taking 6 or more drugs), and hence their New types of drugs on the horizon are fusion inhibitors and
tolerability. integrase/CCr-5 inhibitors.
Avoid Efavirenz during pregnancy.
Certain combinations are contra-indicated either because they Recurrence of HIV-related disease if no antiretrovirals are
work as antagonists, or are excessively toxic to peripheral used is virtually inevitable with many complications,
nerves or bone marrow. Other toxic side-effects, potentially but especially so with TB and malignant disease such as
fatal, are: pancreatitis, hypersensitivity reactions (including Kaposi sarcoma or lymphoma.
Stevens-Johnson syndrome) and lactic acidosis (with d4T, ddI Co-infection with hepatitis B hugely increases the
or AZT): this presents with abdominal pain and dyspnoea. mortality.
Long-term side-effects are lipodystrophy, osteodystrophy and
insulin resistance. Treatment to reduce mother-to-child transmission is
now standardized: use zidovudine 200mg at the onset of
Occasionally you will need to substitute one drug for another labour. If pains turn out to be false labour, try a repeat dose
of the same type: get advice about this. of 200mg at the actual onset of labour. Alternatively advise
Nonetheless you should warn patients of potential side-effects, a dose at 28wks’ gestation at home, in case premature
e.g. vivid dreams with starting EFV, rash with NVP, anaemia labour occurs, with instructions as to when to take the drug.
with AZT, peripheral neuropathy with d4T or ddI.
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Further, use one 6mg dose to the new-born baby (in liquid
form) between 48 and 72hrs after delivery, or at discharge.
For babies under 2kg, reduce the dosage to 2mg/kg. If the baby
vomits <1hr after taking the medication, repeat the dose.
Should the baby be born <2hrs after the mother had her dose,
supply an immediate dose to the baby, and repeat this at
discharge.
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Even if an abscess has ruptured spontaneously, EXAMINATION. Assess the general condition carefully,
adequate drainage by incision is necessary. There is no especially if there are many abscesses, or large ones.
need to curette the walls of an abscess, except in the hand Look for anaemia. SPECIAL TESTS.
where you want inflammation to resolve particularly (1);If the infection is severe, take blood cultures.
rapidly and completely. Suspect a wound abscess if a You may be able to isolate the causative organism
suture line becomes indurated and tender; it may not be (this is important in osteomyelitis).
fluctuant (11.13). (2);Test the blood or urine for sugar; this may be the first
So incise an abscess adequately and let the pus flow out; presentation of diabetes: always do this if there is more
break down any septa in a large cavity and open up any than one septic infection.
smaller cavities (loculi) off the main one. (3);If there is a particularly large or unusual abscess
(especially in the hand in the absence of trauma or
Abscesses are often placed at the end of an operating list penetrating foreign body, thyroid, muscle, abdominal wall,
of otherwise 'clean' cases, and are often left to very junior retroperitoneal space, penis and scrotum, or in the breast of
staff. They are often not treated as genuine emergencies, a non-lactating woman), or recurrent ones, test for HIV.
even though the great risk of septicaemia is ever present.
Do not therefore underestimate the seriousness of ANTIBIOTICS are not usually needed. Use them only if:
abscesses! (1);there is a severe constitutional disturbance with high
fever and toxaemia;
Nevertheless, be careful: (2);there are signs that the infection is spreading:
(1) The diagnosis can be difficult, e.g. an iliac abscess increasing erythema, cellulitis, lymphangitis, severe
(6.16). lymphadenitis, or fever;
(2) Drainage has its risks, especially severe bleeding when (3);the abscess is in the groin (a ‘bubo’)
there is a large abscess or many of them, so watch blood related to chlamydia (lymphogranuloma venereum):
loss carefully. use doxycycline;
(3) A superficial abscess over the tibia, femur, or humerus (4);the abscess is deep-seated, e,g. in the brain or liver
may turn out to be pyomyositis (7.1) or, more seriously, (15.10).
osteomyelitis (7.2).
(4) A 'chronic abscess' may turn out to be a solid tumour. DRAINAGE OF AN ABSCESS (GRADE 1.2)
Some cancers may present as infections! (24.4; 34.15). INDICATIONS. A collection of pus anywhere accessible.
(5) Do not forget the possibility of TB! If you suspect that there is a foreign body in an abscess,
this is an added reason for exploring it. Try to remove the
ULTRASOUND will readily demonstrate a collection of offending object and drain the cavity at the same time.
fluid: use this if you can when the diagnosis is unclear. If you are not sure if pus is present or not, aspirate the
lesion with a wide bore needle to see if you can withdraw
pus. If pus is present, drain it.
If you fail to aspirate pus with a needle, this does not
mean that there is no pus present!
Signs that an infection is spreading are not a
contraindication to drainage; if you suspect pus is present,
drain it.
ANAESTHESIA.
(1);You do not need muscular relaxation, so ketamine is
very suitable.
(2);If an abscess is already pointing, but the superficial
skin is not paper thin, you can infiltrate the skin at the site
of the incision with LA (6-2A). Alternatively you can
infiltrate all around circumference of the abscess, if this is
not too big.
(3);Use morphine or pethidine beforehand if the abscess is
big, or in a sensitive spot, especially for in-patients.
(4);Ethyl chloride local spray is the least satisfactory,
but you can use it for very superficial abscesses where the
skin is so thin that LA infiltration is virtually impossible.
It makes the tissues hard and difficult to incise.
(5);For babies <6-9 months a quick incision is safer
Fig. 6-2 INCISION AND DRAINAGE (I&D). (and kinder) than multiple needle pricks to establish LA or
A-C, linear incision being made and its edges spread. GA.
D-F, cross-shaped incision, cutting off the edges of the skin, and so
removing the roof of the abscess. After Hill GJ. Outpatient Surgery, WB
(6) IV diazepam with pethidine has the hazards of a proper
Saunders 1973 Fig. 5.12, with kind permission. GA and requires all the usual precautions, and has no
advantage over ketamine.
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INCISION. If the foot is infected (8.17), raise the foot of the bed.
Drain the abscess at the site of maximum tenderness and Make sure your nurses wash the abscess cavity and do not
try to follow Langer's lines (34-1E). merely put a dressing on the surface: the wound will
If an abscess is superficial, use a pointed (#11) blade then close over the cavity and the abscess will recur.
(6-2). Make sure free drainage remains possible.
CAUTION!
(1).If the abscess is deep, try to incise parallel to any DIFFICULTIES WITH ABSCESSES
nerves or vessels, not across them. If there is severe prostration without a fever,
(2).A common mistake is not to make the incision large suspect that resistance to infection is low and treat with
enough, so extend the incision the whole diameter of the particular care. Check the HIV status.
abscess!
If there are many abscesses, with pyaemia, multiple sites
HILTON'S METHOD is indicated if there is anything near of pyomyositis, or septicaemia, bleeding may be profuse
the abscess which you might possibly injure. Incise the when you drain the abscesses. For anaemia, transfuse pre-
tissues down to the deep fascia; then push blunt scissors or operatively and, if necessary, again during the operation.
a haemostat into the softest or most prominent part of the Draining multiple abscesses is a major procedure,
swelling. Open them out inside the abscess. If necessary, particularly if a child is severely anaemic or malnourished,
enlarge the wound by blunt dissection inside the tissues. so be careful before you incise too many abscesses at once
children have been known to bleed to death!
DRAIN THE PUS by putting your finger into the abscess,
and breaking down all the loculi, so that there remains If there is a huge abscess in a very ill patient, he will not
only one cavity. Use your little finger if the abscess is tolerate an extensive procedure. It may occasionally be
small. necessary to take him to the theatre several days in
If there is much pus, suck it out or clean out the cavity succession for repeated drainage slowly increasing the
with a swab. Make sure you remove all the pus: rinse the exposure.
cavity thoroughly with water: you may need to squeeze for
some time till all the pus comes out: this is painful for the If an abscess fails to heal, do not forget the possibility of
patient so use adequate analgesia. diabetes, tuberculosis (5.7) or HIV (5.6), or a combination
PROVIDE FREE DRAINAGE. Make sure that any more of these, an underlying tumour, or occasionally
pus which collects can drain from the bottom of the cavity. actinomycosis (which produces yellow so-called ‘sulphur’
granules). Check if no foreign body, e.g. part of a drain or
If the abscess you are draining has a tendency to heal suture has been left in situ.
over and leave a cavity, deroof it, (6-2F). N.B. The best instrument to find and pull out a suture
This is especially necessary with perianal (6.17) and knot in a chronically infected wound is a crochet hook!
Bartholin's abscesses. Cut away some skin, particularly
any dead skin. Allow drainage with a soft rubber drain
with a suture to hold it in place.
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Clean the skin round the boil with water, and cover it with If you have limited imaging facilities, your problem will
a dry dressing. Let it burst spontaneously. If it is pointing, be to diagnose an extradural abscess in the first place and
a small incision will let it discharge and will reduce the to know where it is: the abscess is underneath the swelling.
pain. You can use a sterile needle to do this. SPECIAL TESTS: The skull radiograph will only show
CAUTION! Never squeeze a pustule; especially on the changes if an extradural abscess is chronic, or if there is
face, never let the patient squeeze it. osteomyelitis of the bone. If you can perform a carotid
arteriogram (38.1), this will localize the abscess
If there are many pustules, advise washing thoroughly beautifully.
with soap and water, and to shower bd. The bath, shower
and toilets must be clean. Advise a daily change of DRAINAGE (GRADE 3.3)
underwear, and washing it by boiling. Exposure to the sun Drain the extradural abscess through a burr hole.
is one of the best cures. Avoid using ‘roll-on’ deodorants. Make this on the edge of the area of swelling on the skull
(where present), and nibble away the skull around it until
the abscess is well drained.
If the abscess is secondary to osteitis, and there is a
6.4 Carbuncles sequestrum, removing it will drain the abscess
A carbuncle is typically the result of neglected skin adequately. Likewise, if it is secondary to a neglected
infection in a dirty, malnourished, and underprivileged compound depressed skull fracture, elevation of the bone
patient, particularly a diabetic or one with HIV. fragments will locate and drain the abscess.
A staphylococcal infection starts in one of the hair
follicles, usually at the back of the neck or on the back of a
finger (8.1), and then spreads. In doing so the infection 6.6 Infections of the orbit
lifts the skin above it on a sea of necrotic fat and pus.
At presentation, pus will probably be discharging. Acute suppurative infection is common near the eye,
Antibiotics do not cure a carbuncle, although they may especially in children. It can occur in front of or behind the
stop it spreading. You will probably have to let the slough orbital septum. This is a sheet of fibrous tissue which
separate slowly, and then remove it. stretches from the edges of the orbit into the eyelids,
Be sure to test the blood or urine for sugar. Consider HIV and divides the periorbital region from the orbit. Infections
testing. of both these regions usually start acutely with erythema
If a collection of pus forms, cut down on it and drain it. and oedema of the eyelids; distinguish between them as
If the skin around the carbuncle is hairy, shave it with described below. The danger with any infection in this
as little trauma as you can. Wash it with water, apply dry region is that infection may occasionally kill the patient by
gauze, and change this frequently. A large slough will spreading to the cavernous sinus or the meninges.
form in the middle of the carbuncle. You may be able to
lift the slough off painlessly without an anaesthesic.
If the slough is slow to separate, excise it, and apply a
dressing of Vaseline (petroleum jelly) gauze.
If the bare area is large, apply a split skin graft, as soon
as it is clean and granulating.
If a black central pustule with surrounding vesicles
forms, consider ANTHRAX and treat with penicillin IV.
Pus may gather between the skull and dura as the result of:
(1) The spread of infection from sepsis nearby.
(2) Exposure of the bone as the result of an injury.
(3) Metastatic spread from elsewhere in the body.
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Periorbital cellulitis occurs in front of the orbital septum, Do not be frightened of operating in the orbit. Because of
is more common than orbital cellulitis and occurs in the danger of cavernous sinus thrombosis you must drain
younger children. It can be primary, or secondary to: pus early. A negative exploration will not cause harm,
(1) local trauma, (2) skin sepsis, (3) a recent upper and you are very unlikely to damage the globe.
respiratory infection often with H. influenzae (associated
RANGIT (60yrs) was admitted with a history of septic teeth for many
with bacteraemia).
years. Recently he had had fever, headache, rigors, and gradual swelling
of the mandible. He was ill, dehydrated, shocked, jaundiced,
Orbital cellulitis occurs behind the orbital septum, and is and confused. Pus discharged from his mouth, the submental glands were
less common but more serious. It is usually due to spread enlarged, the neck was stiff, and Kernig's test was postive. Both globes
were proptosed, particularly the left, which was fixed; the forehead and
from the paranasal, commonly the frontal or ethmoid,
cheek were oedematous, and the CSF turbid. Despite vigorous antibiotic
sinuses treatment he died. Postmortem examination revealed left dental and
mandibular abscesses; the left orbit and cavernous sinus were full of pus.
Subperiosteal abscesses may form when bacteria spread LESSONS (1) This is a very dangerous condition. (2) Proptosis in the
presence of facial sepsis is a sign of danger. (3) The organisms
from the adjacent sinuses.
responsible are often penicillin-resistant.
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Abscesses round the tonsils are quite common, and follow If severe bleeding follows and you cannot control it,
tonsillitis. The patient, who is usually a child, has a tense try firm compression through the mouth with a tightly
swelling above and behind one of the tonsils, displacing it rolled swab. You will then be faced with a very difficult
downwards and forwards. Non-operative treatment is intubation, keeping pressure on the tonsillar fossa in order
almost always successful, and is much safer than draining to insert tight figure of 8 sutures around the bleeding
which is a heroic procedure and is seldom necessary, points.
because much of the swelling is inflammatory oedema.
TREATMENT
If the patient is dehydrated, correct the deficit with IV
fluids.
INCISION (GRADE 1.5)
ACUTE ABSCESS IN A CHILD.
The great danger of a GA is that the patient will inhale
pus. Ketamine is relatively safe because the cough reflex is
less suppressed. Use it IV, and keep the head down.
Have a tracheostomy set (29.15) and suction ready.
Put the child supine with the head over the end of the
table, so that the pharynx is as nearly upside down as
possible.
Fig. 6-6 TWO ABSCESSES IN THE THROAT.
A, the danger with a retropharyngeal abscess is that an unconscious
If the abscess is pointing, you may be able to open it with
child may inhale pus and get bronchopneumonia. Avoid this by sinus forceps alone. If you can get a really good view,
incising it while the head is hanging over the end of a table. you may be able to aspirate it with a needle. If this is
B, peritonsillar abscess occasionally follows tonsillitis, and may need impractical, open the abscess with a guarded knife (6-6A).
draining. Do both these incisions with a guarded knife that cannot
cut too deeply.
Put your index finger into the mouth, and slide the knife
along it. Drain it by Hilton's method (6.2), as for a
peritonsillar abscess.
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CAUTION! Do not allow inhalation of pus: (6).In the pterygomandibular space between the medial
aspirate immediately you incise. pterygoid and the ascending ramus of the mandible.
(7).In the sublingual space above or below the mylohyoid
If severe bleeding follows, and you cannot control it, muscle.
apply local pressure for 15mins. If that fails (rare), (8).In the submandibular space superficial to the
be prepared to tie the external carotid artery. mylohyoid.
(9).In the submental space in the midline under the jaw.
ACUTE ABSCESS IN AN ADULT. (10).Anywhere down the side of the neck. Do not be
Anaesthetize the mucosa over the abscess with 4% daunted by the complexity of this anatomy. Some of these
lidocaine, preferably as an aerosol, and incise it with the spaces communicate with one another and more than one
head down and on one side, as in a child. space may be involved.
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HISTORY & EXAMINATION. (3);Ethyl chloride local spray is suitable for an abscess
which presents on the face or in the labial or buccal sulci.
A patient of any age >5yrs has a swollen face, looking ill Isolate the infected area with gauze packs, and then spray
and distressed. He has usually had toothache in the past, on ethyl chloride until crusting occurs. Then open the
and now he tells you that he has had pain for 1wk. abscess with a #11 blade.
He has fever, trismus, and a unilateral, tender, shiny, CAUTION! Avoid GA, unless it is expert (especially if
warm, indurated swelling. Looking at him will tell you there is danger of respiratory obstruction), with intubation
which side of the face and which jaw is involved. throat packing.
Feel for warmth with the back of your index finger and test
for fluctuation. ALVEOLAR ABSCESSES.
A tooth with large holes in it probably has an apical A dentist may be able to save the tooth by draining the
abscess under it. It may be firm, but is usually loose. abscess through it, and later filling its root. If you cannot
If there are either obvious periodontal disease, refer to a dentist, remove the tooth. Many abscessed teeth
or several loose teeth, suspect a periodontal abscess. are loose, and you can then easily pick them out of their
If you are in doubt as to which of the teeth is the site of sockets.
infection, tap them with some metal object or press them Removing the tooth to allow pus to drain through the
with your gloved index finger. A tooth which is much socket may be sufficient. Do not incise a non-fluctuant
more painful than the others is probably the source of an swelling. If it is not yet fluctuant and ripe for incision,
alveolar infection. It may also be slightly raised in its use hot saline mouth washes, as hot as can be borne
socket. A tooth with a periodontal abscess is usually not without the risk of being scalded, several times a day.
tender to percussion, but often loose. Treat with cloxacillin and metronidazole and wait till the
N.B. It is quite difficult sometimes to localize the cellulitis settles.
affected tooth; be gentle and patient to be certain which CAUTION!
tooth is the offending one. It is a tragedy to remove the (1);Do not pull out the tooth (31.3) before starting
wrong tooth! treatment for peri-odontal cellulitis.
(2);If there is a tense inflammatory swelling of the
RADIOGRAPHS. If possible, X-ray the offending tooth. upper part of the neck, suspect Ludwig's angina and treat
You may see: urgently (6.11).
(1);A radiolucent area at its apex when an apical abscess
has been present for 2-3wks. PUS POINTING INSIDE THE MOUTH can point in
(2).Caries between two adjacent teeth which may not be several places:
visible from the mouth. If an abscess is pointing on the alveolus, open it into the
(3).The impacted tooth which is responsible for a mouth.
pericoronal abscess.
(4) Some other source for the infection, such as an infected If it is pointing in the labial sulcus (6-7C), make a 1·5cm
cyst, or a fracture. incision through the mucous membrane parallel to the
alveolar ridge. Push a fine haemostat into it and open the
DIFFERENTIAL DIAGNOSIS includes acute jaws.
inflammation of the salivary glands (6.10), mumps,
Burkitt's lymphoma (17.6), lymph node swellings and If it is pointing in the palate, make an antero-posterior
glandular fever, as well as snake bite, and trigeminal incision, parallel to the nerves and vessels, remove an
neuralgia. ellipse of tissue and let the pus flow out.
TREATMENT. Make sure fluid intake is adequate If there is pus in the pterygomandibular, lateral
because drinking may be difficult. pharyngeal, or submasseteric spaces, drain it through a
CAUTION! Do not apply poultices or any kind of local vertical incision inside the mouth parallel to the ascending
heat to the face: that may spread the infection. ramus of the mandible, taking care to avoid the parotid
If an abscess is pointing inside the mouth, hot saline mouth duct. This runs in the cheek under the middle ⅓ of a line
washes may ease the pain. between the tragus of the ear and the commissure of the
ANTIBIOTICS are often unnecessary, because many lips, and opens in line with the first molar tooth.
dental infections can be treated by local drainage only. Push forceps to the lingual or buccal side of the ramus,
Use IV penicillin if there is surrounding cellulitis or wherever the pus seems to be pointing. If it is under the
actinomycosis (31.6). When you have drained an abscess, masseter, insert a drain deep to this muscle down to the
culture the pus and change the antibiotic if necessary. mandible from outside the face. Insert the drain through an
CAUTION! Explain that a course of antibiotics is not incision just below the inferior border of the mandible.
sufficient treatment for the abscess, and that review is
essential, even if the swelling improves. PUS POINTING OUTSIDE THE MOUTH.
ANAESTHESIA. Drain it through one of the incisions below, as soon as you
(1);2% or 4% lidocaine spray or a swab soaked in have started antibiotics for any cellulitis present.
lidocaine solution. Removing the tooth to let the pus drain is not enough, even
(2);Inject LA solution into the outer wall of the abscess if it does drip from the root canal. If the abscess is
over the proposed site of the incision. fluctuant, it needs draining too.
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If you are not sure if it is ready for drainage or not, 6.10 Parotid abscess
insert a wide bore needle under LA. If you aspirate pus,
incise it by Hilton's method (6.2) where it points at the
softest and most tender spot. To minimize scarring, Although a parotid abscess can occur without any obvious
make an incision below the inferior border of the cause, it occurs most often in debilitated or HIV+ve
mandible, where possible. Make an incision on the face in patients, or after major surgery when mouth care has been
line with the creases in the skin. These may not always be neglected. The parotid is painful and is usually much
over the most fluctuant part of the abscess. swollen; the skin over it is tight and shiny. You may see
pus coming from the parotid duct (inside the cheek level
INCISION FOR DENTAL ABSCESS (GRADE 1.3) with the first molar tooth). Pus forms in several lobules of
CAUTION! When you plan your incision, consult 6-8 the gland between its septa, and does not form a single
and remember important features of the anatomy: abscess. This, and the division of the facial nerve into its
(1) The extension of the lower pole of the parotid gland five branches within the parotid gland, make drainage
into the side of the neck. difficult; it is however essential.
(2) The mandibular branches of the facial nerve. These run Do not wait for fluctuation.
horizontally and cross the lower border of the mandible,
just anterior to the masseter, deep to the platysma muscle
in the anterior mandibular region and deep to the fascia
posteriorly.
(3);The facial artery and vein. These enter the face from
between the submandibular salivary gland and the lower
border of the mandible; they cross the ramus of the
mandible 3cm from the angle of the jaw and then run
obliquely across the lower third of the face superficially on
the buccinator muscle. You may have to compromise
between choosing the best site for dependent drainage and
an inconspicuous scar in the crease lines of the face.
Here are some likely sites:
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ULTRASOUND (38.2G) is the best way of diagnosing TREATMENT. The pus must be drained. You may not
and defining a retroperitoneal collection, and can know for certain if it is perinephric, subphrenic (especially
distinguish this from a subphrenic collection. You can also in the posterior or subhepatic spaces, 10-5B), or has spread
gain information on the kidney in this way, and use from osteitis of the spine. Treat with chloramphenicol or a
ultrasound to localize where to insert a needle for cephalosporin. If you can, insert a tube drain under LA
diagnosis and a therapeutic drain. with ultrasound guidance.
RADIOGRAPHS. A plain radiograph may show POSITION. Lateral, as for a nephrostomy (27.14).
obliteration of the psoas shadow, and scoliosis with a
concavity towards the abscess. Look also for disease of the INCISION FOR RETROPERITONEAL ABSCESS.
spine, especially narrowing of intervertebral discs and (GRADE 3.2)
erosion of the bodies of the vertebrae nearby, especially The retroperitoneal abscess of HIV may become
anteriorly (osteomyelitis, an important differential so superficial that dissection is not necessary.
diagnosis). An IVU is not usually necessary; it may show a Otherwise, make a 15cm lumbotomy incision slightly
normally functioning kidney which may be displaced, below the 12th rib just lateral to the sacrospinalis muscle
especially medially or posteriorly, or a hydro- or (about the mid point of the rib) extending down obliquely
pyo-nephrosis, but ultrasound is the imaging of choice. towards the posterior iliac spine. You can extend this
laterally just above the line of the posterior iliac spine if
DIFFERENTIAL DIAGNOSIS. necessary. Take care to avoid the iliohypogastric nerve at
(1);Pyomyositis of the abdominal wall or paraspinal the lower end of the incision. Retract latissimus dorsi,
muscles. external and internal oblique and transversus abdominis
(2) Pyonephrosis. muscle origins, and cut through the deep fascia onto
(3) Subphrenic abscess. retroperitoneal fat behind the kidney. If the pus is in the
(4);Osteomyelitis of the spine, with spread to the muscles (pyomyositis), you will discover this before you
paraspinal tissues. reach the rib (unless it is in the psoas or quadratus
(5);Retroperitoneal sarcoma: this is rare, but if you incise lumborum). If it is spreading from the spine or is
into the tumour, you will lose the chance to excise it subphrenic, you will also find it.
properly. N.B. The lumbotomy incision is easier than the 12th rib
bed incision, but gives poorer access to the kidney itself;
it is, however, perfectly satisfactory for drainage of an
abscess.
Drain the pus by Hilton's method (6.2). Insert a wide bore
tube or corrugated drain and close the wound in layers.
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This condition (iliac abscess) is also known as iliac Suggesting an appendix abscess: a different anatomical
adenitis, deep inguinal adenitis, extraperitoneal iliac site: intraperitoneally in the right iliac fossa, with nausea
abscess, or suppurating deep iliac nodes. It has several and vomiting, less spasm, and only mild flexion of the hip
important differential diagnoses, and is often (14.1).
misdiagnosed.
Suggesting septic arthritis of the hip: severe joint spasm,
acute pain on percussing the greater trochanter,
no palpable mass, no movement of the hip owing to severe
pain, and a radiograph showing a widened joint space.
This is equivalent to osteomyelitis because the epiphyseal
plate is inside the capsule of the hip joint (7.18).
Fig. 6-12 A PAINFUL FLEXED HIP in an ill patient has a variety of NON-OPERATIVE TREATMENT. Deep inguinal (iliac)
differential diagnoses. A, typically the hip more flexed than is shown adenitis with periadenitis and without pus formation does
here. B, iliac abscess forms in the iliac nodes. C, exploring not require drainage. The hip is flexed as when an
extraperitoneally for iliac suppuration. D, incision for an iliac
abscess. C,D, after Dudley HAF (ed), Hamilton Bailey's Emergency abscess is present. You can feel deep tender glands above
Surgery, Wright 10th ed 1977 p.287 Fig 26.1 with kind permission. the inguinal ligament. Treat with penicillin or
chloramphenicol. If infection is slow to resolve, use skin
DIFFERENTIAL DIAGNOSIS is that of the 'sick child traction (1/7th of the body weight) to avoid contracture and
with the painful flexed hip'. It is more difficult if the right raise the foot of the bed.
hip is flexed, because the diagnosis on this side includes
appendicitis. DRAINAGE. (GRADE 2.4) If you have aspirated pus
with a needle, you can safely open up the deeper layers.
Suggesting iliac adenitis with periadenitis or an The abscess will have pushed the peritoneal lining of the
abscess: a septic lesion on the skin which may be minimal right iliac fossa medially and superiorly. Make an incision
and have healed (adenitis may appear 2wks after the 5-10cm or more over the swelling about 2cm above
primary lesion has settled), a markedly flexed hip with a the inguinal ligament, starting just medial to the
short history, a mass in the groin or right iliac fossa just antero-superior iliac spine (6-12D). Take a long haemostat
above the inguinal ligament, no pain when you percuss the and push this through the muscle over the abscess until
greater trochanter; you can flex the hip a bit more, no you find pus. Then, using your fingers, enlarge the
spasm of the sacrospinalis, and no radiographic changes. opening. Take a specimen, drain the lesion, and continue
antibiotics.
Suggesting pyomyositis of the iliopsoas: the same signs If the leg remains in spasm, apply traction as above.
as iliac adenitis. The differential diagnosis may be CAUTION! Draining an iliac abscess is potentially
impossible, and is not important because the treatment is dangerous: you may injure the caecum or the iliac vessels.
the same. So follow the method above and aspirate first.
Ultrasound guidance (38.2) will help.
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6.17 Anorectal abscess Here are the classical types of anorectal abscess, but you
may see combinations, and the diagnosis can be difficult.
Only the 1st two are common.
An anorectal abscess usually originates in an anal gland,
and may communicate through a tiny opening with the A perianal abscess presents as a red tender swelling close
anal canal, at the pectinate line. A connection between the to the anus. On rectal examination, there is little or no
skin and the anus (a fistula) is the reason why about half of tenderness, induration, or bulging in the anal canal.
these abscesses recur, or discharge persistently. There may be a fistulous track, going straight through or
Abscesses (with no opening to the skin), sinuses above the subcutaneous external sphincter, and usually
(with an opening to the skin, but not to the anus), through the lowest part of the internal sphincter.
and fistulae (with openings to both) are thus part of the
same disease process (26.3). Most abscesses settle by An ischiorectal abscess lies deeper than a perianal one,
discharging spontaneously, or being drained, but a serious is larger and further from the anus; it forms a deep tender
life-threatening infection can sometimes spread in the soft brawny swelling and is not fluctuant until late.
tissues, or deeply into the pelvis. The patient is likely to be toxic, febrile, and debilitated.
Presentation is usually acute because the pain is intense: On rectal examination you may feel a tender induration
severe throbbing pain keeps the patient awake at night. bulging into the anal canal on the same side. The infection
On examination, you find a tense tender swelling near the may spread posteriorly and then to the other side as a
anus. Sometimes, there may be little to see and no horseshoe abscess, so that there now are signs on both
fluctuation to feel, except mild tenderness at the anal sides. The presentation may then be with urinary retention.
margin, or, the whole perineum may feel tense and tender.
If the pain suddenly resolves, the abscess has probably A submucous or high intermuscular abscess (rare)
spontaneously ruptured. But there may now be a presents with pain in the rectum and no external swelling,
persistently discharging sinus or fistula opening on to the unless it is complicated by an ischiorectal or perianal
skin near the anus. abscess. On rectal examination you may be able to feel a
soft, diffuse, tender swelling extending upwards from the
pectinate line. You will often need to administer a GA to
do a rectal examination: confirm and treat the condition by
draining the abscess!
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ANTIBIOTICS will not treat an abscess and are useful POSTOPERATIVELY, insert a soft drain, suture it in
only if there are signs of spreading infection. If so, treat place, and make sure the patient showers bd. Insert a pad
with chloramphenicol and metronidazole, and look if there inside the underwear. Recommend laxatives if there is a
are signs of necrotizing fasciitis (6.23) which needs wide tendency to constipation.
debridement. Occasionally use prophylactic antibiotics if
the patient has a hip prosthesis in situ or has had rheumatic DIFFICULTIES WITH AN ANORECTAL ABSCESS
fever. Rarely, if there is severe neutropenia due to bone If there is an abscess on both buttocks,
marrow failure, you should use antibiotics rather than use circumferential incisions 3-5cm apart on both sides
performing an incision, as in this case there will be no pus! and loop a drain between them to keep the space open
(6-15). There is sure to be a track across the midline
ANAESTHESIA. behind the anus. But be sure not to cut in the mid-line
For a large abscess, use GA or ketamine: make sure you either anteriorly or posteriorly because healing will be
put the legs up in the lithotomy position before you give very slow and you may damage the sphincter.
the ketamine, otherwise the legs may be too stiff to elevate!
N.B. LA is unsatisfactory, except for a small abscess. If there is pus draining from the anus, the abscess has
either drained internally, or there is an infected
EXAMINATION UNDER ANAESTHESIA. HIV-related anal ulcer (26.2), or other underlying disease
Use the lithotomy position. Put a finger into the anus and (e.g. tumour, amoebiasis, schistosomiasis, gonorrhoea,
feel its entire wall between two fingers (26-2F). tuberculosis, inflammatory bowel disease or trauma).
Feel if there is an indurated upward extension of the
abscess under the mucosa 3cm or more above the internal If there is an internal opening which communicates with
sphincter. Feel the extent of the abscess, and for the point the ischiorectal fossa above the anorectal ring, (rare)
of maximum fluctuation. Insert a bivalve speculum and do not cut externally, or incontinence will result!
look for pus coming out of an internal opening near the Drain the abscess internally. You may then possibly avoid
dentate line. Press on the abscess: you may see a bead of the complications of a fistula.
pus escape from the internal opening. You may feel the
opening as a localized tender depression in the anal canal
in the place suggested by Goodsall's rule (26-6I).
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DIFFERENTIAL DIAGNOSES.
(1) A perianal abscess.
(2);A scrotal abscess is in a different place and is not
associated with urinary symptoms.
(3) Localized penile extravasation of urine.
Fig. 6-15 DRAINAGE OF A HORSESHOE ISCHIORECTAL DRAINAGE (GRADE 1.4) Try passing a soft rubber
ABSCESS. urethral catheter (even if there is no urinary retention).
Incisions circumferential to the anal canal 3-5cm on both sides
without crossing the midline: a loop drain between them keeps the If catheterization is successful, drain the abscess by a
space open. Adapted from Dudley HAF (ed) Hamilton Bailey's
Emergency Surgery, Wright 10th ed. 1977 p.384 Fig 39.5 midline perineal incision; be sure to open it widely,
but take care not to damage the urethra.
If the abscess extends submucosally (rare: 6-13),
make an opening internally. Do not lay it open as it will If catheterization fails, as it probably will, and you
probably bleed copiously, and if there is untreated HIV cannot identify the urethra, perform a suprapubic
disease, it may never heal. cystostomy (27.8); then drain the abscess.
If there is a supralevator abscess (very rare), explore the If the stricture is short and the sepsis minimal, gently
abdomen and drain the abscess, preferably pass a bougie until the stricture is reached.
extraperitoneally. Open the abscess as before and feel for the bougie; display
the urethra and perform an external urethrotomy by
If there are signs of spreading infection, such as gross opening it longitudinally from the bougie distally across
inflammatory swelling, areas of necrosis, or crepitation, the stricture in order to pass the bougie into the bladder.
this is necrotizing fasciitis. Start urgent IV metronidazole Do not cut into the roof of the urethra! Replace the bougie
plus chloramphenicol or a cephalosporin and perform a by a urethral catheter. (It will then be much easier to
wide debridement. manage the stricture than if you leave it and try to dilate it
later.) Do not extend your incision in the bulbar urethra
If a fistula develops later, pass a seton (26.3) as massive haemorrhage may result, which will be very
difficult to control. Insert a soft rubber drain and
If there is a recurrent abscess (common), there is almost encourage showering bd. Manage the stricture by gently
certainly an underlying fistula. The opening may be very attempting to pass a bougie after 2-3wks.
small, and you may have overlooked it when you drained
the first abscess. Check the HIV status, and glucose. DIFFICULTIES WITH A PERIURETHRAL ABSCESS
Drain the abscess and attend to the fistula when the If the urine extravasates, treat with antibiotics and divert
infection has settled. the urine (27.12).
If there is gross faecal incontinence, If the abscess recurs, consider diabetes, HIV, tuberculosis
fashion a defunctioning colostomy to allow the sepsis to or carcinoma of the urethra.
settle, and later re-examine the remaining fistula(e).
If a fistula develops, divert the urine (27.11).
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Gonococci or coliforms can infect the prostate. To begin This is rare; the symptoms are the same as with an abscess
with they cause a prostatitis, and later a frank abscess. of the prostate, but the warmth, the swelling and the
The patient presents with urgency, frequency, and dysuria, tenderness, instead of being over the prostate, are higher
or with urinary retention. There is fever, rigors, and severe and more to the side, over one, or occasionally both, of the
rectal or perineal pain, sometimes with tenesmus. seminal vesicles. There may also be pain suprapubically,
The prostate is enlarged, usually more so on one side than in the back, or down the inner side of the thighs.
the other, and is exquisitely tender. Untreated, the abscess
may burst into: DRAINAGE (GRADE 2.4).
(1) the urethra, Use an exaggerated lithotomy position, and make an
(2);the perirectal tissues, where it can present as an oblique lateral perineal incision. Dissect bluntly until you
ischiorectal abscess, feel the swollen vesicle. Push a haemostat into it, drain it,
(3) the perineum, and close the wound lightly round a drain.
(4) the rectum, forming a rectourethral fistula.
DIFFERENTIAL DIAGNOSIS.
Extreme prostatic tenderness should make the diagnosis 6.21 Penoscrotal abscess
clear. Do not confuse a prostatic abscess with:
(1);An ischiorectal abscess: the swelling is to one side of
the midline. PENILE INFECTION (BALANITIS)
(2);An abscess in a seminal vesicle: rectally, the site of Infection of opposing surfaces of the prepuce and glans
maximum swelling and tenderness will be higher and more may be the result of inadequate hygiene, incomplete
to one side. retraction of the foreskin, underlying ulceration with
chancroid, syphilis or carcinoma, or unusual sexual
SPECIAL TESTS. Test the urine for sugar, and culture it. practice.
Check the HIV status.
SPECIAL TESTS.
ANTIBIOTICS. Treat with ampicillin or chloramphenicol, Test for diabetes & HIV. Biopsy a suspicious ulcer.
until you know the results of culture.
TREATMENT
MANAGEMENT. If proper cleaning with chlorhexidine (or similar) fails,
If the prostate is not fluctuant, see what antibiotics alone either because of the severity of the infection or because
will do in 48hrs. Try to find an expert urologist, there is phimosis or underlying ulceration, use an
who can drain the abscess into the urethra with a antibiotic such as cloxacillin, and arrange circumcision
resectoscope. Otherwise drain the abscess yourself, when the inflammation has settled.
as follows. Fortunately, this is very rarely necessary.
If there is phimosis and urinary retention, perform a
DRAINAGE. (GRADE 2.4) circumcision. (27.29). A dorsal slit is not really adequate.
The ideal if antibiotics fail to cause a marked improvement
in 48hrs, or the abscess is fluctuant, is endoscopic drainage If gangrenous patches develop, this is phagedaena and
by a urologist using a resectoscope. If this is not possible, the patient becomes septicaemic. Use IV chloramphenicol
use an exaggerated lithotomy position and administer a and cloxacillin, and under ketamine, debride necrotic
GA. Start by passing a rubber Jacques catheter. tissues widely. This will involve removing the foreskin,
If this passes easily, leave it in place. If you cannot pass it, and may mean removing skin from the penile shaft also.
perform a suprapubic cystotomy. If sepsis is extensive, insert a urethral catheter in order to
show you where the urethra is and avoid damaging it
To drain the abscess, pass a metal sound, and cut down on during debridement.
to this through a 5cm midline incision immediately in front
of the anus.
SCROTAL ABSCESS
Remove the sound and control bleeding. Put your finger
through the incision into the prostatic urethra, and then If pain and swelling develop with explosive rapidity in
through its posterior wall into the abscess cavity. the scrotum and the base of the penis, with
If this contains several loculi, break down the septa hypotension, this is acute necrotizing infection known as
between them. FOURNIER'S GANGRENE (6.23).
Pack the wound loosely with a dry dressing and leave it
open, or suture the skin edges loosely over it. Remove the SPECIAL TESTS. Test for diabetes and HIV.
catheter about the 7th day.
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TREATMENT
Antibiotics (usually doxycycline) may already have been
given. Explore the scrotum through a transverse incision;
if the testis and/or epididymis are severely infected,
perform an orchidectomy (27.26) and close the wound
round a drain.
6.22 Cellulitis
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In necrotizing fasciitis (6.23), the skin is not shiny but The skin is not shiny, but dull and purplish. The necrotic
dull and purplish. fascia is greyish in colour and has lost its sheen but there is
also a telltale milky exudate separating the sick fascia from
TREATMENT. the fat. Septicaemia soon overtakes, and he becomes very
Start IV Cloxacillin 1g stat, then 500mg qid preferably; toxic, dehydrated and anaemic.
if penicillin is ineffective, valuable time may be lost trying
it out. However, the most important thing is to elevate the With certain infections, however, and typically
limb so that (for the leg), the big toe is level with the nose mycobacterium ulcerans, the necrosis is slower to develop
and (for the arm), the hand is strung up inside a sling on a and limited to subcutaneous fat and results in a
drip stand, and insist on bed rest. Once the temperature has well-defined tropical ulcer (34.9), with an undermined
come down, give antibiotics orally and when the swelling edge due to skin survival through development of
has reduced (the skin often becomes wrinkly as the collateral circulation.
oedema disappears) you need no longer continue elevating
the limb. SPECIAL TESTS
Test for diabetes & HIV. Cross-match blood if necrosis is
DIFFICULTIES WITH CELLULITIS extensive.
If sepsis persists, do blood cultures and change to a
different antibiotic, check that the patient has not been DEBRIDEMENT (GRADE 2.3)
walking around, and look for any abscess formation or Start IV gentamicin or chloramphenicol and
necrosis. Make sure any foreign body has been removed. metronidazole. Resuscitate with IV saline rapidly to
If swelling worsens with purplish discolouration and correct dehydration which is almost universal.
skin peeling, there is developed necrotizing fasciitis (6.23) Add fluconazole if you suspect mucormycosis.
and this needs urgent widespread debridement.
If there is chest pain or dyspnoea, think of DVT: Do this in the septic theatre. Excise all the affected fascia;
if this is more likely, start anticoagulants. this is inevitably more widespread than the overlying skin,
In children, cellulitis is often secondary to acute and debridement must be radical. If you leave dead tissue
osteomyelitis (7.3), which needs drilling. behind, the patient will die. (Necrosis involving the breast
In the diabetic foot, (8.17) sepsis often spreads rapidly may mean doing a mastectomy!) You may not know how
and even more so with HIV disease, resulting in far the necrosis has spread, but you must continue till no
osteomyelitis and gangrene; radical debridement with more grey fascia is found! You may lose a considerable
amputation of suspect toes is necessary. Frequently you amount of blood, so transfuse especially if he is anaemic to
will have to perform a below or above-knee amputation to start with. Irrigate the wound with hydrogen peroxide.
clear the sepsis
You will be surprised how drastically the condition
improves if you have done an adequate debridement
6.23 Necrotizing fasciitis (and how miserably it deteriorates if you haven’t).
Extend the debridement if you find more necrosis.
Inspect the wound bd, and skin graft the defect when it is
Mixed infection in the superficial and deep fascial tissues clean. You can speed up this process dramatically by using
with aerobes and anaerobes can cause extremely rapid suction dressings (11.13).
dissolution of collagen in connective tissue, gross oedema
and so interruption of blood supply to the overlying skin,
MAZHOU (36yrs) was brought to a small Mission hospital in extremis.
and fat, which necrose. Advance of infection however may He had uraemic frost, he was hardly conscious with shallow breathing,
be sudden, alarming and relentless, and its extent is greater and had necrotizing fasciitis extending from the base of the scrotum to
than at first seems apparent, particularly if there is the costal margins. Whilst intravenous saline was poured in, under
oxygen alone all the necrotic fascia was cut away: it hardly bled, and
mucormycosis (fungal infestation), which can occur in
gave off ammonia fumes! Towards the end of the procedure he started
extensive natural disasters such as volcanic eruptions. moving and needed nitrous oxide to finish the operation. The next day he
was conscious and hungry. He then explained that the scrotal swelling
It can occur anywhere: in the abdomen it is known as began after someone forcibly removed a urethral catheter that had been
inserted when he’d been admitted with cerebral malaria. He was
Meleney’s gangrene, maybe as a result of contamination
faithfully married with 3 children, and later tested HIV-ve. The urethral
from a colostomy, or in the scrotum as Fournier’s stricture was later successfully dilated, and the extensive abdominal
gangrene (6.21), maybe as a result of extravasation of wound grafted.
septic urine. However it is often spontaneous, especially in LESSONS (1) Extensive surgery is possible in extremis with no or hardly
any anaesthesia, (2) Radical debridement gives results, (3) A small
HIV disease and diabetics. The limbs, neck, chest wall
blunder gave rise to a huge problem, (4) Urethral catheterization is
and breast may all be affected; in the mouth it leads to invasive and potentially hazardous, (5) Not everyone who is moribund is
gross facial destruction (cancrum oris, 31.5). HIV+ve.
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This is an anaerobic infection of injured muscle caused by DIFFERENTIAL DIAGNOSIS Gas gangrene is not the
various species of clostridia. only cause of gas in the tissues. Air sometimes escapes
Suspect that it may occur if: into the tissues from under the skin. In ischaemic gangrene
(1) There are extensively lacerated muscles, or a missile (35.2), there is no toxaemia, unless the gangrenous tissue
wound, especially if this involves the buttocks, thighs, becomes secondarily infected. The diagnosis is usually
or axillae, or the retroperitoneal muscles following an clear.
injury to the colon.
(2) The blood supply to these parts of the body has been GAS GANGRENE: Areas at particular risk
interfered with.
(3) The wound is grossly or deeply contaminated with soil.
(4) There is prolonged dead conceptus in the uterus.
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RESUSCITATION Infuse IV saline rapidly, and keep this Fig. 6-18 SEVERE GAS GANGRENE.
running during the operation. You may need to transfuse This followed an intramuscular injection, but it could equally well
have followed a severely contaminated wound.
blood if there is severe anaemia. From a photograph, Fry,D. with kind permission of Tropical Doctor.
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If there is a succession of abscesses (pyaemia), However, other sites of infection are also common:
drain them as they appear, culture the pus, and treat with the proximal femur, the proximal humerus, the distal
an appropriate antibiotic as soon as you know the results radius or ulna, the distal tibia, or the calcaneus.
of culture. Treat with cloxacillin or chloramphenicol But any bone can be involved, and sometimes several of
meanwhile. Check the HIV status. them at the same time, especially in neonates where the
maxilla is often involved (7.14), and the origin
DIFFICULTIES WITH PYOMYOSITIS of the sepsis may be umbilical, pneumonic or from
If blood pours from the abscess, pack the cavity tightly gastro-enteritis.
with gauze for 24hrs. Do not curette an abscess. Metaphyses are endowed with a rich network of
It may be an infected false aneurysm (35.8); subperiosteal vessels and it appears that the primary lesion
make sure you have vascular clamps ready when you is a subperiosteal hematoma. People who walk barefoot
re-explore. and whose skin is exposed to all manner of scratches and
If there are very many or very severe lesions, thorn pricks and insect bites, people who suffer from
you may have to make >10 incisions, with repeated staged pimples, eye and ear infections and who pick their noses,
visits to the theatre, to evacuate pus and remove dead are prone to episodes of bacteraemia. Boluses of bacteria
muscle. are quickly eliminated from the circulation but devitalized
If there is overlying black necrotic skin, removing it blood is an excellent culture medium and hence if bacteria
may reveal a huge quantity of avascular greyish-pink, settle in the subperiosteal hematoma, infection will ensue
mushy suppurating muscle extending deeply underneath. and a subperiosteal abscess will develop. Pus accumulates
Remove this, taking care: (1) not to injure vital structures, under pressure, breaks out through a hole in the bone,
(2) not to lose more blood than is inevitable. Survival may and comes to lie under the periosteum. Pus then strips the
depend on aggressive (but not too aggressive) surgery, periosteum off the shaft and deprives part of the bone of its
intensive antibiotic treatment, and IV fluid replacement. blood supply, so that it dies and forms a sequestrum.
If you have had to remove much muscle, there will Although acute haematogenous osteomyelitis can be
inevitably be resulting weakness, deformity, and loss of caused by a whole array of micro-organisms,
function but you will have saved the patient’s life! If you staphylococci are by far the most common bacteria
are afraid of too much blood and muscle loss, do an implicated, salmonellae are probably the second
amputation (35.3). commonest microbes. E.coli and other enterobacteria are
If there are fever and rigors after drainage, often found with sickle cell disease or other
there is septicaemia, either from new abscesses, haemoglobinopathies.
or inadequate drainage. With HIV disease, haematogenous osteomyelitis occurs in
If abscesses are near joints and liable to develop adults as well as children, often with enterobacteria but
contractures (32.1), apply skin traction or a cast, as also with all manner of bacteria. There is little periosteal
appropriate. reaction, but osteopenia leading to bone destruction.
Before the age of 6 months, an epiphysis offers no barrier
to the spread of infection, so that pus in a metaphysis
7.2 The pathology of osteomyelitis rapidly spreads to a joint. After this age the cartilage of an
epiphyseal plate limits the spread of infection, so that a
joint is only infected if an infected metaphysis extends
Osteomyelitis is a particularly tragic preventable disease inside a joint capsule, as in the hip or shoulder.
which often disables for life if it is treated late or
inadequately. You can only treat osteomyelitis B. ACUTE TRAUMATIC OSTEOMYELITIS
satisfactorily if you treat it early. Later treatment is
difficult, expensive, and time-consuming. There are Here the organisms reach bone directly from an open
several kinds. fracture, particularly if the wound is contaminated in road
vehicle trauma, war, or a gunshot incident. The bone in
A. HAEMATOGENOUS OSTEOMYELITIS such wounds is always at risk especially if there is
The acute stage of haematogenous osteomyelitis is a inadequate wound toilet, or immediate instead of delayed
systemic disease which may be life threatening. wound closure.
It is an indicator of poverty, manifested by poor hygiene Similarly, infection can reach bone through internal
and a poor nutritional state. Typically it is an affliction of fixation of fractures, and so you must seriously weigh the
children between 4-14yrs and is more common in boys, advantages of such procedures against their risks.
probably because boys are more prone to trauma and boys
are socially allowed to be dirtier. There is often a history C. SUBACUTE LOCALIZED PYOGENIC
of minor trauma, such as being kicked on the football OSTEOMYELITIS
field, and the most commonly affected bones are the tibia
and the femur where the commonest sites of injury are the Here the infection develops insidiously from the
distal metaphyses of the femur and the proximal metaphysis of a long bone, which cavitates and produces a
metaphyses of the tibia. surrounding reactive bone sclerosis, known as a Brodie's
abscess (7-2A). Ultimately the marrow cavity is
obliterated.
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The only sure way to confirm or exclude osteomyelitis is Ordinary radiographs may not show any abnormality
to decompress the bone, urgently. Many doctors are only especially when the disease is early and treatable!
used to soft tissue surgery and do not like working on bone Blood tests, particularly the white blood cell count is
and look upon it as specialized orthopaedics. unhelpful, as are sedimentation rate and C-reactive protein,
The main message of this chapter is that you must for they simply suggest the presence of inflammation.
decompress osteomyelitis early!
Do your utmost to drain pus from an infected bone before DIAGNOSING OSTEOMYELITIS
it has stripped the periosteum off the shaft. After this has If a child has a high fever and is acutely tender over a
happened, the bone normally heals by forming a bone, this is osteomyelitis until you have proved
sequestrum and an involucrum, with all the disability that otherwise. If the mother tells you that there was an injury
this causes. Early treatment needs early diagnosis, up to 2wks before, this may indeed have been true in 50%
so everyone who provides primary medical care must be of cases as increased blood supply to the area may have
aware of osteomyelitis. Make sure that your staff in the been the pre-disposing factor producing the infection.
clinics know about it, and immediately refer any child with Radiographs do not help in the early diagnosis of
fever and a painful limb. Because of the common practice osteomyelitis, but they will exclude a fracture.
of giving antibiotics and seeing if the patient improves, If the tenderness is in the soft tissues, rather than over
osteomyelitis is apt to be one of the worst treated diseases a bone, this is more likely to be cellulitis or pyomyositis
in primary care. One reason why it is such an important than osteomyelitis.
disease in resource-poor settings, is that patients are so If the lower leg is swollen, oedematous, tender and
often referred to hospital late, after they have been warm, but the tenderness is not particularly localized
inadequately treated in peripheral units. over a bone, should you explore it or not? Its exact site
Any of the diseases in the list below can cause pain, fever, may help you to decide. If you are still in doubt, be safe
and inability to move a limb. Local redness and oedema and drill. You will probably operate on some cases of
are later signs. The important decision is not what the cellulitis unnecessarily, but if you do not operate, you will
exact diagnosis is, but whether you should decompress miss osteomyelitis.
bone or not. The site of the greatest tenderness (at the end If the point of maximal tenderness is over a joint, not
of a metaphysis near a joint) is a useful point of over the adjacent bone, and all its movements are
differential diagnosis, and so is the young age of the exquisitely painful, this is probably a primary septic
patient. The tenderness is localized and is greatest on arthritis. Aspirate the joint and if necessary, drain it.
direct pressure and percussion. If there is fever and an acutely painful hip which is
extremely painful to move, this is osteomyelitis of the
MURARULAL (9yrs) was brought in by the mother with a one-day neck of the femur with septic arthritis (they are in effect
history of a limp. There was tenderness over the right fibula and had a
the same disease). Aspirate to confirm that pus is present
low grade fever, but no other signs, and no radiographic changes.
The diagnosis was uncertain, so the fibula was explored. It looked normal (7.16). Drill the upper femur and its neck, and drain the
when it was exposed, but even so it was drilled. Pus came out under hip (7.18).
pressure. The wound was dressed and left open and he was given If the muscles are swollen and tender, this is probably
chloramphenicol. He rapidly improved and the wound healed
pyomyositis (7.1): feel the site of tenderness carefully.
spontaneously. A month later he had no limp and no discharge,
but a radiograph showed periosteal elevation. A year later the radiograph If sickle-cell disease is common, suspect that infarction of
was normal. the bone, which is common in this condition, may be
BUROO (8yrs) was admitted with a swelling over the upper end of her causing the symptoms if:
right tibia present for the last 4 days. A small abscess pointed. This was
(1) several of the bones are involved.
incised and drained. A week later a radiograph was taken and considered
normal. After three months of antibiotic treatment, her wound was still (2);an unusual bone is involved, such as the skull, or the
discharging, and radiographs showed obvious chronic osteomyelitis. small bones of the hands or feet, particularly if he is an
LESSON (1) If osteomyelitis is a possibility, drill the bone, especially the infant.
upper tibia. (2) Drill it even if it looks normal when you expose it.
Osteomyelitis can complicate avascular necrosis, both
If Buroo's bone had been drilled early, she would have been spared many
years of disability. (3) When you have found pus, leave the wound open. diseases may be present. There is no certain way of
distinguishing a sickle-cell crisis from osteomyelitis except
by decompression. If there is sickle-cell disease, a wait of
HIGH FEVER AND A TENDER BONE 24hrs is reasonable, because the pain of an infarct
MEAN OSTEOMYELITIS improves rapidly. Signs in a SS patient are usually obvious
clinically, but are not in SC patients (quite common in
DIAGNOSIS West Africa).
The diagnosis is clinical, except if the admitting institution If lesions in the hands are causing diagnostic
is sophisticated and in the possession of imaging difficulties, remember that:
machinery such as radio isotope scan and MRI and people (1);Tuberculous dactylitis is much less painful than
who are familiar with that machinery, a situation that will sickle-cell dactylitis.
rarely be found where this disease is common. (2);Syphilis will probably show abundant new bone
The simplest and fastest method of diagnosing a formation elsewhere.
subperiosteal abscess, and proving the diagnosis,
is aspiration, which, at the same time, will yield a
specimen.
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EXAMINATION. Elicit tenderness and hypersensitivity to GENERAL CARE & IMMOBILIZATION. Correct
vibration by holding a tuning fork against the bone, dehydration. Ease pain with IV analgesics. Splint the limb
even distant from the affected area. in the position of function, or use skin traction for a leg.
Look for a septic problem anywhere, but especially from a
child's skin, chest or stool from which the infection may ANTIBIOTICS. Start these immediately after you have
have spread. Culture any skin lesion, sputum and diarrhoea taken a pus swab, and if possible a blood culture also.
stool. If you have been able to drain the lesion early and it is
clinically quiescent, and there is no bone necrosis,
BLOOD CULTURES. If there is pyrexia, take a blood continue for 2-3wks. Before you know the results of
culture (if you can), and preferably 2 more at 2hrly culture, or if culture is impossible, treat with IV
intervals, before you start antibiotic treatment. If treatment chloramphenicol 10mg/kg qid, or IV cloxacillin 10mg/kg
has already started, cultures will probably be unhelpful. qid. Monitor the leucocyte count.
Treatment has 3 objectives:
RADIOGRAPHS Do not expect any signs in an early (1) to treat and prevent pain,
case. You will only see bony changes >10days in an older (2) to treat the septicemia and the associated inflammatory
child, or >5days in an infant. Examine the edge of the bone syndrome, and
with care: the earliest sign is the faintest second line of (3) to prevent the bone from dying.
new bone about 1mm away from the shaft. You will see You need to administer IV antibiotics and analgesia fast!
this more easily if you look at the film obliquely. Whilst the periosteum is relatively inelastic and cannot
Nonetheless it is useful to have a radiograph as a baseline. accommodate much inflammatory exudation, the bone is
altogether incapable to adjust to the pressure rising in the
IF YOU SUSPECT OSTEOMYELITIS, Haversian system. Therefore, as the subperiosteal lesion
DECOMPRESS THE BONE & LET OUT THE PUS! expands, the periosteum will be stripped from the
diaphysis, and as the pressure in the Haversian system
NEEDLE ASPIRATION using a 16G needle may be eventually exceeds capillary pressure, the bone will
useful in localizing pus. Unfortunately, if pus is present become ischaemic and will die. Consequently, the third
under the periosteum the disease is already advanced. objective of treatment is addressed by decompressing the
Good results are obtained by decompressing bone earlier subperiosteal abscess. At a very early stage, antibiotics
than this. Aspiration is useful for diagnosing septic alone may abort the process, but in the regions where the
arthritis, but not for treatment. condition is common presentation is usually late,
and decompression is necessary.
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If the bone looks normal, drilling holes through the If no pus or tissue fluid under pressure comes out, there
cortex of the diaphysis into the medullary cavity may in is probably no osteomyelitis, provided you really have
early cases decompress the Haversian system. drilled the tender area. If pus flows from the first hole,
The unfortunate circumstance in poor-resource settings is send a specimen for culture. Drill 1-2 more holes 1cm
that in the overwhelming majority of cases the bone, apart in a lazy zig-zag line down the shaft of the bone until
or parts of it, are dead at the time of presentation. only blood or tissue fluid flows out of the hole from
healthy bone.
If septicaemia persists, grave complications will follow:
pneumonia, endocarditis, pericarditis, and ‘metastatic’ CAUTION!
abscesses. Fortunately most patients recover from (1);Do not elevate the periosteum, because the bone under
septicaemia and if the bone has not died, the local it will die.
inflammation will subside. (2);Do not elevate too much muscle either, because
periosteum receives its blood supply from the muscles
If the bone has died, as is usually the case, pain and local over it.
signs will continue to be present. After 10-14days, (3);Do not incise the periosteum beyond the epiphyseal
a radiograph will show the extent of the dead bone: line, or you may spread the infection to the epiphysis.
this will be relatively denser than the living bone, (4) Do not remove any periosteum, because the bone under
for the living bone will have began to lose mineral density the raw area will not regenerate.
whereas the dead bone will not. (5) Never drill a row of holes transversely across a bone,
because they weaken it.
N.B. Damage to the growth plate in childhood may lead (6);N.B. A single drill hole may not drain an abscess
to stunted growth, and limb shortening or deformity. sufficiently.
(7);Do not use suction drainage, because this might suck
excessive amounts of bone marrow straight out of the
7.4 Exploring a bone for pus medullary cavity.
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Surgery for chronic osteomyelitis is difficult, bloody, Encourage a strong involucrum to form by exercising the
and dangerous. If you have to operate, do so only to limb so that the newly growing bone of the involucrum is
relieve persistent pain or remove persistent sinuses, gently stressed, without being angulated or shortened.
not merely to improve the radiographs. For example, in the femur use a trunk-to-groin (hip spica)
If an area of bone is abnormally dense on the or groin-to-knee cast, add crutches and allow cautious
radiograph, showing that it is dying or dead, it may be weight-bearing.
absorbed slowly if it is attached to existing healthy bone. Occasionally there is localized sclerotic osteitis without an
But if it is lying free as a sequestrum, it will act as a involucrum (Brodie's abscess).
foreign body and will not be absorbed, so you will have to
remove it. Occasionally, you can remove a small SEQUESTRECTOMY (GRADE 2.5)
sequestrum through a sinus, but you usually need to cut a INDICATIONS. Consider removing any sequestrum
window in the involucrum. Once you have removed a which you cannot remove through a sinus. Do not operate
sequestrum, no new involucrum will form. This is an to remove a large sequestrum until:
important exception to the general rule that a foreign body (1).The involucrum extends across the defect that will
should be removed immediately, especially in the presence follow.
of infection. (2).The involucrum is made of rigid bone.
. (3).The limb must be capable of being supported, either by
the remaining healthy shaft, or by a sufficiently strong
involucrum.
CAUTION! If you remove the sequestrum too early,
the involucrum will stop making new bone, and will
collapse, so that there is no hope of a sound limb.
PREPARATION
ANTIBIOTICS. Culture the pus and start the appropriate
antibiotic in high dose, at induction of anaesthesia for
2-3days.
METHYLENE BLUE may help to show up sequestra
during an operation. Sterilize a 1% solution, and inject it
into the sinus 24hrs beforehand. It will stain everything
blue, except the sequestra, which will remain white.
EQUIPMENT. As for acute osteomyelitis (7.3), plus 6 and 10mm
osteotomes and gouges; 10 & 15mm chisels; a 250g mallet, a Volkmann's
scoop, a curved sequestrum forceps, and a bone nibbler. In the thigh you
will need strong retractors, a strong assistant, and a good light. Use an
ordinary electric drill (held in a sterile glove) with a rotation saw (which
you can autoclave).
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You will usually only need part of an incision. Very often After some weeks there will be a floor of healthy
it will include the draining sinuses. If possible, make the granulation tissue, which will either epithelialize
incision over one of the larger gaps in the involucrum. spontaneously, or can be grafted. As you change the
The tissues will be tough, so use a sharp scalpel. dressings you will find that fewer are needed as it closes.
Open the indurated periosteum in the length of the A large wound takes a long time to close.
incision, and elevate it on each side. You will have to CAUTION! Remove all the dressings you put into a
make a hole by chisel or drill and rongeur in the wound. If any fragments remain, they will act as foreign
involucrum so that you can extract the sequestrum. bodies, and cause infection to persist. If you use pieces of
Either: enlarge an existing gap in the involucrum with a gauze to pack a wound, knot them together, so that you
gouge. Or: drill holes so as to outline a window (7-6). can pull them all out at the same time.
Then open it with an osteotome.
CAUTION! POSTOPERATIVELY, the wound will ooze. Do all you
(1) Scar tissue may have disturbed the normal position of can to improve nutrition. You will need quantities of
the nerves and arteries. sterile dressings. Change them regularly. Remove any
(2) Do not break the bone. If you have carefully outlined dead tissue as necessary. After you have removed all the
the window with drill holes, this will be less likely. dead tissue, the disease process comes to an end and
Use a hammer and gouges or chisels to cut bits of bone rehabilitation can begin. Encourage use of the limb,
from the involucrum until you get to the marrow cavity. walking with crutches without weight-bearing if the lesion
Look for sequestra inside it. was in the leg, and the use of the arm as much as possible.
In severe cases this active movement will encourage the
SEQUESTRA move separately from the surrounding periosteum to produce a really robust involucrum, which
involucrum. If they have been covered by tissues they are will not happen if the limb remains completely immobile.
ivory white and have a brittle texture which is different If the involucrum might fracture, apply a cast and
from ordinary bone. If they have been exposed to the air window it. Or, in the leg, apply skin traction. If a large
they may be black or grey. area of bone has been destroyed, careful splinting is
Sometimes it is necessary to break the sequestrum and essential.
remove it piecemeal. To prevent the bone splitting, Get radiographs at a convenient time postoperatively.
use a drill with a rotation saw instead of a hammer and This is only necessary to assess the strength of the leg for
gouge to chip away the involucrum around each weight bearing, or, if sinuses persist, to look for more
sequestrum so that you can remove it. To minimize sequestra.
weakening, make a window in the bone longitudinally.
Round or taper the ends of the window; these will be DIFFICULTIES WITH CHRONIC OSTEOMYELITIS
stronger and allow it to fill with soft tissue more easily. If there is severe bleeding into the dressings,
Pull out sequestra with sequestrectomy forceps. return to theatre, open the wound, tie off any bleeding
If necessary, remove more involucrum to free a vessels, repack it tightly, and apply a pressure bandage.
sequestrum. There will be pus, but usually not much. Back in the ward raise the limb, and put a cradle over it, so
When you have removed all the sequestra you can find, that you can inspect it readily. Do not leave a pressure
explore the abscess cavity up and down quite widely with dressing in place for >48hrs, or it will promote infection.
a probe. If necessary, extend the skin incision and enlarge If pus continues to discharge from the wound,
the hole in the involucrum until you have explored the it may be due to:
whole cavity. Scrape the granulation tissue in its walls (1).Inadequate excision of fibrous tissue and curettage of
with a bone curette (Volkmann's spoon), until you reach the granulations.
bleeding healthy bone. If sinus tracts in the soft tissues are (2) Leaving sequestra behind.
short, excise them. If they are long, curette them. (3).Leaving a swab or piece of dressing in the wound.
If bone overhangs the edge of the cavity, chisel it away. (4) Not opening up the cavity in the bone widely enough.
Lavage the cavity with warm water. If the leg has malunited in a deformed position,
CAUTION! If the operation is to succeed, you must an osteotomy may be necessary.
remove all sequestrated bone. The radiographs will If there is a pathological fracture, splint the limb in the
suggest how much there is, but expect to find more. correct position in a cast until it has healed soundly. While
Allow muscle to fall into the cavity (7-10); if this is it is healing pay special attention to the alignment of the
inadequate, mobilize a flap of muscle, preserving its blood knee and ankle. Keep the wound open, dress and toilet it
supply, to fill the cavity. regularly. Skin traction is suitable for the femur and upper
tibia, especially <14yrs. Otherwise an external fixator is
CLOSURE: Complete meticulous haemostasis is essential. best.
A suction drain may be beneficial to avoid accumulation If osteomyelitis has followed internal fixation with a
of blood. Fix the drain to the wound with a stitch, because plate, remove it. The only exception is an AO
it may fall inside the wound, get lost, and act as a foreign compression plate. If this is still maintaining compression,
body. leave it, but if it is holding a gap open between the
Apply a pressure dressing for the first 48hrs, but watch the fractured ends, remove it.
circulation distally.
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In an infant, the bone will probably heal well, even after If necessary, you can split the brachialis to within 3cm of
you have removed a large sequestrum. If an operation is the epicondyles without entering the elbow joint.
needed, do not hesitate to operate as soon as a satisfactory Do not extend the incision beyond the flexor crease of the
involucrum has formed. elbow, because you may cut the radial artery.
If there is sickle-cell disease, new bone will form
particularly slowly.
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Osteomyelitis of the femur commonly involves the hip If there is bleeding from the vessels of the linea aspera,
joint, and occasionally the knee, but seldom both. catch them with a haemostat, and transfix them with a
When a child's knee is involved, the distal femoral ligature on a curved needle. Pass the needle round under
epiphysis may slip. If this happens, the shaft of the femur the haemostat and the vessels at least twice.
usually slips anteriorly in front of the distal epiphysis, Pull the ligatures tight as you release the haemostat.
unlike in injury in which it slips posteriorly. They are usually too deep into the wound to tie on the tip
Prevent further slipping by applying skin traction up to the of a haemostat. If you cannot reach a bleeding vessel, pack
mid thigh. You may need to manipulate it under GA. the wound tightly, raise the foot of the table and wait for
the bleeding to stop.
If you are operating towards the distal end of the
femur:
(1) Do not enter the knee joint or the suprapatellar bursa.
(2) Stay strictly on the lateral side of the knee.
(3);Do not go posteriorly: you may injure the lateral
popliteal nerve.
(4);Do not go medially because you may injure the main
vessels.
Postoperatively, apply skin traction. This will be easier
than applying a medial plaster splint, which is the
alternative. Later, use a hip spica or a plaster cylinder from
the groin to the knee, add crutches, and encourage weight-
bearing.
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SEQUESTRECTOMY. Make the main part of the 7.11 Osteomyelitis of the fibula
incision over the muscles rather than the bone.
Make the longitudinal part of the incision 1cm lateral to its
anterior border. Proximally, do not extend it higher than Osteomyelitis of the fibula is uncommon. If the tibia is not
the tibial tubercle. If possible, avoid taking it across the involved, you can remove a sequestrum from the fibula as
tibia where this is infected, because the scar from the soon as is convenient, without waiting for an involucrum
incision will stick to the bone and become painful later. to form, because the tibia will support the leg.
If necessary, curve its upper and lower ends to cross the You can expose any part of the fibula by approaching it
anterior border of the bone. between the peroneal muscles anteriorly and the soleus
Reflect the skin with the periosteum. They will probably posteriorly. The posterior tibial nerve and vessels are well
be so closely bound together that you will be unable to out of harm's way; but be careful not to injure the peroneal
separate them. Hold the skin flap lightly with skin hooks. artery and veins which are close to the postero-medial
Incise the periosteum midway between the anterior and angle of the shaft of the fibula. If the head of the fibula is
posteromedial borders of the bone. involved (rare) be very careful not to injure the common
If the position of sinus tracks are medial, you can make peroneal nerve.
a medial flap in the same way, with most of the length of
the incision over the muscle on the medial side of the tibia.
After you have removed the sequestrum:
(1) If the tissues are not too tight, close the wound lightly
and insert a drain in its lower part.
(2) If the tissues are tight, let the skin edges fall into the
wound and leave it unsutured (7-10H,I). Healing will take
longer like this. Apply a posterior slab or a long leg cast
with the ankle in neutral, and the knee in 20º of flexion.
Mark a window in it while it is still soft, cut out the
window with a knife, or with a plaster saw 2days later
when it is hard. Dress the wound through this window.
If you have left a deep trough in the front of the tibia
which is slow to granulate and epithelialize, graft it.
CAUTION!
(1) Do not go directly anteriorly through the subcutaneous
surface of the tibia.
(2) Make sure your assistant retracts the skin flaps gently,
because they can easily necrose.
Apply a long leg cast with a walking heel, then encourage
early weight bearing with as normal a gait as possible.
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THE TALUS
Flat bones like those of the skull differ from long ones:
(1);They have little marrow between their diploë, so that
when they are infected the condition is an osteitis, rather
than an osteomyelitis.
(2);Unlike long bones, flat bones seldom sequestrate, and
do not form an involucrum.
(N.B. Osteitis of a rib is usually due to TB).
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When you plan the incision, consider the arteries of the 7.14 Osteomyelitis of the jaws
scalp, and incise between them. For example, do not make
a transverse incision in the temple which will divide the
temporal artery. Split skin grafts will not take on bare Osteomyelitis can affect either of the jaws, usually the
skull, but they will take on granulations. So, if necessary, lower one, and can be secondary to:
remove dead bone, apply saline dressings for a few days, (1);An infected tooth socket in an adult, especially the
and wait for granulations to form. mandible (6.9, 31.3). Suspect it if there is pain, swelling,
CAUTION! (1) If a sequestrum is firmly anchored, use tenderness, trismus, and fever after he has had an infected
an osteotome and light taps from a heavy hammer; tooth removed (sometimes months before), or an alveolar
do not open the dura or injure the brain. abscess drained.
If the osteomyelitis becomes chronic there may be sinuses
If osteitis follows FRONTAL SINUSITIS (29.8). over the lower face, or over the inferior border of the
Define the extent of the frontal sinus with radiographs. mandible (31-9). The offending teeth are usually loose,
Shave the anterior 3cm of the scalp. Make a long incision and you may see pus discharging around them.
above the hairline from ear to ear, and reflect the skin of (2) An open fracture, especially comminuted, of the lower
the forehead downwards as a flap, based on the jaw.
supraorbital vessels. (3) Cancrum oris (31.5).
(4) Sickle-cell disease.
(5) Actinomycosis (31.6)
ACUTE OSTEOMYELITIS
CHRONIC OSTEOMYELITIS
SEQUESTRECTOMY
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(5).You can easily confuse tuberculous with subacute Congenital syphilis presents as swelling of both knees
suppurative arthritis. To distinguish them, rely on the without much fever, in childhood.
radiograph and your findings on aspiration (pus or caseous Actinomycosis and mycetoma (34.11) may also invade
tissue). joints from outside.
If you are still in doubt, treat for both diseases. Review the
progress at 3 & 6wks, when suppurative arthritis should Several things can happen to a severely damaged joint:
show much improvement, whereas it is still too early for (1) It can dislocate.
tuberculosis to show much change. (2);An epiphysis can slip, either immediately, or several
weeks later (7-14).
(3);It can become fixed in a painless stable bony ankylosis
in the position of function.
(4);It can develop a painful unstable fibrous ankylosis,
which can be a serious disability.
HASINA (17yrs) was admitted with pain in her left hip and inability to
walk for 3 days. She was given physiotherapy, nursed on a fracture bed
for 3wks, and discharged on crutches. Some weeks later she was
readmitted, pyrexial, and with a swelling of her right thigh extending
from her knee to her iliac crest. 3l yellow-green pus were aspirated
(7-14).
MARIAMU (12yrs) was admitted with osteomyelitis of her tibia.
This was settling nicely when she developed pain in her left hip and
became pyrexial. The radiographs of her hip were normal, septic arthritis
was diagnosed, and she was given large doses of the latest
broad-spectrum antibiotic. Her pain improved slowly but her fever
continued. Later, radiographs showed destruction of the head of her
femur. Traction was applied. Sinuses developed, and she was never
able to walk again. Two years later her pain was so severe that she had to
have her hip disarticulated. All this happened in a 'good' hospital.
LESSONS (1) The early diagnosis of septic arthritis of Hasina's hip was
not made, although the history and signs were obvious. (2) Rest in bed on
traction would have prevented her epiphysis slipping. At best she will
have a painful hip, either for life, or until her hip has ankylosed
spontaneously, or been fused surgically.(3) Explore a hip on the suspicion
of septic arthritis.
Septic arthritis is more common in the disadvantaged and If you fail to aspirate a joint that you think is infected,
malnourished and also in infancy and old age. you must incise and drain it, i.e. perform an arthrotomy.
It is common in HIV disease, as well as diabetes mellitus, The results of not doing so are so serious, that the dangers
chronic renal failure and in joints previously damaged by of attempting it are well worthwhile. Likewise, if the pus
trauma or inflammatory disease. is too thick to aspirate properly, perform an arthrotomy to
Staphylococcus aureus is the dominant organism, but if the wash out the joint.
patient has HIV or sickle-cell disease, you may find E. coli
or salmonella in the joint. Haemophilus influenzae is the SPECIAL TESTS. Culture the synovial fluid (30% +ve
most frequent organism in newborns, but is seldom seen in result) and blood (14%). Screen for HIV.
older patients.
Other organisms include streptococci, brucellae,
and gonococci.
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If, when you drain an infected joint and wash out the
pus, its joint surfaces are smooth, there is a good chance
of having a normal or nearly normal joint. The prognosis is
worse if cartilage has been lost, if the joint surfaces are
rough, if the bone is soft, or if the radiograph shows severe
joint destruction. Even so, there is still some hope of a
movable joint, especially in the young; a child's epiphysis
may appear to be largely destroyed on a radiograph, and
yet regenerate considerably.
Joints need to be in particular positions for particular The position of rest is the most comfortable position for a
purposes, so be sure to get it right. These positions seldom joint to lie. Put it into this position if it has to be rested for
coincide with one another, and the position of function is any reason, but is in no danger of ankylosing.
absolutely critical.
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The neutral position of a joint is that from which its THE POSITION OF A JOINT IS ALL IMPORTANT!
movement is measured. It is for anatomical description
only. A. THE SHOULDER
POSITION OF FUNCTION.
Put the shoulder into a spica in 45º of abduction, with the
elbow just anterior to the coronal plane, in 70º of medial
rotation so that the hand can reach the mouth.
B. THE ELBOW
ASPIRATION.
Bend the elbow to 90º. Feel for the head of the radius,
the olecranon and the lateral epicondyle of the humerus.
Using these points of a triangle, push the needle through
its centre into the posterolateral aspect of the joint.
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If the dominant elbow is going to ankylose, consider the EXPLORATION ARTHROTOMY. (GRADE 2.4)
patient’s needs. For example, Muslims and many other With the knee extended, make a 5cm incision 2cm behind
peoples write and eat with their right hands and use their the medial edge of the patella and its tendon. Go through
left hands for toilet purposes. If so, the right elbow should the quadriceps expansion, longitudinally, and put a curved
be more flexed than the left. The dominant elbow will haemostat into the suprapatellar pouch, under the surface
probably be most useful if it is flexed 10º beyond a right of the patella. Put your finger into the joint and use it to
angle, with the forearm pronated 45º so that feeding, remove the pus. Take a piece of joint capsule for biopsy.
scratching the nose, and writing are possible. Put it into Irrigate the joint with warm sterile water. Leave the wound
this position by fitting a collar and cuff. open, or sew up the upper part, and leave a corrugated
drain in place. Dress the wound and apply skin traction,
If both the elbows are going to ankylose, arrange their or a plaster backslab. Without one or other a painful
positions so that the dominant arm can reach the mouth. flexion contracture is likely. Leave the drain in for
Let the non-dominant elbow fuse in 10º short of full 4-7days.
extension, so the hand can reach the anus.
POSITION OF REST.
C. THE WRIST Apply skin traction to the lower leg to prevent flexion.
Or apply a plaster backslab held on with a crepe bandage.
ASPIRATION.
Feel for the radial styloid; it will show you the line of the If there is already a flexion contracture following septic
joint. Feel for the tendons of extensor pollicis longus on arthritis, put the knee in extension traction until it has
the radial side of the 'anatomical snuffbox'. Aspirate on its been corrected. Then apply a cylindrical cast and
ulnar aspect, at the level of the wrist joint. Push the needle encourage weight-bearing. With luck, a painless bony
between extensor pollicis longus and the index tendon of ankylosis will develop. If this does not happen,
extensor digitorum into the joint inclining it proximally a compression arthrodesis of the knee will be necessary.
45º (7-15A).
POSITION OF FUNCTION.
EXPLORATION ARTHROTOMY. (GRADE 2.4) Make sure the knee ankyloses in 10º of flexion, so the foot
Flex and extend the wrist, as you feel for the exact line of can just clear the ground on walking. Do the same when
the joint. Feel for the hollow between the tendons of both knees are ankylosed.
extensor pollicis longus and the index tendon of extensor
digitorum. Make a 3cm transverse incision, taking care not F. THE ANKLE
to cut the cutaneous branch of the radial nerve which runs
in the web space of the thumb. Retract the skin edges and ASPIRATION.
expose the joint through a longitudinal incision between Find the line of the joint by moving the ankle. Insert the
the two tendons. Irrigate the joint with warm sterile water. needle into its anterior aspect just medial to the lateral
malleolus. Push it backwards and slightly downwards,
POSITIONS OF REST AND FUNCTION. so that it enters the space in the angle between the tibia
Keep the wrist in 30º of extension with a volar plaster slab. and the talus.
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7.18 Septic arthritis of the hip Bend the knee to 90º and then flex the hip (7-17B).
If the leg turns to external rotation as you do this, the head
of the femur may have slipped. Confirm this by taking a
An acutely tender hip in varying degrees of flexion, ‘frog-leg view’ radiograph. If a sequestrum has formed,
together with fever, suggests infection. An important sign open the hip joint and remove it.
is spasm of the hip muscles. Test for this by rolling the (3);The hip joint may be destroyed. When this happens,
thigh (7-17). If this is acutely painful, suspect that the hip there are 2 choices:
is infected. If there is septic arthritis or osteomyelitis (a) Fuse the hip in the position of function by applying a
tapping the greater trochanter lightly with your clenched spica for 3 months or more.
fist will be painful; if there is deep inguinal adenitis (6.16) (b) Remove the remains of the partly destroyed head and
or pyomyositis (7.1), it will not. In septic arthritis or neck of the femur by Girdlestone's operation (7.19).
osteomyelitis the epiphysis of the femur may become This will result in a much more comfortable joint with
indistinct, or even absent on a radiograph, but it often some movement.
reappears. This is not an indication for its removal! (4);The infection may extend into the acetabulum and
involve the bones of the pelvis. When this has happened,
there is little you can do, except drain the pus. The osteitis
usually settles.
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ANTERIOR APPROACH
POSITION. Use the supine position, but with a tilt to the
opposite side by putting a sandbag under the affected hip.
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POSITION OF FUNCTION.
Put the hip in a minimum amount of flexion, preferably
none, 5º of abduction, and no rotation. However, do not
apply a spica with the hip in the position of function,
especially in a child.
Otherwise, when you remove it, that spasm has rotated the
pelvis anteriorly, and there is too much flexion.
Instead, immobilize the hip in a spica in complete
extension and 15º of abduction. When you remove the
spica, you will find that it has gone into 15º of flexion,
which is where you want it to be.
Fig. 7-20 LATERAL POSITION FOR POSTERIOR APPROACH RELIEF OF SPASM. In a child, use diazepam, and apply
TO THE HIP.
The affected limb rests horizontally upon a simple platform. up to 1/7th of the body weight of extension (skin) traction.
The unaffected limb either lies beneath the platform, or, preferably, This will relieve the spasm of the muscles, and will
flex it at the hip and knee in order to stabilize the pelvis. Place a prevent development of a flexion contracture.
pillow on the table to protect the leg from its hard edges!
After Crawford Adams J, Standard Ortthopaedic Operations. Churchill
Livingstone 1976 p.25, Fig 10.
7.19 Girdlestone's operation
If you find pus in the muscles of the buttock, before (Hip.excision.arthroplasty)
you reach the hip, this is pyomyositis. If you go further
and open a normal hip through an abscess in the muscles,
you will probably infect it, so stop! Most procedures for infected hips are needed by children.
Ask an assistant to take hold of the ankle and rotate the hip An excision arthroplasty may help an adult whose hip has
internally, so as to increase the space between the been partly destroyed by infection, avascular necrosis or a
trochanter and the acetabulum. Make a small incision in painful non-united femoral neck fracture. Walking will be
the distended capsule of the hip joint and widen it with a less painful, if what is left of the head and neck of the
haemostat. Irrigate the joint with warm sterile water. femur is excised, so as to allow the upper end of the femur
CAUTION! to bear on scar tissue on the under side of the ilium.
(1) The sciatic nerve leaves the buttock half way between A false joint will develop, the leg will be short and a stick
the greater trochanter and the ischial tuberosity. and a shoe-raise will be necessary but there will probably
There is no need to incise or dissect this far medially. be very little pain.
(2) The capsule of the hip joint is only 2cm wide between Girdlestone's operation is a salvage procedure to relieve
the posterior aspect of the greater trochanter and the pain when an arthrodesis or, exceptionally, a prosthesis is
posterior margin of the acetabulum. impractical. It is inelegant and old-fashioned, and is not as
good as an arthrodesis or a hip prosthesis, but better than
If the upper femoral epiphysis has slipped and is nothing.
forming a sequestrum, remove it. You will need to
modify the incision by carrying it down to the greater INDICATIONS
trochanter. Remove the loose head of the femur with large Walking painfully as the result of:
bone forceps, and as much of its neck as is necrotic. (1) Previous septic or tuberculous arthritis, which is now
inactive.
POSTOPERATIVELY, reduce the tendency of the hip to (2) Aseptic necrosis of the head of the femur.
slide proximally by using traction for 6wks (3);A longstanding non-united fracture of the femoral
postoperatively, while fibrous tissue forms to limit neck.
movement. The result will be an unstable hip, needing a (4) An infected hip prosthesis.
crutch for support, but it should be pain-free and walking (5) A joint extensively damaged by a gunshot wound.
will be possible.
PREPARATION. Cross-match 2 units of blood. Use the
POSITION OF REST FOR THE HIP. lateral position with the affected hip uppermost (7-20)
If you are sure that the painful hip is only temporary, rest it
in moderate flexion and 15º of abduction. In this position INCISION. (GRADE 3.5)
the legs are comfortably spread apart. Hold the hip in this Reach the hip joint by the posterior approach (7.18)
position with skin traction. To produce abduction, bring extending the incision down the leg for 10cm. Retract the
the cord holding the weight to the end of the bar at the foot sciatic nerve well medially. Incise the capsule of the
of the bed. If necessary, make sure it stays there by patient's hip joint widely to expose the head and neck of
moulding a plaster pulley on the bar. Or, have a detachable the femur and the remainder of the greater trochanter.
bar with notches at suitable places, which you can tie to
the foot of the bed. Or, put both the legs into abduction.
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You will find that removing the head is easier if you excise DIFFICULTIES WITH EXCISION HIP ARTHROPLASTY
part of the upper rim of the acetabulum. Dislocate the hip
by lateral or medial rotation of the femur. Curette all If the head of the femur is not necrotic, or the hip is
necrotic and infected bone from inside. Cut the femoral ankylosed, do not proceed with the operation!
neck right down to its base from greater to lesser
trochanter, and smooth it by chiselling away all sharp If there is a prosthesis or cement in situ, remove these
edges (7-21). with a hammer, chisel and osteotome: this may present
formidable difficulty, but you must get all the infected
cement out.
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There are many spaces in the hand where pus can collect;
each type of abscess has its own signs and incisions.
These spaces are not rigidly defined; some run into one
another, and more than one may be infected at the same
time (8-5), so do not be dismayed by their apparent
complexity. The common places for pus to collect are in
the pulp spaces of the fingers (8.5), and in the web spaces
(8.7). Even after pus has formed, recovery should be
complete if treatment is correct, provided that tendon
sheaths are not involved.
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If there is lymphangitis, lymphadenitis, or fever, If more than one space is infected, adapt your incision(s)
the infection is spreading. If pus is present, incise the hand accordingly. For example, if the mid-palmar space, several
under antibiotic cover, and continue after the temperature web spaces and the tendon sheaths are infected, you may
and pulse have become normal. need to make several incisions (8-5). As soon as you are
CAUTION! Pus is much more likely to be present on through the skin, insert a haemostat, open it, and explore
the palmar surface than on the dorsum, so do not be misled the abscess cavity (Hilton's method). Culture the pus.
by swelling on the back of the hand. The commonest cause
of a swollen dorsum is a web space infection. If there are no vulnerable structures such as
SPECIAL TESTS. Screen for diabetes & HIV. periosteum, nerves or tendon sheaths nearby,
scrape away the lining of the abscess with curette or a
TREATMENT swab. If there are vulnerable structures nearby,
RAISE THE HAND for comfort and to promote healing. be more cautious, and only use a swab.
In less severe infections, raise the arm in a St. John's sling. Drain the abscess by putting a piece of rubber glove into it.
In more severe cases, such as a tendon sheath infection, Or, leave a piece of petroleum jelly gauze between the
make sure you rinse the tendon sheaths (8.12), and admit wound edges.
the patient and raise the hand in a roller towel. CAUTION!
ANTIBIOTICS are necessary if the infection is spreading: (1) Do not cut the nerves (8-6).
treat with metronidazole and cloxacillin or The digital nerves run near the anterolateral margins of the
chloramphenicol. Do not forget to add an analgesic. fingers. So either cut near the middle of the palmar
surfaces of the fingers, or on their lateral surfaces fairly
INDICATIONS FOR INCISION posteriorly at the apex of the finger creases.
Do not try to treat an infected hand by aspiration only. The muscular branch of the median nerve comes off the
Base your decision to incise on: main trunk just distal to the tuberosity of the scaphoid and
(1);The presence of acute local tenderness: this shows that curves round into the thenar muscles.
pus is present and where it is pointing. (2) Do not pack the wound tightly.
(2);The length of the history, particularly if symptoms are
worse after 48hrs. CONTROL BLEEDING after removing the tourniquet by
(3);The severity of the swelling. raising the arm and pressing firmly on the wound for
(4);The nature of the pain especially if throbbing pain 5mins without interruption.
prevents sleep.
POSTOPERATIVELY, be sure to elevate the hand,
ANAESTHESIA must be adequate. For any but the until pain and swelling subside: this is an important way of
most minor infection, avoid LA close to the infection, reducing stiffness. Rapid resolution of inflammatory
because this will only spread it and increase the swelling. oedema is more important than early movement in
reducing stiffness. Wrap the wound with plenty of gauze,
If the infection is in the distal ⅔ of the finger or thumb and use the dressings to splint it in the position of safety.
you should use a distal palmar block without adrenaline. Inspect the wound daily and wash with water bd.
For all other hand infections, use an axillary block, If the infection was extensive, check for residual
or an IV forearm block, or ketamine, or GA. infection or necrotic tissue which may need further
debridement.
A TOURNIQUET is essential in all but the most CAUTION! Start active movements as soon as pain has
superficial infections, because a bloodless field makes the subsided.
operation easier (3.4). Do not exsanguinate the arm with
an Esmarch bandage, because it may spread the infection. RAISE AN INFECTED HAND
STIFF FINGERS RESULT IN POOR FUNCTION
If the pus is in the distal segment, wrap a rubber catheter
twice round the base of the finger or thumb, and clamp it
with a heavy haemostat. 8.2 Subcutaneous hand infection
The skin and subcutaneous tissue can be infected
If the pus is anywhere else, apply a pneumatic tourniquet anywhere in the hand. Pulp infections and paronychia are
(3.4). merely subcutaneous infections at the tip of a finger,
the latter at the nail border. If there is pus under the
INCISING, DESLOUGHING AND DRAINING THE keratinized layers of the epidermis, strip these off, and see
HAND (GRADE 1.3) if you can find the hole through which it has tracked from
Clean the skin with antiseptic. Incise where pus points, a deeper abscess underneath. An abscess near the surface
and take care you do not cut the digital nerves or spread may communicate with pus deep inside the hand through a
superficial pus deeply (8-6). When you extend an incision, narrow opening, forming a 'collar-stud abscess' (8-1).
do so in a skin crease. If necessary, jump from one crease So, whenever you find a superficial abscess, look for the
to another by making a Z-shaped incision. Remove skin passage which might be joining it to a deeper abscess.
that is already dead. If necessary, extend an incision to Carbuncles (6.4) may form in the hair follicles on the back
explore the whole abscess cavity, and remove deeper dead of the fingers and hand. Antibiotics will not cure this,
tissues. so desloughing is necessary.
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If the pus lies under one corner of the nail, reflect a little
flap and remove that corner only (8-2G-H).
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If the infection has been neglected, so that the whole 8.6 Infection on the volar surface of the
terminal segment of the finger is swollen, continue the middle or proximal phalanx
incision over the end of the finger and round to the other
side. Divide the vertical septa and let the wound to gape Pus sometimes collects on the volar surfaces of the fingers,
open. Dress it as above. superficial to the tendon sheaths (8-1A). The spaces where
it forms are separated from one another by the fibrous
CAUTION! septa which run dorsally from the flexor creases of the
(1);Do not incise the tips of the fingers, or the palmar fingers. The proximal space in each finger communicates
surfaces of the distal phalanges, unless pus is already with the web spaces in the palm. Pus may collect under the
pointing there, because pressure on the scar may be epidermis or under the deep fascia, and is less likely to
painful. remain localized than in a terminal phalanx.
(2);Any incision, other than those described, is likely to be The swollen, tender, indurated finger remains semi-flexed.
a painful nuisance later, especially if you carry it towards Trying to straighten it is acutely painful. Explore the finger
the palmar surface. and rinse the infected space abundantly with sterile water,
(3) Do not damage the periosteum. using a cannula. Drain pus from a volar space through a
(4) Check for a collar-stud abscess (easy to see if you have transverse incision over the point of greatest tenderness.
used a tourniquet to provide a bloodless field). If the tendon sheath is infected, rinse it out thoroughly by
making incisions c.2-3cm apart (8.12). Take great care not
DIFFICULTIES WITH FINGER PULP SPACE INFECTION. to cut into the tendon underneath or to damage the digital
If the infected finger continues to discharge for >2wks, vessels or nerves (8-6G). Use a tourniquet to provide a
suspect osteomyelitis (8.16) or the presence of a foreign bloodless field.
body. Obtain a radiograph. When this shows a foreign
body, or a sequestrum that has separated, remove it. In a EXPLORE A TENDON SHEATH BUT DO
child, the distal phalanx will regenerate under its NOT OPEN A JOINT UNLESS IT IS INFECTED
periosteum. In an adult, the result will be an ugly curved
nail and a short terminal phalanx.
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8.11 Doral hand and finger infection Fig. 8-6 INCISIONS FOR HAND INFECTIONS.
A-D, incisions for more serious hand infections: Incision 1 for web
Infection almost anywhere in the hand makes the dorsum space infections. Alternative incisions 2,3 for a mid-palmar space
swell, but pus seldom collects there. On the rare occasions infection. Alternative incisions 4,5 for a thenar space infection.
when it does, it is usually subcutaneous, and only Incision 6 for pus in the space of Parona (proximal to the flexor
retinaculum and deep to the flexor tendons). Incision 7 for mild
occasionally in the subaponeurotic space under the tendon sheath infection. Incision 9; 9a the 1st part, and 9b the 2nd part
extensor tendons (8-1B). if necessary for more serious infections. Incisions 11 or 12 drain the
radial bursa. E, cross section of the finger. F, tendon sheaths, radial
If localized tenderness persists for >48hrs, and ulnar bursae, lumbrical muscles, & flexor retinaculum.
G, incision 10 for dividing the flexor retinaculum.
do not wait for fluctuation. Drain it through a longitudinal On the ulnar side of the retinaculum, the palpable landmarks are the
incision over the point of greatest tenderness. pisiform and the hook of the hamate. On the radial side you can feel
the tubercle of the scaphoid and, more deeply, the tuberosity of the
trapezium. The digital nerves are at the 'edges' of the palmar
surfaces, so do not incise there. Either incise towards the middle of
the palmar surfaces or laterally towards the dorsum as shown by the
arrows. Incisions for the finger tips are shown in 8-2,3.
Some infections do not have fixed incisions (the volar surfaces of the
proximal and middle phalanges, the superficial palmar space, and
the dorsum of the hand). E-F, after Basmajian, JV, Grant's Method of
Anatomy, 9th ed 1975. Williams & Wilkins, with kind permission.
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CAUTION! Do not take the incisions laterally where Divide the flexor retinaculum deep to opponens digiti
they may injure the neurovascular bundles. minimi: you will see the bulging ulnar bursa.
Wash out the pus with water. Do not close the incision; Wash this out, as for a tendon sheath infection (8.12)
the flaps will heal by granulation to leave a linear scar. You can also drain the mid-palmar space through this
incision (8.9).
If a tendon has become a grey slough, extend the
incision, withdraw the dead part into the wound,
and excise it. Preserve its sheath and pulley.
Allow the wound to heal. If the hand settles well, it may be 8.14 Radial bursa infection
possible to insert a tendon graft later. This will only be
worthwhile if the joints of the fingers are mobile. The radial bursa is a continuation of the tendon sheath of
So, as soon as the swelling is starting to settle, the flexor pollicis longus, so that any infection inevitably
start intensive physiotherapy, both by the patient himself involves both of them. The distal phalanx of the thumb is
and by a physiotherapist: this is important! If the finger flexed and rigid. Extension of the thumb is impossible but
remains stiff, try to persuade that it should be amputated extension of the other fingers is possible. The hand is
(35.4) as a stiff finger can be a severe handicap. tender over the sheath of flexor pollicis longus, and you
may be able to feel a swelling above the flexor
If a tendon and its sheath are extensively disorganized, retinaculum. If treatment is delayed, infection may spread
amputate the finger. If you do not do so: to the ulnar bursa, or the tendon of flexor pollicis longus
(1);infection may spread and cause further damage, may slough.
(2);when the finger heals, it will be stiff, and cause Incise the radial bursa (8-6B: incision 11) along the
considerable disability by impairing the grip of the other proximal phalanx of the thumb. Open it at its distal end;
fingers (35.4). pass a probe proximally towards the wrist, and make a 2nd
N.B. A stiff thumb is much better than no thumb, incision over its proximal end (8-6B: incision 12). Insert
so do not amputate the thumb. a fine catheter down the sheath and irrigate it with water.
CAUTION! Do not incise along the radial border of the
If the palm is seriously infected, divide the flexor first metacarpal. Dissecting among the muscles there may
retinaculum to free the tendons. Approach this either: impair the ability to bring the thumb across the palm.
(a) through a longitudinal incision 1cm to the ulnar side of
the scaphoid tubercle. Make a 5cm longitudinal incision
over the retinaculum. Keep to the ulnar side of the median 8.15 Septic arthritis of the finger
nerve and its ulnar branch (8-6G: incision 10), or,
(b) as shown for the ulnar bursa (8-6A: incision 3).
The finger joints are easily infected from open wounds,
or from nearby infections. A human bite into a joint is
AN UNNECESSARY INCISION IS BETTER particularly dangerous. The infected joint is acutely tender,
THAN A LOST FINGER swollen and painful. An early sign is if twisting the joint is
painful. Its ligaments, cartilage, and bone are soon
involved, so that inevitably the result is a stiff joint.
A stiff dip joint is little disability, but a stiff mcp or pip
joint produces a severely disabled finger which is probably
8.13 Ulnar bursa infection better amputated.
Treat with cloxacillin or chloramphenicol and
Infection of the ulnar bursa is the most serious hand metronidazole; but this is less important than drainage and
infection, because it contains all the flexor tendons of the an efficient surgical toilet.
fingers. The whole hand is oedematous, the palm is Open the joint immediately, especially if there is a wound
moderately swollen, and there may be a fulness over it. If the edges of the wound are not obviously
immediately above the flexor retinaculum. The flexed infected, excise their extreme margins. Examine the
fingers resist extension, particularly the little finger, extensor tendon.
and least of all, the index.
The radial and ulnar bursa sometimes communicate with DO NOT AMPUTATE THE THUMB
one another. So if one of them has been infected, infection (except in extreme circumstances)
may follow in the other a day or two later.
Open the tendon sheath of the little finger with palmar If you have not divided the extensor tendon, enter the
flaps (8-6B: incisions 9a and if necessary 9b). dorsolateral aspect of the joint and retract it to the opposite
Incise the skin and deep fascia over the antero-medial side side. Look inside the joint. Remove any debris and loose
of the 5th metacarpal (8-6A: incision 3). Separate the bits of cartilage or bone. Syringe it out with water.
abductor and flexor digiti minimi muscles from the bone. Leave the skin wound open for delayed primary closure.
Retract them forwards and you will see the opponens digiti If you had to divide the extensor expansion, repair it
minimi muscle. Divide this close to its attachment to the when you have drained the pus. Immobilize the joint in the
flexor retinaculum. position of function (7.17), in case it stiffens,
not the position of safety.
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There is great danger of a serious infection, particularly If it involves a metacarpal (uncommon), treat this as if it
with anaerobes. If you treat early, recovery is likely with a were any other long bone. Approach it through a dorsal
useful, mobile hand. If presentation is late (8-9) it will incision, and reflect the extensor tendons. Approach the
remain stiff, especially if a joint or a tendon sheath is middle and lateral phalanges through mid-lateral incisions.
involved. When the infection is controlled, amputate the
stiff useless finger (35.4). If it involves a distal phalanx this will usually present at
the finger tip. Cut it off with a bone nibbler.
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If discharge and pain persist, this from: INFECTIONS OF THE DORSUM OF THE FOOT
(1) Inadequate drainage and desloughing. present early, and you can usually drain them through a
(2) Osteomyelitis. small incision using LA.
(3);Spread of a more superficial infection to a tendon
sheath, or another fascial space. INFECTIONS OF THE TENDON SHEATHS are
(4) Sloughing of a tendon. uncommon except in leprosy, and when there is a foreign
(5) A foreign body. body involving the tendon sheath. Incise over the infected
part, drain it, and leave the wound open. In a late case you
If an adult's finger continues to be painful and may need to remove necrotic tendon.
discharge because of osteomyelitis or established septic
arthritis of a mcp or pip joint, consider AMPUTATION SEPTIC ARTHRITIS can involve any joint.
(35.4), because the proximal joints may become stiff too. If a pip or dip joint is involved, open it widely through a
A stiff dip joint is not much of a disability. Amputate at longitudinal incision on the dorsal surface to one side of
least through the joint proximal to the bone involved. the extensor tendon. Clean it out and leave it open to drain.
Do not merely remove part of the involved bone, because
the infection will spread. The thumb is an exception; spare If a mcp joint is involved, approach it either from the
as much bone as you can, and do not amputate if you can dorsal surface (open it from just one side of the extensor
avoid doing so, because even a stiff stump of a thumb is tendon), or from the plantar surface. Open the wound
better than no thumb at all. widely and let it drain. Wounds in the plantar surface heal
CAUTION! A child is much more likely to regain some well.
useful movement eventually, so do not amputate unless the
finger remains stiff after infection has settled. If other joints are involved, approach them from the side
where the bone is nearest to the surface. Clean the joint out
well and leave it open.
8.17 Pus in the foot
Foot infections are common, especially in communities OSTEITIS. Treat with cloxacillin or chloramphenicol and
where people do not wear shoes. Fine movements are not remove necrotic bone as necessary in chronic cases.
so important in the foot as they are in the hand, so that If the phalanges are involved, drain the infection and it
infection of the tendon sheaths of the foot is less of a will probably settle. Osteitis commonly follows infection
disaster. You must however drain septic arthritis and in the soft tissues, especially infections of the pulp of the
osteitis, or persistent sinuses may follow. distal phalanx.
Some foot infections are more complicated,
e.g. osteomyelitis of the calcaneus and talus (7.12) If the metatarsals are involved (rare), there may be:
and mycetoma (34.11). Diabetic and leprosy patients are (1) Osteomyelitis following an injury. Approach the bone
particularly liable to foot infections (32.2), because of through a dorsal incision and reflect the extensor tendons.
neuropathies. Drain the wound and remove necrotic tissue. Loss of 1 or
2 metatarsals is of little functional importance.
SUPERFICIAL INFECTIONS (2) Acute haematogenous osteomyelitis. In a child <10yrs,
Manage subcutaneous infections (8.2), apical toe space an antibiotic alone may be adequate. In a child >10yrs, the
infections (8.3), paronychia (8.4), pulp infections (8.5) bone will also need drilling.
and web space infection (8.7) as in the hand. They are all (3).Chronic haematogenous osteomyelitis. This presents
fairly common with persistent pain and sinuses. Remove necrotic bone,
without waiting for the formation of an involucrum.
For all but the most superficial infections use a tourniquet CAUTION!
(3.4), unless the circulation has been impaired by If the foot becomes infected without obvious reason search
ischaemic disease. carefully for:
(1) A foreign body.
DEEP INFECTION OF THE PLANTAR SURFACE OF (2) Diabetes.
THE FOOT is usually due to an injury, such as a thorn, (3) HIV disease.
which has penetrated deeply. (4) Ischaemia.
(5) Leprosy (32.2)
If you suspect a foreign body, incise the abscess, search Severe infection in these cases is best treated by
for it and clean out the cavity thoroughly. Leave the below-knee (35.6), through-knee or above-knee
wound open sufficiently for it to heal up from below. amputation (35.5) as piece-meal debridement usually fails
to control the sepsis and just prolongs the agony.
If infection is spreading on to the foot and up the leg,
explore and drain the lesion, and treat with an antibiotic POSTOPERATIVELY, stop weight bearing.
suitable for the staphylococci in your area. As in the hand, If there is a severe infection, apply a plaster gutter splint
rapidly spreading infections are likely to be due to to hold the foot in neutral position. This will reduce pain
haemolytic streptococci. and ensure that the foot is in the best position if it does
becomes stiff.
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N.B. A ruptured diaphragm or hiatus hernia with If radiographs show disappearance of the empyema and
stomach or colon in the chest may look like a re-expansion of the lung, cut the suture securing the tube,
pyopneumothorax on a radiograph if there is no air and pull it out quickly while closing the hole with a purse-
visible! string suture. Remember to follow up for diagnosis of TB.
If there is no improvement, proceed to open drainage.
ULTRASOUND is very useful and will indicate if there
are septations in the pleural fluid.
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When drainage stops or becomes <5ml/day, remove the Further dependent drainage is all that is probably needed
tube. The residual sinus will heal, provided that there is no for (1), (2) or (3).
bronchopleural fistula. This can take 2 to 3months. Instil 5-10ml of contrast medium, repeat the radiograph,
and if necessary resect another rib.
CHILD WITH AN EMPYEMA. You cannot drain a small
child's pleural cavity adequately by inserting an
intercostal drain between two ribs, because the drain will
be nipped by the ribs or obstructed by pus. So remove 9.2 Pus in the pericardium
1-2cm of rib, using ketamine (LA is inadequate in
children), to make a hole which is big enough for a tube. Fluid sometimes accumulates in the pericardium.
Adequate drainage will eventually achieve a cure if: In sufficient quantity this may embarrass the action of the
(1) the lung is not immobilized with thick fibrin, heart (cardiac tamponade) and may be fatal, so you should
(2) there is no bronchopleural fistula, and remove it urgently! The fluid may be blood after a cardiac
(3) the empyema is localized. injury or an effusion from many causes, either infected or
Start drainage with an underwater seal drainage bottle. sterile. Presentation with symptoms that immediately
This will limit activity, and may cause the drain to be suggest a pericardial effusion is unlikely. Another initial
pulled out; but the lung will expand. diagnosis is likely before you observe some of the
When you are confident that the lung has stuck to the ribs following signs:
(see above), cut the tube short, fit it with a pin and (1) grossly distended neck veins,
butterfly strapping, put a colostomy bag over it to collect (2);pulsus paradoxus (>10mm Hg fall in arterial pulse
the pus and allow exercise. Increased activity is the best pressure on inspiration),
physiotherapy. (3) a large cardiac shadow on a chest radiograph.
DIFFICULTIES WITH AN EMPYEMA Elsewhere in the body, you drain pus to treat an infection.
In the pericardium, you are mainly draining it to overcome
If air comes out with the pus, there is a its mechanical effects.
BRONCHOPLEURAL FISTULA which is unlikely to Severe illness with fever and breathlessness is
close spontaneously. You can confirm this if, accompanied by signs of a low cardiac output with a poor
on coughing, pleural irrigating fluid comes up. peripheral circulation; there is a small pulse volume,
Make sure tuberculosis is treated, if present. Once there is tachycardia, a low normal or subnormal blood pressure,
no more pus draining, fill the drainage bottle with 500ml and soft heart sounds. Early on you may hear a pericardial
sterile water and empty this into the pleural space to clean rub, but the accumulation of fluid soon separates the
it. Drain this and repeat the process till the fluid comes out pericardial surfaces and stops the rub. There are the signs
clear. and symptoms of heart failure (enlarged liver, dependent
Then perform a PLEURODESIS mix 2-5g talcum powder oedema or ascites), and an increased area of cardiac
(or tetracycline, if there is an allergy to talc) with 50ml dullness. The severity of the signs of cardiac tamponade is
saline to make an opaque milky fluid which can still flow, related more to the rate at which fluid accumulates in the
and introduce this into the pleural space through the chest pericardium than to the volume of fluid in it. The diagnosis
drain using a bladder syringe. If the patient feels a pleuritic may be obvious, or if fluid has accumulated slowly, it may
pain when you do this, the inflammatory reaction may well be difficult.
seal the fistula. If this procedure fails, you can repeat it
one or two times more. Otherwise a decortication may be There are problems:
needed. (1);Any cause of cardiac failure may have distended the
neck veins.
If the intercostal vessels bleed, encircle them with a (2);Although pulsus paradoxus strongly suggests a
needle and thread. Avoid tying the nerve because this is pericardial effusion, not all patients show it.
painful. If you have difficulty, transfix the vessels with a (3);The radiographic finding of a large globular heart can
ligature, so that they are compressed against the stump of also be due to gross cardiac enlargement without there
the rib which remains. being any fluid in the pericardium.
Ultrasound is much more reliable, and can also give you
If the empyema fails to heal: information about the thickness of the pericardium and the
(1) You may have put the drainage tube too high or too far thickness of the fluid in the sac. It can also guide you
forward. during aspiration.
(2) You may have removed it too early. The great danger in putting a needle into the pericardial
(3) You may have put it in too late. cavity to drain it is that:
(4);There may be a foreign body, such as a piece of (1);You can easily penetrate the right ventricle,
drainage tube, in the chest. cause bleeding, increase the fluid in the pericardial cavity,
(5);There maybe a fistula between the bronchi and the and produce an acute fatal tamponade.
pleura. (2);You may cause ventricular fibrillation with the tip of
(6);There may be tuberculosis, carcinoma, actinomycosis, the needle. Even so, in spite of these dangers,
or a ruptured liver abscess (15.10), which may be amoebic. not aspirating the pericardium may be more deleterious
than aspirating it, when there is tamponade.
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N.B. The fluid from the pericardium may be heavily DIFFERENTIAL DIAGNOSIS OF PERICARDIAL EFFUSION
blood-stained and come out in a pulsatile manner, giving leading to tamponade is in probable order of frequency:
you the false impression you have entered the heart!
However with HIV, a pericardial effusion is so likely to be Suggesting tuberculosis: a history of cough, bloody
due to TB, that you should start treatment without sputum, weight loss and chronic malaise, known HIV
aspiration, particularly if ultrasound confirms a thickened infection.
pericardium.
Suggesting malignancy: blood-stained fluid aspirated:
RADIOGRAPHS. A very large globular heart, often with e.g. Kaposi sarcoma.
venous congestion. Depending on what is causing the
pericarditis, you may see basal shadows in the lungs, Suggesting viral myocarditis: an influenza-like illness
or pneumonia obscuring the heart. with generalized muscle pains. Early, you may hear a
pericardial friction rub. Fluid may be blood-stained.
ULTRASOUND. You can easily recognize fluid around
the heart. A thickened pericardium suggests a chronic Suggesting a pyogenic bacterial cause: some other site
process like TB, but not every case of pericardial effusion of infection, such as pneumonia, meningitis, or measles
is tuberculous! with secondary staphylococcal infection. Often, there is
some obvious site of infection, but not always
ECG. Tachycardia, usually sinus rhythm, a raised S-T
segment (non-specific), an inverted T wave (late, Other causes of pericardial effusion that might cause
non-specific), low voltage QRS complexes (highly tamponade include: uraemia, malignant deposits (only if
suggestive). they bleed seriously), collagen diseases, and the rupture of
an amoebic abscess into the pericardium (rare).
These are some causes of a large heart without fluid in the
pericardial cavity:
PREPARATION.
Prepare as you would a theatre case using GA. Find two
assistants, one to watch the ECG, or the pulse, and ready
to resuscitate if necessary, and another to fetch anything
more that might be needed for resuscitation. Have the full
resuscitation equipment available: laryngoscope, tracheal
tubes, a sucker, oxygen, and an anaesthetic machine or an
Ambu bag. Perform an ECG while you are aspirating,
or failing this ask someone to feel the pulse continuously.
Place the patient sitting comfortably at 45o; be sure to have
IV access.
EQUIPMENT. An 16G (or 12G for thick pus) long cannula, a 3-way tap,
and a 20 or 50ml syringe.
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If you can, aspirate under ultrasound guidance. 9.3 Pus in the lung
Advance the needle slowly 1-2cm, aspirating frequently
until fluid is withdrawn into the syringe. If the needle Pus can collect in the substance of the lung as a result of:
touches the heart, a sudden ST elevation will appear on the (1).aspiration of vomit, especially after getting drunk or
ECG monitor, and you will feel it knock against the during anaesthesia,
needle. Withdraw it a little and remove the needle, leaving (2).aspiration of pus, e.g. from a retropharyngeal abscess,
the plastic cannula to drain the fluid. Repeat the (3).inhalation of a foreign body, especially organic,
ultrasound, if possible, to check if you have succeeded in such as a peanut,
draining all the fluid, or if it has re-accumulated. (4).lateral spread from pneumonia, especially from
Staphylococcus aureus or Klebsiella pneumoniae if
CAUTION! If there is a sudden deterioration with multiple or Streptococcus pneumoniae if solitary in a
absence of a pulse: lower lobe,
(1) Immediately remove the cannula. (5) lung contusion,
(2) Clear the airway and ventilate with the Ambu bag. (6) bronchial obstruction by carcinoma,
(3).Start external cardiac massage at a rate of 30 beats to (7) an infected pulmonary embolus
1 ventilation. (8) haematogenous spread especially in HIV.
(4).Administer 1mg adrenaline IV (and flush it through
with saline) if there is no trace on ECG, or 50-100mg Presentation is with coughing up copious amounts of foul
(2·5-5ml 2%) lidocaine IV if there is ventricular sputum; there may be finger clubbing, and radiographs
tachycardia (VT) or ventricular fibrillation (VF), or 0·3mg show a cavity with a fluid level. This may look like a
atropine IV if there is bradycardia. Continue cardiac tuberculous cavity if small, and a pyopneumothorax if
massage. (A defibrillator is useful, if available, for VT & large.
VF) Pus, like everywhere else, must be removed, but not
usually by incision. Postural drainage at physiotherapy is
If a normal heart trace does not return, administer the most important treatment (11-24); use antibiotics to
further doses of drugs as required, and add 50ml 8·4% prevent spread of infection into the rest of the lungs.
sodium bicarbonate. Only when the situation is under Drainage, however, may not be successful if the bronchus
control, should you intubate and ventilate the patient is blocked by a foreign body or carcinoma: it may be
mechanically. possible by bronchoscopy (29.14) to remove the former
and biopsy the latter.
PERICARDIAL DRAINAGE (PERICARDIAL WINDOW) If there is a large lung cavity, especially peripherally
(GRADE 2.5). placed, you can drain it through a rib resection (9-3) using
If you aspirate pus, and it recurs, proceed to open drainage. a chest tube.
Make a 4-5cm incision on the left side of the N.B. However, some lung abscesses, especially in
xiphisternum; incise the linea alba and proceed upwards in children, need to be removed by pulmonary lobectomy.
the extraperitoneal plane until you reach the pericardium.
Put two stay sutures through the pericardium and lift this
off the heart; then cautiously incise the pericardium,
enlarge the hole and insert a Ch16 balloon catheter for thin
pus and a Ch22 one for thick pus. Flush this with saline.
Leave this draining for 2-6wks into a bag: no underwater
seal is needed. If you leave the drain in long, it may erode
the friable myocardium with disastrous results!
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The common mistakes are: Colicky pain may come before the pain of peritonitis,
(1).Not to ask the right questions properly and but is not the pain of inflammation.
methodically.
(2).Not to examine the patient carefully and Pain may also be referred from the diseased area to the
systematically, admit him and monitor him carefully and other parts of the body that are derived from the same
to look at him again if you are not clear of the diagnosis, spinal segment. For example, pain from the gall-bladder
or to see if the condition has worsened. may be referred to below the right scapula; pus or blood
(3).Not to make and record a diagnosis and a differential under the diaphragm may present with pain in the
diagnosis, especially if you are handing over to a shoulder.
colleague.
(4).To forget that many medical conditions, especially There can be pain of more than one kind. For example,
pneumonia (by causing diaphragmatic pain) can mimic an when the lumen of the appendix is obstructed, there is
acute abdomen. central abdominal pain of type (3), but as soon as the
(5) Not to consider other non-surgical conditions. peritoneum over it becomes inflamed, there is pain of type
(6) To forget that age and sex can profoundly influence the (1) in the right iliac fossa. If the appendix becomes
probability of a particular diagnosis gangrenous, there is ischaemic pain of type (2).
(7).Not to make adequate allowance for the late case
whose history is obscured, whose mind is clouded, and
whose signs are altered.
(8).To forget the 'silent interval' between the immediate
chemical peritonitis and the delayed onset of bacterial
peritonitis (13.3).
(9).To forget that signs you expect may be obscured in
advanced peritonitis, septic shock, diabetes, HIV disease,
aged patients and with steroid therapy.
(10) Finally, worst of all, not to go and see a patient with a
suspected abdominal emergency immediately.
Base your diagnosis on as many items of information as
possible. The explanations given for a particular sign or
symptom are suggestions only.
HISTORY
Except in the very young, the very old, the demented,
confused, psychotic and unconscious, PAIN is the cardinal
symptom. Constitutional disturbances such as anorexia,
nausea and vomiting, the inability to pass flatus in the
presence of either constipation or diarrhoea and frequency
of micturition are common. In general, the patient with
peritonitis is weak, thirsty, anorexic and nauseated.
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“Where is the pain and where did it start?” “What is the association between the pain and the
Epigastrium/Umbilicus Small bowel/Appendix vomiting?”
Hypogastrium Large Bowel Vomiting before the pain Gastroenteritis
All over abdomen Perforated peptic ulcer Vomiting sudden and soon Strangulation or obstruction of
Ruptured ectopic gestation after the pain proximal small bowel
Ruptured pyosalpinx Cholecystitis
Loin & testicle (retroperitoneal Ureteric colic
not causing peritonitis) Vomiting c.4hrs after the pain Distal small bowel obstruction
Back Ruptured aortic aneurysm Appendicitis
Pancreatitis Peptic ulcer
Tip of the shoulder Subphrenic/liver abscess, Pain but no vomiting Salpingitis,
Diaphragmatic pleurisy, Tubo-ovarian abscess
Ruptured spleen Haemoperitoneum.
Gastric volvulus
“What is it like?” Oesophageal perforation
Throbbing/Constant/Burning Inflammatory (the cause is outside the bowel)
(e.g. appendicitis, Large bowel obstruction
salpingitis)
Burning/Boring (e.g. peptic ulcer, PREVIOUS HISTORY.
pancreatitis) “Have you ever had pain like this before?”
Intermittent with spasms Colic Like the present but less severe: Intussusception
If it is colicky, how long do the spasms last, and is there Obstruction
complete relief between them? Appendicitis
Torsion
“Has it moved?” When hungry relieved by food: Duodenal ulcer
Started in the umbilical region & Appendicitis Epigastric irregularly related to Cholecystitis
moved to the right iliac fossa: meals
From the loin to the groin/testis on Ureteric colic Related to NSAID or steroid use Gastritis,
the same side: Peptic ulcer
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Do not forget to ask about possible trauma. Vigorous The temperature is raised; if it is not, the inflammation is
massage of the abdomen may cause bowel injury! early or there is pure intestinal obstruction. Severe fever
from the onset may occur in typhoid, basal pneumonia,
GENERAL EXAMINATION FOR PERITONITIS or pyelonephritis.
Abdominal tenderness, rebound tenderness and distension
are the cardinal signs. There may be shortness of breath THE ABDOMEN. Ask the patient to point to where the
(which you may note simply by a difficulty in speaking), pain started, to where it is now, and to where it is worst.
tachypnoea and cyanosis. Look at the abdomen. Is its contour normal?
Tachycardia is common as is sweating whereby the Look for distension due to gas, or fluid: test for shifting
extremities may be warm or cold. Fever is not always dullness. Initially in peritonitis the abdomen is tympanitic,
present and infants as well as the aged may have later it will fill with ascitic fluid.
hypothermia. There may be jaundice. Abdominal sepsis, Does the abdomen move freely on breathing? Ask the
almost invariably, if untreated, leads to septic shock. patient to inhale and exhale fully and cough: inability to do
this properly indicates peritoneal irritation. Peritonitis
The general condition may be surprisingly normal anywhere may splint all or part of the abdomen, and stops
especially early on in the disease. Later on prostration and the normal movement that accompanies breathing.
apprehension supervene. Look at the state of nutrition. Reduced movement in the lower abdomen suggests PID,
If the patient is limp, lethargic, and slow to respond, or appendicitis.
suspect toxaemia, septicaemia, or shock. If he is restless, Visible peristalsis means there is obstruction not paralytic
suspect cerebral hypoxia, due to hypovolaemia. ileus, and so no peritonitis.
Look for a dry tongue and lack of skin turgor Expose the whole abdomen including genitalia & look at
(dehydration), pale conjunctivae (anaemia), mouth signs of the groins: there may be an obstructed irreducible hernia.
HIV disease (5.6), and a sickly sweet breath smell Are there any old operation scars?
(ketones). Look at the unpigmented skin for blotchy N.B. Do not miss the Pfannenstiel scar in an obese
purplish discolouration (shock). woman or the subumbilical laparoscopy scar!)
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Avoid the painful area, and start abdominal palpation as The iliopsoas test is only indicated if the patient is not
far from it as you can. (Don't worry if the patient tells you very ill, and does not have generalized peritonitis.
it is the wrong place!). Move towards it slowly. Get him to lie on the opposite side to where the pain is,
Find where the area of greatest tenderness is. It will be and extend the thigh on the affected side to its fullest
easier to find if there is no generalized guarding, and is a extent. If this is painful, there is some inflammatory lesion
useful clue to the organ involved, e.g. the right iliac fossa near the psoas muscle (appendix abscess, iliac abscess,
(appendicitis), or the right hypochondrium (cholecystitis, pyomyositis of the iliopsoas). This test is not useful if the
liver abscess). anterior abdominal wall is rigid.
N.B. A doughy feel suggests chronic tuberculous The obturator test. If rotating the flexed thigh so as to
peritonitis, especially if ascites is present. stretch this muscle causes pain, there is pus or perhaps a
CAUTION! A patient may show very little rigidity if: haematocoele (in a woman) in contact with the surface of
(1) He is HIV+ve and has a neuropathy, or is very old. (2) the obturator internus.
The peritonitis is advanced and ascitic fluid dilutes the The thoracic percussion test. Percuss gently with your fist
peritoneal irritation: so as he gets more ill, the tenderness over the lower chest wall. On the right a sharp pain
diminishes! indicates an inflammation around the diaphragm or liver
(3) He is anyway very toxaemic and ill. (often present in acute hepatitis); on the left inflammation
(4);She is a woman who is pregnant, or whose abdominal around the diaphragm, spleen, or stomach.
muscles are stretched after delivery. Percuss for liver dullness in the right nipple line from the
(5);He has been given narcotic analgesia, especially 5th rib to below the costal margin. If liver dullness is
postoperatively, or is paraplegic with a sensory level at the absent, there is probably free gas in the abdominal cavity.
10th thoracic vertebra (T10) or above.
(6) He is taking steroid medication.
(7) He is diabetic.
(8) The perforation occurred about 6hrs before, so that the
immediate rigidity has had time to go, and secondary
bacterial peritonitis has not yet had time to develop.
(9) He is very fat and flabby, and the muscles are thin and
weak.
(10) Pathology is confined to the pelvis, retroperitoneum,
or high under the diaphragm.
N.B The cause of peritonitis does not relate to the
intensity of the pain.
Can you feel any masses? In the right iliac fossa this may
be a tuberculoma, an appendix mass, amoebiasis, a mass
of ascaris worms, a lymphoma; in the right
hypochondrium it may be an empyema of the gallbladder,
or a liver abscess; in the loin a pyonephrosis; in the pelvis
a full bladder, adnexal mass or enlarged uterus.
Faeces in the bowel is compressible, but may appear as a
fairly solid mass. A tender mass adjacent to the midline
(haematoma from rupture of the epigastric artery) will not
disappear when the patient tenses the abdominal wall
(Fothergill’s sign).
N.B. In very severe pain, a moderate dose of opioid may:
(1) reduce the pain,
(2);make for more comfort and improve getting a good
history, and
(3);prevent immediate guarding of the abdomen whenever
you touch it, so that the physical signs become more
localized and the cause clearer.
Fig. 10-2 THREE SIGNS.
A, iliopsoas test. Ask the patient to flex the hip against the resistance
Listen to the abdomen for decreased or absent bowel of your hand. If he feels pain, there is inflammation in relation to the
sounds: you may need to wait for 3mins! High-pitched psoas muscle. B, obturator test. Flex the hip to 90º and gently rotate it
tinkling bowel sounds, coinciding with worsening of internally and externally. If this causes pain, there is inflammation in
abdominal pain, are a sign of obstruction not peritonitis. relation to the obturator muscle. C, fist percussion test. Percuss gently
with your fist over the chest wall. On the right a sharp pain indicates
‘Diminished’ bowel sounds means nothing specific! an inflammatory lesion of the diaphragm or liver; on the left one of
the diaphragm, spleen, or stomach. Kindly contributed by Jack Lange.
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Do not forget the HERNIAL ORIFICES. Feel both Occasionally you can remove all the pus in an abscess by
femoral and inguinal openings, the umbilicus, and any old means of aspiration; this is more reliable, however,
incisions. if you can position the tube for drainage and irrigation
CAUTION! under ultrasound control.
(1) An obstructed hernia is usually tense, tender, or painful You can also diagnose free fluid, recognize para-aortic
but does not have to be so. lymphadenopathy, ectopic gestation, abdominal masses,
(2) It may be small, especially if it is a femoral hernia, and note any inflamed thickened structures, as well as an
<2cm diameter. aneurysm. However, beware of trying to diagnose
(3) The patient may be quite unaware of it. appendicitis exclusively by ultrasound! Note, also, that an
(4) Femoral hernias are very easy to miss in fat patients. ultrasound will not easily show if an aneurysm has
(5);Don't overlook a small umbilical hernia lying deep in ruptured.
fat, or think a lump is not a hernia because the symptoms
are not very acute. RADIOGRAPHS must be good, because you are
(6);Ask if the hernia has not been pushed back in recently: interested in the disposition and pattern of gas.
there may be obstruction from 'reduction en masse', Be selective, and look at the films yourself. There is no
i.e. without relief of strangulation. point in ordering radiographs (except of the chest) if you
(7);In a baby, it is not the bulging inguinal hernia which have already made a diagnosis of peritonitis and have
will strangulate, but the small slim one containing only a decided to operate. An erect chest film is best to see gas
thin loop of the tiny bowel. It may only feel like slightly under the left hemi-diaphragm (and also to look at the
thickened cord and testicle, with reddening and oedema of condition of the lungs). It may also show a pleural effusion
the scrotal skin. (18.5) or empyema.
If the patient is too sick to sit up, you may see free gas
THE PELVIS is just as important as the abdomen. under the abdominal wall in a lateral decubitus film of the
You will find a vaginal examination often more useful abdomen.
than a rectal examination (except in a child). Do both.
Never forget to examine the rectum. Lay the patient in the Signs on abdominal films (erect & supine) are subtle:
lateral position. Pass a well-lubricated finger as far up the (1);Air in the small bowel: this is always abnormal except
anal canal as it will go. Feel for tenderness in all in a child <2yrs. You may see gas both inside and outside
directions. Feel forwards, in a man for an enlarged the bowel wall, though, (Rigler’s sign, which is a sign of
prostate, a distended bladder, or enlarged seminal vesicles; bowel perforation), and air on the lateral border of the
and in a woman for swellings in the pouch of Douglas or liver, outlining its edge clearly.
displacements of the uterus. Feel upwards for a stricture, (2);Displacement of the colon: a ruptured spleen may
the apex of an intussusception, or the bulging of an abscess displace the shadow of the splenic flexure downwards and
against the rectal wall. Feel laterally for the tenderness of medially.
an inflamed swollen appendix. Feel bimanually for a (3);Obliteration of the psoas shadow: this can be caused by
pelvic tumour or swelling, or for any fullness in the pouch pyomyositis of the psoas, a psoas abscess from a
of Douglas. Look if there is blood or mucus on your glove tuberculous spine, a retroperitoneal abscess or by bleeding
afterwards. from an injured kidney.
(4);Multiple small bowel fluid levels, identical in
OTHER SYSTEMS. radiographic appearance to small bowel obstruction:
Don't forget to listen to the chest; there might be a basal occurs in long-standing paralytic ileus.
pneumonia, pleural effusion or empyema. Examine the (5);Urinary calculi: look for these along the lines joining
spine (spinal tuberculosis or a tumour can cause root pain the tips of the transverse processes of the vertebrae to the
felt in the abdomen). Feel for a stiff neck (meningitis can sacroiliac joints.
cause vomiting and abdominal pain). Look at the testes to (6);A faecolith in the area of the appendix, when there are
exclude torsion. good symptoms and signs of appendicitis, confirms the
diagnosis.
SPECIAL TESTS. (7);Gas in the portal vein (you see the outline of the veins
Get a full blood count: N.B. in untreated HIV+ve patients, peripherally in the liver: from mesenteric ischaemia,
the white count may not be raised even in severe portal pyaemia, or severe colitis (this is a real danger
peritonitis. Check the blood or urine for sugar, red cells sign).
and white cells. Check urea & electrolytes if there is (8);Gas within the wall of the bowel or the gallbladder
dehydration or the urine output is poor, if you can, and the (this implies necrosis or ischaemia.)
amylase if you suspect pancreatitis. If there is septicaemia, CAUTION! There may still be a perforation without gas
do blood cultures and check the clotting time. If the under the diaphragm (especially early on), and in closed
albumin is very low, this is a bad sign. bowel obstruction with strangulation, there may be no
fluid levels.
ULTRASOUND (38.2K) is possible at the bedside, and is
the investigation of choice: it will show fluid accumulation LAPAROSCOPY. If you cannot make a diagnosis,
and tissue necrosis, and usually allows immediate think of using a laparoscope (19.5) to help.
aspiration of pus, proving the diagnosis and providing a
specimen for bacteriological examination.
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Do not rely on the findings unless you are very As is usual in medicine, a patient is more likely to have a
experienced with this technique. You may easily miss some rare presentation of a common disease, than a common
relevant pathology. On the other hand, you may, having presentation of a rare one. Be familiar with the pattern in
initiated an operation under GA, be persuaded your own area. “Common things are common, and most
unnecessarily to remove a normal appendix. people get what most people get.” If you think there is
peritonitis, but are not sure, the list below may help you.
A. GENERALIZED PERITONITIS Don't be frightened by its length.
Concentrate on the pattern of symptoms and signs.
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Angio-oedema is an allergic reaction (usually with INDICATIONS FOR OPERATION, after adequate
prodromal minor episodes of swelling of lips, ears or resuscitation, are:
throat) which can cause intestinal oedema. If associated (1);Diagnosis of peritonitis.
with urticaria and itching, you can use adrenaline and (2);Diagnosis uncertain, and condition deteriorating after
salbutamol to reduce the oedema. Beware! Surgery may 4hrs of active management.
precipitate an even worse reaction resulting in death by (3);Diagnosis uncertain after a routine laparotomy, but
asphyxia. signs suggestive of peritonitis or condition deteriorating.
Snake bites, particularly krait in India, may not cause
local pain, but give rise to severe cramps before producing INDICATIONS FOR DRAINAGE:
neurotoxic effects. (1) Localized collections of pus identified by ultrasound.
(2) Pelvic abscess (10.3)
DIFFICULTIES DIAGNOSING PERITONITIS.
If you are in any doubt about the diagnosis when you SPECIAL INDICATIONS for NON-OPERATIVE
first see a patient, admit him. Then come back repeatedly TREATMENT:
to re-examine him, feel the abdomen and monitor him (1) Acute pancreatitis (15.13).
carefully, if necessary every hour. He will be easier to (2) Acute cholecystitis (15.2).
assess in the ward than in the outpatient or casualty (3) Abdominal mass with resolving peritoneal irritation.
department. You are also likely to get a more reliable (4) A typhoid perforation of slow onset showing no signs
reading of the pulse and temperature. This is especially of deterioration (14.3)
important if you suspect strangulated bowel, appendicitis, (5) Necrotizing enterocolitis (14.4)
or a peptic ulcer. The diagnostic use of a single opioid (6) Medical conditions giving rise to abdominal pain
dose may be helpful: if he feels much better after one dose
of opioid and no longer has any signs of peritoneal N.B. Note that in these medical causes of an acute
irritation, it is very unlikely that anything serious is going abdomen, there is rarely abdominal guarding present.
on. This is very useful if you think he might be hysterical.
There is a small chance it is the Münchhausen syndrome RESUSCITATION. The need for this varies:
(exhibited by a clever group of patients, including medical If the pulse is rapid, there is postural hypotension and
personnel, who persistently fake their symptoms). especially if the blood pressure is low, delay operation
Decide if he needs an operation, and if so, when? for a few hours (preferably ≤4hrs) for proper resuscitation.
However if he is no better, or in fact worse, peritonitis is Use Ringer's lactate or 0·9% Saline IV (provide an adult
likely. If he deteriorates, operate. Do not leave a patient 1lper day of illness). Be sure to correct potassium
like this if you hand over to a colleague without giving a deficiency. If possible, measure the CVP and keep it at
very clear picture of his condition. This is where recording 6-8cm of water. Pass a nasogastric tube and do not allow
of your findings is most important. Often, when you have oral intake. Monitor the urine output hourly and keep a
made the diagnosis, all you will know before you operate fluid balance chart. Catheterise the bladder.
is that there isperitonitis, without knowing why. Start gentamicin or chloramphenicol or a cephalosporin
Try to establish how advanced it is from the history and and metronidazole. (Note gentamicin may prolong activity
the signs. A laparotomy is usually mandatory and even if of relaxants, and is a hazard in renal impairment).
you are in doubt, most patients who are young will Improve hypoxia by administering oxygen by a mask.
not suffer untowardly from a negative laparotomy, Operate as soon as the pulse rate falls, the blood pressure
but they will die from neglected abdominal sepsis. rises, and the peripheral circulation improves.
Resuscitation should not take >6hrs.
BETTER A SCAR ON THE ABDOMEN THAN A If the CVP remains low, continue rapid intravenous
SCAR ON YOUR CONSCIENCE fluid infusion! If signs of peripheral circulatory failure do
not respond to generous resuscitation, death may occur
As you will see below, there are some special indications despite all your efforts. Dopamine and noradrenaline
for non-operative treatment. However, if you are uncertain infusions need ICU care.
about these in a particular case, it is wiser to operate than If there is confusion, severe hypotension, and
not to do so. It is more important to decide when to hyperventilation, with a fast pulse, and warm pink
operate and when not to operate, than the exact diagnosis. extremities, or cold clammy ones, this is septic shock.
''If in doubt, it is better to look and see than to wait and
see''. The patient may be so sick that you should do the
But, do not operate if the only symptom is pain, and there minimum just to save his life while you proceed with
are no abnormal signs, radiographs and lab results resuscitation and antibiotics. This is the so-called ‘damage
whatsoever. control laparotomy’. If you can, drain the septic focus.
N.B. Don’t delay operation on a pregnant woman with Timing is important: he must be fit enough to withstand
peritonitis because you fear for premature delivery. the operation, so overcome shock, and then do the simplest
The need to act quickly is even more vital: if you delay, possible operation. This may be just inserting drains into
the toxaemia may well kill the baby, or even the mother! the flanks under LA, to allow pus to drain and give you the
opportunity to wash out the abdomen. The condition may
then improve sufficiently to perform a laparotomy much
more safely later.
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PREPARATION. This is very important: check everything SMELL can tell you a lot. If a puff of gas greets you as
is ready (11.1-2) you open the peritoneum, the bowel has probably
perforated. However, in advanced sepsis, especially from
PHILOSOPHY. The primary objective of the operation is the pelvis, this may be due to gas-forming organisms.
to remove all dead tissue (necrosis, pus, clots, fibrin, If there is an abnormal smell, it may be:
faeces etc), to clean the abdominal cavity and to prevent (1) acrid (perforated peptic or typhoid ulcer),
leakage and further accumulation of noxious materials. (2) faeculent (ruptured large bowel),
Repair of intra-abdominal anatomy and of the abdominal (3) characteristic of anaerobes (suppurative appendicitis),
wall are desirable but not the primary objectives of the (4) putrid (gynaecological sepsis), or
emergency operation. (5) urine (from an intraperitoneal rupture of the bladder).
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LOOK FOR FLUID in the abdominal cavity, which may Pack away the rest of the abdomen with swabs, so if you
be: do spill content, you contaminate the peritoneal cavity as
purulent fluid of various thickness little as possible. Always lift up bowel from behind with
(appendicitis, salpingitis, perforated peptic ulcer, your fingers, never pull it! If a loop is hopelessly stuck in
primary peritonitis, mesenteric adenitis, including the pelvis where you can’t see it properly, you may be able
tuberculous, diverticulitis) to pinch it off, and whilst still holding the bowel wall tight
foul, turbid brown fluid in your fingers, deliver it out of the abdomen.
(peritonitis from appendicitis or sigmoid volvulus, This way, although you will certainly have to repair the
ruptured ovarian cyst, ruptured liver abscess) perforation (11-5) or resect that piece, you will have
blood avoided spilling bowel contents in an uncontrolled
(ectopic gestation, injured liver, spleen, or mesentery, manner. Occasionally you will be able to lift a whole
ruptured ovarian lutein cyst) clump of bowel out of the abdomen, and be able to work
pale straw-coloured fluid on it outside, whilst packing away the rest of the incision.
(intestinal obstruction without strangulation,
mesenteric adenitis, tuberculous ascites, cirrhosis) If thickened oedematous omentum is adherent to
blood-stained something, it points to the site of acute inflammation,
(ischaemic bowel, torsion of ovarian cyst, strangulation (12.2), or abscess formation (14.1,2).
streptococcal peritonitis, acute pancreatitis) Take care you don’t damage a viscus by pulling off the
bile-tinged omentum: this may actually be sealing off a perforation.
(perforated stomach, duodenum or small bowel) Think carefully if it is best left alone; if necessary cut
frank bile away the omentum with the damaged viscus.
(ruptured gallbladder, injured liver)
watery, reddish-brown, offensive fluid MINIMIZE THE RISK OF SEPSIS.
(strangulation with incipient gangrene) (1) If you have to open a hollow organ, or a septic
clear colourless fluid collection, pack the abdominal cavity round it with moist
(ruptured hydatid cyst) swabs. If it is walled off from the rest of the abdominal
porridge-like material cavity and this is unaffected by sepsis, just drain it and
(ruptured dermoid cyst) leave the remaining abdomen alone or you will spread
sticky mucous fluid infection into a clean peritoneal area.
(ruptured ovarian cyst) (2) Handle an inflammatory mass carefully: don't let it
urine burst and discharge pus everywhere.
(ruptured bladder, divided ureter) (3) If an area does become contaminated, wash it out.
(4) Insert drains only when indicated (4.9).
If there is any exudate, send it for culture, if you can.
If the peritoneum is fiery red with flakes of fibrinous DECOMPRESS THE BOWEL (12.4) because this will:
exudate, this is severe peritonitis. If these flakes are clear (1).give you a better view to see what you need to do next,
or nodular, they are probably due to tuberculosis. Firmer (2).reduce the risk of rupturing the bowel if its wall is thin,
nodules are from metastatic carcinoma. Fatty flakes, which (3).help you close the abdomen at the end of the operation,
may look very much like tuberculosis, are from severe and reduce the risk of the abdominal compartment
pancreatitis. syndrome (11.10),
(4).greatly reduce the risk of postoperative vomiting and
BREAK DOWN ADHESIONS with the greatest possible aspiration,
care. Break down light ones with your fingers. If they are (5).reduce the risk of any bowel leaking by reducing the
dense, define them carefully, and cut them with scissors. volume of fluid passing any anastomosis you make.
If you are rough, you may drastically worsen the N.B. Generalized peritonitis, particularly of some days’
peritonitis by adding more organisms to the bacterial soup duration, will always have distended loops of bowel
already present and you increase the chances of a faecal present.
fistula, which may be a disaster.
If you do make a hole in the bowel, isolate and cover it If the bowel is already open, suck its contents out
with a swab, clamp the bowel either side of the hole with through the perforation using either a Poole’s or Savage
non-crushing bowel clamps, and carry on. Do not waste sucker; or else, mobilize the bowel out of the abdominal
time at this stage by repairing the perforation: do this after cavity, and drain the contents into a bowl holding the open
you have freed all the bowel. bowel end with Babcock’s forceps. This is messy, but as
You may need to sacrifice an impossibly matted segment long as you take care to avoid spillage of contents into the
of bowel (11.3): this is better than causing a lot of bleeding abdominal cavity, it is extremely worthwhile.
trying to fee it and using up a great deal of time with a sick
patient on the operating table. When faced with bowel that If the bowel is not open, you can decompress its content
is very stuck, approach it from a normal segment on both either by (a) massaging contents proximally towards the
sides, and try to massage bowel content out of the affected stomach and suctioning via a wide-bore nasogastric tube,
segment and hold it empty between non-crushing bowel or (b) clamping an appropriate segment of bowel, making
clamps. If then you do perforate it, you won’t spill its a small hole on the anti-mesenteric border of the bowel,
contents. and decompressing it through that, as above.
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Do (a) if the bowel distension is relatively slight, you have If the patient is still in shock, is hypothermic, acidotic
good suction and an experienced anaesthetist who knows or has signs of coagulopathy, terminate the operation in
how to suction the mouth if there is spillage there. the most expeditious way. This may entail the sealing of
Do (b) if there is serious bowel distension with thick all holes or intestinal ends by using, for instance, umbilical
bowel content, your suction machine is unreliable, tapes and leaving the abdomen open. Physiology takes
the anaesthetist is inexperienced, or the patient is a child precedence over anatomy. The best place to correct
with an uncuffed endotracheal tube. You may hesitate to physiology is the ICU. Try to finish emergency surgery
open bowel if it is not already opened. Do so, if otherwise within 45mins.
closure of the abdomen would in any way be difficult: N.B. Do not remove the appendix ‘prophylactically’.
the advantages far outweigh the disadvantages!
LAVAGE.
EXAMINE THE ABDOMINAL CAVITY If there is generalized peritonitis, lavage the abdominal
If peritonitis is widespread, search systematically until cavity.
you can find its cause. You should know where this might If the peritonitis is localized, pack off the affected area
be from: and then lavage or mop out the infected space. Sometimes,
(1) The history. you can safely wash out only the pelvis.
(2) The nature of the exudate. Tip in several litres of warm (c.30ºC) fluid, slosh it around
(3) The place where pus and exudate are most intense. with your hand, and suck it out until the fluid which
(4);The density of the adhesions; the densest ones may returns is clear. You may need 8-10l. Usually 3-4l are
indicate the origin of the infection. enough. Wash out the upper abdomen, the sub-
CAUTION! diaphragmatic and sub-hepatic spaces, the paracolic
(1) Suck out all free pus before you start. gutters, the infracolic area, between all the loops of bowel
(2) You must have good exposure. and the pelvis. You do not need to use saline: 10l of warm
(3);If you find localized pus, try to minimize its spread sterile water is preferable to 500ml of saline!
around the peritoneum! If there is much adherent septic fibrin on the bowel,
(4);You face the dilemma described above, when to divide liver, spleen and omentum, only peel away the parts that
adhesions and when not to. come away easily. Otherwise you may damage the viscera
or bowel, simply in a vain attempt to make the abdomen
Inspect the abdominal cavity thoroughly, unless you are look clean!
certain from the onset that sepsis is localized to one area.
Inspection of the entire cavity may be difficult because of DRAINS. You cannot drain generalized peritonitis and
adhesions. All necrotic tissue must be removed; this may multiple intra-abdominal collections, because the area to
entail resection of bowel. be drained is too large and the drains block anyway:
You need: so wash out the pus vigorously. It may, however,
(1) adequate exposure: make the incision big enough, be appropriate to drain a retroperitoneal collection,
(2) a good light focused in the right place: get assistance or e.g.in the pelvis (vaginally in a female, or rectally in a
use a head-light, male) using a Penrose drain (4.9).
(3) good retraction: you can’t operate on your own, Drains have limited use (11.8): if you do use them, insert a
(4).a good view: position the patient in the best way, soft tube drain with several perforations cut in it on low
e.g. Trendelenburg for pelvic sepsis, and pack away the suction, and irrigate it with liquid to keep it open.
bowels (but count the packs and don’t forget them inside Place the drain away from bowel and vessels, protecting
at the end of the operation!) these with omentum; bring it out away from a wound by
the shortest route.
MANAGING THE UNDERLYING CAUSE. If the intra-abdominal tension remains high,
First, you will have to find it, and this may not be easy. do not attempt to close the abdomen!
Let the smell and nature of the fluid guide you. Go first for Leave the abdomen open as a laparostomy (11.10) if:
your preoperative diagnosis. Look for signs of (1);you expect to have to look inside again within 48hrs,
inflammation (pus or adhesions), of perforation, e.g. if you are uncertain about an anastomosis, or the
or tumour. vascularity of bowel, or if you had to leave a pack inside,
If you are faced with something you are not sure how to or if you have limited your intervention because of severe
handle, unscrub and refer to this text, or get an assistant to metabolic disturbance (damage control),
do so: you do not need to pretend you know it all! For this (2) there is gross faecal soiling or sepsis requiring repeated
reason, keep these books in theatre! lavage,
Some places are difficult to see. If the source of sepsis is (3) there are multiple bowel fistulae,
not obvious, look: in the lesser sac, under the liver, behind (4) there is severe haemorrhagic necrotizing pancreatitis,
the duodenum (mobilize it using the Kocher manoeuvre, (5) there is more tissue necrosis which you were unable to
13.5), and behind the colon (especially both flexures) and remove,
rectum. (6) you simply cannot close the abdomen without tension.
Play safe: the patient is desperately sick, and you must not N.B. Your hands may smelly horribly after cleaning out
risk complications. Remember ‘damage control a septic abdomen, even wearing 2 pairs of gloves:
laparotomy’. The decision how to proceed depends on the no amount of soap or perfume will remove the odour,
condition. but washing with coffee will!
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CLOSURE. Confirm all the routine checks are done (1.8). 10..Mobilisation. Mobilise early, even from the 1st day
Then, not before, close the abdomen with continuous postop to prevent thrombo-embolic and respiratory
through-and-through sutures of stout monofilament nylon, complications as well as bed sores.
polydioxanone, poliglecaprone or steel deep to the skin
(11.8). For skin, use subcuticular absorbable or nylon. OTHER MEASURES. Review the charts carefully each
You should not have to pull the abdominal wall together day for complications. Watch the temperature chart, the
with tight tension sutures! Go back and decompress the general state of alertness, the abdominal girth, the bowel
bowel. sounds, the urine output and ask whether the patient
passed flatus or stools. Start feeding early. Look if the
POSTOPERATIVE CARE AFTER LAPAROTOMY FOR wound is soiled or smelly.
PERITONITIS
N.B. The postoperative care is just as important as the POSTOPERATIVE COMPLICATIONS are many, and
operation itself ! may occur after any laparotomy (11.9,15); so be especially
Checklist: aware of:
1..Nasogastric suction. If there is generalized peritonitis, (1) Abdominal sepsis (may lead to septic shock).
ileus is sure to follow; suction will reduce the distension, (2) Wound infection.
although it will not reduce its duration. You may suck out (3) Urinary infection.
2-6lfluid daily. Replace the fluid loss with IV 0·9% saline (4) Pneumonia.
or Ringer's lactate in addition to the standard requirements. (5) Malnourishment
2..Intravenous fluids. For maintenance an adult needs at
least 3-4l in 24hrs: use 1-2l 0·9% saline, or Ringer's If there is NO IMPROVEMENT, there may be residual
lactate, and 2l 5% dextrose in 24hrs. sepsis and you should arrange another (‘Second-look’)
3..Bladder drainage. You need to monitor the urine laparotomy. Intra-abdominal sepsis is an extremely
output (if possible 2hrly for the first 48hrs). Use a Paul’s difficult diagnosis to make, particularly post-operatively,
tubing (condom catheter) in a young male; remember and you will often wish you had made it earlier. Be very
catheterization is invasive and potentially hazardous. gentle because the bowel will be friable and oedematous:
4..Fluid Balance. Keep an accurate fluid balance chart till do not use sharp dissection. Direct your attention to the
the fluid balance is stable (at least for 48hrs, usually source of the problem, rather than randomly extracting
3-6days). The common error is not to infuse enough fluid loops of bowel and dividing adhesions unnecessarily.
and not to chart the fluid input and output properly. If the Re-open a patient with severe generalized peritonitis
initial fluid resuscitation was inadequate, there may still be routinely after 48hrs in order to:
a deficit to make up. Infuse sufficient IV fluids to keep the (1) lavage residual sepsis,
urine output >1ml/kg/hr. (2) detect any missed pathology,
5..Potassium supplements. Don't forget these, especially (3) examine the viability of the bowel,
if there is a large volume of gastric aspirate. Start them (4) check bowel anastomoses for patency,
when the postoperative diuresis begins. (5).check for walled off abscesses in all far and deep
6..Blood. If there was major blood loss during the corners of the abdominal cavity,
operation (>2l), especially if previously anaemic and this (6).prevent abdominal compartment syndrome
loss was not replaced, check the Hb level; if it is <8g/dl, (where intra-abdominal pressure is >20mmHg (11.10)
transfuse 2 units of blood.
7..Acidosis. There are several ways you can correct this: In very severe cases, particularly where fistulae are
(1) Treat with 200ml of 8·4% sodium bicarbonate present, and to decompress the abdominal compartment,
(200mmol), or with 500ml of 4·2% sodium bicarbonate leave the abdomen open as a laparostomy (11.10).
(250mmol). If sepsis persists, a 3rd or even 4thlaparotomy is necessary,
(2) Treat with 1l 1/6molar lactate. but with diminishing chance of success. Remember to
(3) Infuse adequate IV fluids and let the kidneys correct change the antibiotics you are using after the
the acidosis. 2nd re-laparotomy.
If the condition is poor, use (1) or (2), and repeat daily. If there is NO IMPROVEMENT but no sign of fever,
8..Antibiotics. If there was generalized peritonitis, here maybe HIV disease: test for this because you need to
continue the same antibiotics you used preoperatively for know how far you are likely to succeed in this case.
3-5days. Look at the clinical response, rather than by the Make sure you do not fail to treat tuberculosis.
sensitivities reported by the laboratory. If there is no If the ABDOMEN DISTENDS and the volume of the
improvement after 2days consider re-laparotomy rather gastric aspirate remains high (maybe with vomiting),
than changing the antibiotics. either the normal short period of ileus is continuing,
9..Chest exercises. Patients after laparotomy, especially or the bowel is obstructing (12.15).
for peritonitis, tend to have shallow respiration. To prevent If there is pain, a fever and a leucocytosis, suspect
pneumonia, provide adequate amounts of analgesics and leakage of a bowel anastomosis, iatrogenic or spontaneous
encourage deep breathing exercises with physiotherapy. bowel perforation in HIV. This is much more likely than
Serious cases need mechanical ventilation. As soon as you bleeding inside the abdomen. Do not hesitate to re-open
can, get the patient out of bed. the abdomen for a second look.
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If there is a swelling, or oedema, or redness or If the subphrenic collection is recent after laparotomy,
tenderness just below the ribs or in the loin, it may not have walled off, and be associated with other
make the incision there. intra-abdominal collections. In this case, re-open the
If the abscess follows appendicitis, a perforated original laparotomy incision, aspirate all the abscess
duodenal ulcer, or cholecystitis, it will probably be on cavities, and lavage thoroughly with warm water.
the right. If a high gastric ulcer has perforated, it is more Do not insert drains. Plan a repeat laparotomy if the sepsis
likely to be on the left. If an ulcer in the posterior wall of was severe.
the stomach has perforated, there will be pus in the lesser
sac. POSTERIOR APPROACH. Lay the patient on his sound
If you don't know which side it is on, there is about a side with the lumbar region slightly elevated by breaking
75% chance that it will be on the right, probably anterior. up the table or placing pillows under the opposite side.
Approach it anteriorly, if possible through the old Make an incision which is big enough to take your hand
laparotomy wound, unless there are very clear signs that it over the 12th rib posteriorly (10-7E, 10-8). Remove the
is posterior. If one route fails try another. You cannot distal ⅔ of the 12th rib; divide it at its angle. Cut through
readily reach the posterior surface of the liver through an the periosteum, reflect this from the whole circumference
anterior incision, or the anterior liver surface through a of the bone with Faraboef's rougine, as for an empyema
posterior incision, so use the anterior approach by (9.1). Occasionally, you may need to tie the intercostal
preference, and the posterior approach only if you are vessels.
certain pus is there, or you have found none anteriorly. CAUTION! Take great care not to damage the
diaphragm. Incise the inner aspect of the periosteum
ANAESTHESIA. If GA is risky, block the lower horizontally. Push your finger upwards and forwards
6 intercostal nerves. Don’t hesitate to explore the abscess above the renal fascia to enter the abscess (10-7C,D).
because the patient seems too weak for surgery!
ANTERIOR APPROACH.
Preferably re-open the previous laparotomy incision;
otherwise make a subcostal incision which is large enough
to take your hand, a finger's breadth below and parallel to
the right (usually) or the left costal margin.
Cut from the middle of the rectus muscle laterally (10-7B).
Cut the muscle fibres in the line of the incision.
This way you can often drain the septic collection without
entering the general abdominal cavity.
If you have entered through the previous incision,
beware of adhesions, go carefully, and pack off the rest of
the abdomen before you come to the abscess which you
will find by noting tissues adherent to each other.
Sweep your finger gently above the liver from one side to
the other to explore the subphrenic space. If you don’t find
pus, sweep your finger laterally and explore below the
liver. Break down any loculi, and send pus for culture.
Insert a drain. If the liver is not adherent to the diaphragm,
there may still be pus posteriorly, pushing the liver
forwards.
CAUTION!
(1) Try not to enter above the diaphragm. This is more
likely to happen with an anterior approach. If you enter the
pleura, lavage the thoracic cavity thoroughly, especially if
you have spilled pus inside it, then close the diaphragm
with a #1 suture and insert an underwater seal drain.
If you have not yet found the pus, make sure the
diaphragm is well closed before you approach the abscess.
(2) Be sure that there is only one abscess.
Fig. 10-8 POSTERIOR APPROACH TO A SUBPHRENIC
If you damage the pleura accidentally, close it and insert ABSCESS. A, temperature chart: a hectic fever subsided after the
an underwater seal drain. abscess was drained. B, excise the 12th rib and make an incision in its
If pus ruptures into a bronchus in a spasm of coughing, bed. C, divide the bed of the 12th rib, showing the liver and the fat
death from asphyxiation may resultunless you institute round the kidney. After Ochsner A, Graves AM. Subphrenic Abscess:
An Analysis of 3,372 Collected and Personal Cases. Ann Surg.
urgent postural drainage (11.12). The pus is more likely to 1933;98(6):961-90.
have spread from an amoebic liver abscess than from a .
subphrenic abscess.
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CAUTION!
(1);Do not use the Trendelenburg position to improve
exposure; this may spread the infection.
(2) Keep manipulation to a minimum.
(3);When you have found pus, do nothing more than is
necessary to ensure adequate drainage. Don't break down
the outer walls of the abscess cavity, but do break down
any loculi inside. Distinguishing between them may be
difficult.
(4) Do not remove a normal appendix.
Culture the pus and insert a drain. Remove all the packs;
suture the abdominal muscles securely, but do not close
the skin immediately (11.8).
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11 Methods for
abdominal
surgery
11.1 Before a major operation
A patient is much more likely to withstand
major surgery successfully if he is fit.
So do all you can to get him into the best
possible condition first. For example, if you
find that he is anaemic, malnourished, or
suffering with tuberculosis, and the operation is not urgent, Fig. 11-1 THE ANTERIOR ABDOMINAL WALL.
A, Abdominal incisions. After Kirk RM, Williamson RCN, General
correct these things before surgery. Surgical Operations, Churchill Livingstone 1987 p.42, Fig.4.1,2.
Severe malnutrition will greatly reduce his ability to B, Anatomy of the anterior abdominal wall. N.B. Below the arcuate
withstand the operation. Above all, do not operate on a line, the posterior rectus sheath is absent. After Maingot R, Abdominal
patient who is dehydrated; you must correct this. Operations, HK Lewis 4th ed 1961 Fig. 1, with kind permission.
Assess the need for surgery, the best time for it, and the
risks it will involve. If a particular procedure risks being For example, if you might have to remove a testis or make
too much to cope with, ask yourself if there is a lesser a colostomy, discuss this before you operate.
alternative, or whether you could do something under LA, Further, if you promise to close a colostomy eventually,
or what will happen if you do nothing? If there is a choice be sure to do so.
of procedures, do the simplest and safest thing,
for example, colpotomy for a pelvic abscess rather than a PREOPERATIVE PREPARATION
laparotomy (10.3). HISTORY AND EXAMINATION. What previous
Consider whether you need to perform the operation illnesses has the patient had? Is he taking any medicines?
straight away, or after fluid resuscitation, urgently but at a Is he allergic to anything, particularly to streptomycin,
more convenient time, or electively. Consider the help you sulphonamides, penicillin, or chloroquine?
need: are the people you have available actually present? Assess the degree of wasting. Ask about a cough, fever,
Are there other demands on your time: are these really chest pain, dyspnoea, and smoking. How fit is he?
important? Can he climb hills, or do a day's work in the fields?
Can he step up and down off a chair for half a minute
Follow these rules: without becoming short of breath? Or, can he hold his
(1);Do not start an operation without thinking it through breath for 20secs? Can he get out of bed independently on
step by step before you start. If you are not familiar with one side, walk round the bed, and get in again on the other
the patient’s case, make sure you go through the notes and side? (This tests co-ordination, mental faculties, as well as
review the indications for surgery carefully yourself. cardiac output!) Look for signs of anaemia. Feel the
(2);Monitor a patient closely for 48hrs after any strength of his grip (this is a good predictor of surgical risk
emergency or major operation. in men, less so in women).
(3);Prevent aspiration of stomach contents, and treat
respiratory depression immediately. ASK ABOUT TUBAL LIGATION. Always remember to
(4);The most common postoperative complications are ask any pre-menopausal lady over 30yrs who has had 2 or
respiratory, and the answer to most of them is vigorous more children if she is interested in having a simultaneous
chest exercises (11.12). tubal ligation. Most women either forget or are too afraid
(5);Correct any dehydration and make sure enough IV to ask but always regret not having done so. If the lady is
fluids are infused peri-operatively to obtain a urine output agreeable, remember to add the procedure to the consent
of 1ml/kg/hr. form and the operation list!
(6);Discuss the case beforehand with your anaesthetist,
mentioning possible hazards and blood loss. SPECIAL TESTS. Measure the Hb or haematocrit.
(7);The operation may be routine to you, but it is sure to be If sickle-cell disease is common in your area, test for this
a major event in the patient’s life, so try to establish a good routinely. Test the urine for albumin and sugar,
relationship with him and his family. Tell him why you are and examine its deposit. This will exclude any serious
operating, and explain what to expect afterwards, disease of the urinary tract, and help you to diagnose renal
particularly how much pain he will have, and when he will colic, which may present as an acute abdomen. Test the
recover. blood group, and if necessary cross-match blood.
Remember to test for HIV. If you suspect heart or lung
disease, obtain a chest radiograph and/or ultrasound scan.
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ASSOCIATED DISEASE. If necessary, and if time SKIN PREPARATION. If the skin is very dirty, wash the
allows, try to improve the patient’s general operation site several times. If there are pustules, boils,
health, especially his nutrition and hydration. Look for or eczematous patches near the site of your proposed
tuberculosis, chronic renal disease, and signs of HIV incision, treat them before you operate. Bacteria from
disease. them may infect the wound, so if you must operate
urgently, use delayed primary closure (11.8).
If the patient is dehydrated, make sure you provide
enough fluid (usually IV) so that he has a good urine NASOGASTRIC SUCTION. Insert a nasogastric tube
output. (4.9) before all stomach or bowel operations, and in
emergencies if you do not know when the patient last ate
If the patient is malnourished, especially if he is a child, or drank. The danger of aspiration pneumonitis is even
and the disease permits, feed him by mouth or by greater if there is intestinal obstruction or ileus.
nasogastric tube, even for as short a period as 2wks before It is especially present when the patient is relaxed before
you operate. If he is anorexic, feeding him will be difficult, intubation. Aspirate the stomach contents before you go to
so try nasogastric feeding (11.10). theatre. The risks of aspiration are greater if the patient is
lying down or sedated. Get an assist to apply cricoid
If there is pyrexia, consider the possibility of malaria, pressure before and during intubation; aspirate the stomach
HIV or typhoid fever, in addition to the possible surgical contents from time to time during the operation.
causes of fever.
URINARY CATHETERIZATION. Insert a catheter into
If there is anaemia, consider the urgency of the operation the bladder for pelvic and long operations,
in relation to the severity of the anaemia. Most 'routine' where monitoring of the urine output during the operation
operations can be done with a Hb as low as 8g/dl. is helpful, or in an elderly man with a large prostate where
If it is 6-7g/dl, only do urgent procedures. For example, you fear urinary retention post-operatively.
you can transfuse a woman with a Hb of 3g/dl who is Do not insert a catheter routinely!
bleeding slowly from an ectopic pregnancy overnight with
20ml/kg of blood from her abdominal cavity (5.3), PERIOPERATIVE ANTIBIOTICS may be lifesaving
if necessary adding 1mg/kg of furosemide. If an operation (2.9); distinguish between prophylactic and therapeutic
is less urgent, for example a hysterectomy for chronic use!
anaemia due to fibroids, treat with iron sulphate for
4-6wks. For non-urgent surgery where you expect DO NOT OPERATE ON A
bleeding, you can take a unit of blood 4wks and 2wks SEVERELY DEHYDRATED PATIENT:
before a planned major operation, and store the blood.
RESUSCITATE TILL YOU OBTAIN
If there is jaundice, it will greatly increase the risks of YELLOW COLOURED URINE.
surgery, but not operating may worsen liver failure.
Treat with vitamin K 10mg IM od and repeat this if the
jaundice is severe. Exclude hepatitis and malaria first, 11.2 Laparotomy
especially in the acute stage, when anaesthesia can be
dangerous.
A laparotomy for an acute abdomen will be a major test of
your surgical skill. It will be important to know what to do
If there is much purulent sputum brought up, arrange
when you open the abdomen; if you are not sure,
chest physiotherapy and a course of antibiotics prior to
be humble enough to have this book in theatre to help you.
surgery, if possible. Use appropriate anaesthesia, using LA
Try to make a correct diagnosis before you start,
or regional blocks where possible. If there is a common
but do not delay just because you are not certain what you
cold, cancel anything but an emergency operation.
will find. Before you start, get a proper consent and discuss
the operation with the patient and his family, and if he is to
If the patient is diabetic, check the glucose level.
have drainage tubes or a colostomy for example,
If the diabetes is out of control, start a ‘sliding scale’
make sure they understand what they entail.
régime of soluble insulin IV qid, with the total adjusted
according to the total dose, if any, of insulin being taken.
N.B. In some societies the presence of a drain or
If oral hypoglycaemics are being used, omit these on the
colostomy may appear to indicate imminent death,
day of surgery. If insulin is taken bd, reduce the
so take time to explain details such as these carefully.
preoperative evening dose by 20%; omit the insulin on the
morning of operation and start a 5% Dextrose IV infusion.
Try to avoid complications by making an appropriate
Check the glucose again just before operation and try to
incision, handling tissues carefully, and closing accurately.
operate on him first on the list.
Make an incision which is big enough; a common mistake
is to make it too short. Incisions heal from side-to-side,
CHEST PHYSIOTHERAPY before and after the
not from end-to-end, so do not be afraid of making a long
operation will reduce the risk of lung complications
incision.
(11.11,12), especially for the bronchitic, the smoker and
the elderly.
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If possible, make a transverse incision in children <12yrs When you get inside, you will have to decide what to do.
because it heals better, and gives less respiratory problems. Here, only experience can tell you what is normal and
The transverse incision also heals better in adults, what is not. For example, some ascaris worms inside a
and is less likely to develop hernias than the midline, child's bowel may feel so abnormal as to convince you that
but you need to be careful with good haemostasis. they must be the cause of the symptoms, when in fact they
are normal for the community.
In an adult a midline incision will enable you to get access
to everything in the abdomen. You can start with the Be gentle, bowel is highly sensitive. If you handle it
middle part to begin with, and extend it from the roughly, especially if it is obstructed, ileus will follow as
xiphisternum to the pubis, if necessary. If exposure is sure as night follows day. Bowel does not like being
particularly difficult, you can extend the incision laterally frequently drawn out of a wound. So, if you need to draw
to make a 'T' incision. Many patients prefer an incision it out, do so only once, and hold it with a moist swab.
going straight through the umbilicus rather than going While it rests on the abdominal wall, keep it covered with
round it: ask them. warm moist packs or towels, or place it in a large sterile
plastic bag. If it is grossly distended, even the most gentle
A midline incision above the umbilicus is quick, simple, handling may burst it, so decompress it (12-6).
and bloodless. But access to the organs at the sides of the Break down adhesions gently (12-8).
abdomen is not easy. Even so, midline incisions are N.B. Remember, in an emergency, do what has to be
usually best for trauma, for Caesarean Sections where you done as efficiently as you can: do not be tempted to do
are not familiar with a Pfannenstiel incision or other unnecessary things! It is often best to wait 48hrs to
pathology is expected, and almost everything else. stabilize a patient and return when the condition has
If you are planning a purely exploratory laparotomy, and improved.
do not know what you are going to find, make a midline
incision in the correct half of the abdomen, upper or lower.
If you are reopening the abdomen, cut out the old skin
incision. Extend it so that you can enter the abdominal
cavity above or below where any adhesions to the under
surface of the abdominal wall are less likely. Work your
way up or down carefully, dividing any adhesions you
find, so as not to injure any adherent bowel. Do not make a
2nd incision parallel to an earlier one or crossing an
earlier one at an acute angle, because the skin in between
will have no sensation and may become ischaemic.
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LONG MIDLINE INCISION. Do not hesitate to open the GET ADEQUATE EXPOSURE AND A GOOD LIGHT.
abdomen from top to bottom e.g. for advanced generalized You cannot do good work if loops of bowel are always
peritonitis (10.1). You can go straight through the getting in the way, or if the light is bad, so adjust it as best
umbilicus: it leaves a neater scar than going round it, you can. Sterilizeable light handles are very useful;
but remember to clean it thoroughly beforehand. otherwise make sure someone else in the theatre knows
You can also get a little more length by incising between how to move and direct the light. Alternatively use a
the xiphisternum and the costal cartilage. head-light. Get one or two assistants to help you.
Make an adequate incision. If necessary, extend it or close
LOWER MIDLINE INCISION. Make this in a similar it (e.g. if you find a Lanz incision for appendicectomy
way to the upper midline incision. If you cannot see inadequate) and make a good midline incision. If you are
exactly where the midline is between the rectus muscles, working on a lateral organ through the midline, make a
split them apart gently. Make sure you use haemostats or long incision. Or, make a lateral T-shaped extension.
diathermy on bleeding vessels. You will see the Get good retraction. A self-retaining retractor may not be
pyramidalis muscle at the lower end of the wound. enough by itself. Use Deaver's retractor, or any large
Note that below the umbilicus, in the lower ⅔ of the right-angled retractor, and make sure your assistant knows
midline, below the arcuate line, the peritoneum is attached what you want him to do with it. Do not become cross with
only to transversalis fascia. him when the position of the retractor slips if he cannot
see properly!
TRANSVERSE INCISION. Make a cut 3cm above or Get the patient into the best position. You will never get
below the umbilicus and cut through the anterior rectus adequate exposure in the pelvis unless the body is tilted in
sheath, and underlying muscle; you should have diathermy the Trendelenburg position. Similarly, if you are working
available to control bleeding from vessels in the muscle on the upper abdomen (as when exposing the oesophagus),
layer. Then go through the posterior rectus sheath and tilt the head up a little. Extending the back by breaking the
open the peritoneum. You can extend the incision in a table or by putting a pillow under the back will also help.
curve upwards laterally, if you need access to the spleen or If you want to draw the splenic flexure and small bowel
liver. towards you, consider rolling the patient to the right,
either by tilting the table or by using sandbags, or a
PFANNENSTIEL INCISION. Make a slightly curved wooden wedge under the mattress. If you are operating on
transverse incision 2cm above the symphysis pubis. the kidney, a kidney bridge or folded plastic-covered
Cut through the anterior rectus sheath and hold upper and pillows will bring it forwards.
lower flaps with straight forceps. Gently lift this sheath
off the underlying rectus muscle, and split this DON’T MAKE THE INCISION TOO SHORT:
longitudinally to expose the peritoneum in the midline. ALWAYS BE READY TO EXTEND IT!
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If loops of small bowel (or anything else) get in your If a surface is merely oozing, consider applying
way, pack them away. This may save you much time, haemostatic gauze (3.1).
but do not forget to remove the packs afterwards!
Anchor each pack by its tape or corner to a large If the bleeding is annoying, rather than brisk,
haemostat hanging outside the abdomen. you may be able to suck it away while you go on working.
Make sure the scrub nurse checks and counts the packs
and instruments with you at the end of the operation. If you have diathermy, consider applying it to the
Avoid leaving loops of bowel hanging outside the abdomen bleeding point with a fine-tipped dissecting forceps.
exposed, especially under hot theatre lights: they easily You should do this with pin-point accuracy.
get desiccated and the weight of bowel contents may
impair its mesenteric blood supply. Keep the bowel If there is a constant ooze during the operation:
covered with warm wet packs. (1);There may be an excess of citrate after transfusion of
many units of blood. This will not happen if you add 10ml
FOLLOW A ROUTINE. Take note of the smell, look at of 10% calcium gluconate after every 4th unit (500ml) of
the fluid, gently divide adhesions, minimize the risk of blood.
sepsis, decompress the bowel, and make a thorough (2);There may be disseminated intravascular coagulation
examination of the abdomen (10.1). How extensively you (DIC), or some other clotting defect. If possible transfuse
do this will vary. Limit your exploration to what is easily at least 2 units of fresh blood to replace clotting factors.
practicable if: Check the blood clotting time.
(1) there is localized sepsis and you aim to limit its spread
to the rest of the abdomen, If bleeding becomes unmanageable, do not panic:
2) there is an inoperable carcinoma, or apply pressure, then packing. Either ligate or repair a
(3) you are operating on a known problem. major vessel (3.1,2)
However, even then it is good practice to take the CAUTION!
opportunity to make a full examination. Decide carefully (1);Do not stab blindly with a haemostat in a pool of
though if the bowel is very stuck together whether you will blood!
do more harm than good by separating all the adhesions (2);Similarly, do not apply diathermy through a pool of
(10.1). blood: it won't work!
Explore the abdomen in an orderly way: look at the
diaphragm, liver, intra-abdominal oesophagus, spleen, If you accidentally perforate a loop of bowel, do not try
stomach, duodenum, gall-bladder, and then the whole to stop the leak of bowel contents with gauze.
small bowel. Draw each loop out of the wound, looking at Pinch it closed between your fingers while someone gently
both sides, and at the mesentery. If the bowel is distended, places non-crushing clamps proximally and distally.
trace it distally to find the cause. Look at the large bowel Suction any spillage. Surround the injured loop with packs
from caecum to rectum. Feel the major vessels and to prevent the contents of the bowel flooding into the
kidneys, look at the appendix, ureters, bladder, uterus, peritoneal cavity. Repair the perforation (14.3); if there are
Fallopian tubes, and ovaries. Finally look at the hernial ≥2 perforations near each other, it is best to sacrifice a
orifices from inside. If necessary, look into the lesser sac segment of bowel and make one anastomosis (11.3)
through the greater omentum; or behind the duodenum by rather than attempt to repair several holes.
‘kocherizing’ it (13.3); or at the oesophageal hiatus by
dividing the attachments of the left lobe of the liver to the If you open the pleura by mistake, there is a danger that
diaphragm. the lung may collapse and cause marked hypoxia, because
only one lung is being ventilated, and also because blood
Do not forget to record your findings: even negative ones, is passing through the collapsed lung unaltered.
which can be most helpful later. If the patient is not intubated, stop operating to make it
easier for the anaesthetist to pass a cuffed tracheal tube
THE SPECIMEN. If you have removed tissues from the using suxamethonium. Intubation is not essential, but chest
patient and want to examine them, hand them to someone drainage usually is. To do this you may have to move the
else. Ask him to open them away from the patient who patient. As soon as the tube has been inserted, close the
will then not be contaminated by infection or malignancy. hole in the pleura with a continuous multifilament suture.
As you insert the last suture ask the anaesthetist to blow up
DIFFICULTIES WITH A LAPAROTOMY the lung so that it almost touches the pleura. At the end of
If you cannot do an operation through one incision, the operation insert an intercostal water seal drain (36.1)
make another. Keep your original one open until you have and leave it in place for at least 48hrs. Obtain a chest
finished: it may be useful! radiograph, and once the lung is fully expanded, remove
the drain, usually at 2-5 days.
BLEEDING can be difficult. You must know how to:
(1) tie vessels in the depth of a wound (3.2),
(2) place ties, without letting go of the thread (3.2),
(3) use curved and angled forceps,
(4) secure temporary tape control over major vessels.
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If you follow the 7 points above you won't go far wrong. Avoid this disaster by emptying the bowel every time you
Note that any sutures which go right through the wall of make an anastomosis. You will need to make sure that the
the bowel (and so might leak) are usually infolded by a bowel reaches outside the abdomen, and emptying it does
2nd layer of sutures which go through serosa and muscle not contaminate the peritoneal cavity, the very thing you
only; these are called Lembert sutures. Put the first layer want to avoid! Therefore before you empty the bowel,
through all its coats: this is the 'all-coats' layer. pack away the abdomen as a protective measure.
Make the Lembert sutures of the 2nd layer bring the serosa If you can’t make the bowel reach outside the abdomen,
of one loop into contact with the serosa of the other loop. use a strong sucker to decompress it. This will not work in
Only put them through the outside peritoneal layer, the the distal small bowel or colon because the content is
muscle, and the submucosa (the strongest layer of the usually too thick, but that is where it is more important to
bowel), and do not go through the mucosa into the lumen empty it!
of either loop. You will then have to allow the bowel content to pour out
into a bowl, getting an assistant to hold both bowel and
Use a continuous suture: it is easier, cheaper, and probably bowl carefully so as not to spill the fluid, whilst you milk
more reliable than using interrupted sutures, even with the content out. Once you have done this, clamp the ends
large bowel. Avoid catgut: it dissolves just when the bowel of the bowel and clean them with swabs held in sponge
is healing, and so needs a 2nd layer of sutures for forceps (‘swab-on-a-stick’). Finally, dab the bowel ends
protection. If your stocks are limited, preserve some longer with betadine.
lasting absorbable sutures (e.g. polyglycolic acid) specially You can decompress bowel via a nasogastric tube if the
for bowel (4.6). Avoid cutting V-shaped needles on bowel content is very fluid, and your anaesthetist is ready to suck
as these can produce a leak. out the contents. The danger is spillage into the mouth,
You will need to hold the bowel with stay sutures, and from there into the lungs, especially if the
Babcock forceps (4.4) or clamps while you work on it. endotracheal tube is uncuffed: do not use this method
It is also desirable to hold it shut so that its contents do not therefore with children!
leak out. Clamps do this best but you can use a cloth tape.
There are 2 kinds of clamp: non-crushing ones and FORCEPS, intestinal, non-crushing, flexible blades, Kocher's, Doyen's or
Lane's, 75mm. Use these to hold the bowel while you anastomose it.
crushing ones.
Non-crushing clamps have been designed to exert the right pressure
Non-crushing clamps, such as Lane's or Kocher's have without being covered with rubber tubes. If you fit them with rubber, they
thin, wide, flexible blades, and a ratchet with several teeth, may crush too tightly.
so that you can adjust the way you close them to the CLAMP, Payr's, intestinal crushing, lever action, medium size, 110mm.
These are the standard crushing clamps.
thickness of the bowel. Use non-crushing clamps to hold
CLAMP, Payr, intestinal crushing, lever action, small size for pylorus,
bowel without injuring it; hold them between your fingers 60mm.
and 'milk' the bowel contents away from the area you are VIABLE BOWEL ENDS
working on. Apply only as many 'clicks of the ratchet' as MUST BE NICE AND PINK
you need to stop the contents of the bowel from escaping,
and blood from flowing from the cut ends. You can use MINIMIZE CONTAMINATION
Bulldog vascular clamps for baby bowel.
Crushing clamps have narrower, stiffer blades, a ratchet THE CHOICE OF THE METHOD depends on the nature
with fewer teeth, and sometimes interlocking ridges on the of the operation, your skill, and the equipment you have.
blades to grip the bowel more firmly. Crushing clamps
prevent leaking completely. 'Milk' the contents of the IS THE BOWEL VIABLE? TO RESECT OR NOT?
bowel away from the area to be crushed, and then apply a CAUTION! For any method of anastomosis the bowel
crushing clamp with its jaws protruding well beyond the must be viable, which also means that its blood supply
edge of the bowel, because bowel widens as you crush it. must be good enough.
Close the jaws tightly. Crushed bowel dies, so cut the
crushed bowel away with the clamp before making an Wait to decide if the bowel is viable or not until you have
anastomosis. Cut the bowel strictly transversely, removed the cause (divided an obstructing band,
not obliquely (11-5J). As you do this, be sure there is a or untwisted bowel which has twisted on its mesentery).
non-crushing clamp applied to stop the contents of the You can usually tell if bowel is going to survive or not.
bowel spilling out. Crushing clamps are thus always used Base your decision on several of these signs, not on one
in conjunction with non-crushing ones. only.
You will often have to operate on bowel when it is
distended and full of intestinal content: this fluid has Bowel is viable if:
millions of bacteria, particularly anaerobes. Spillage into (1) its surface is glistening,
the peritoneal cavity will cause septicaemia very quickly (2) its colour is pinkish, or only slightly blue,
because the peritoneal layer is such a good absorptive (3) it feels resilient like normal bowel,
surface. So, in this situation, you will have to use clamps; (4) it contracts sluggishly (like a worm) when you pinch it,
however, if you then join bowel which is full of intestinal (5) you can see pulsations in the vessels which run over
fluid, this will all have to pass the anastomosis! the junction between it and its mesentery.
The chance of leakage is then high.
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Fig. 11-7 RESECTION AND END-TO-END ANASTOMOSIS IN Apply non-crushing clamps in Step B and keep them on until Step N.
2 LAYERS WITH CLAMPS. Remove the crushing clamps with the loop of bowel in Step E.
This method uses 2 crushing clamps; it can be done without any The critical parts of this anastomosis are the inverting Connell
clamps using stay sutures or tapes instead. sutures in steps J-N.
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If serosa of one loop is to be in contact with serosa of the If the sizes of the bowel ends differ, calculate taking
other loop at these critical points, invert the bowel here. more widely spaced bites on the bigger bowel end than on
The suture which does this best is the Connell (11-5B,C). the smaller end, so that you reach the mesenteric ends of
The principle of this is that the suture starts outside the both bowel ends simultaneously. This takes some practice.
serosa and comes out into the mucosa; it then goes back
into it again, and it comes out of the serosa of the one end (Alternatively, use interrupted sutures: place stay sutures
of bowel. It then goes back into the serosa again on the at the ante-mesenteric border of both ends of bowel, and
other end of bowel to be anastomosed. It makes a 'loop on tie these together; likewise do the same at the mesenteric
the mucosa' (11-5D). It is this loop which makes the border of both ends of bowel. Then place a suture midway
mucosa invert. The bigger the bite on the outside (serosa) between the 2 sutures on one end, and again midway
and the smaller on the inside (mucosa), the better the between the 2 sutures at the other end, and tie them
bowel ends will invert. together. Continue with another suture midway between
the first ante-mesenteric stay suture and this last one
Decide the length of bowel you want to resect (11-7A). placed in the middle of the bowel, and so divide the bowel
Apply 2 crushing clamps at each end of the non-viable wall distance each time in half. That way, you will not
bowel to be resected, including a small portion of viable end up with excess bowel on the distended side.)
bowel, and non-crushing clamps 2cm away on the viable
parts of bowel to be joined together (11-7B). Do not place Then, using the same suture, pass through from inside to
clamps over the mesenteric vessels. outside the serosa (11-7L) and continue as an all coats
inverting Connell suture on the anterior layer (11-5A,
If the mesentery is too thick for you to see the vessels 11-7M), till you join the beginning of the same suture at
clearly through it, even when the mesentery is held up the ante-mesenteric end again (11-7N). Tie the 2 ends of
against the light, (as in the sigmoid colon, and the small the inner continuous suture together and cut them, leaving
bowel mesentery in moderately fat patients, especially 5mm ends. Now remove the non-crushing clamps.
distally), divide the peritoneal layer covering the You may immediately see a defect; the tension may be
mesentery carefully with fine scissors nearest to you to released by removing the clamps and make the final
outline the vessels (11-7C). Dissect the vessels, place a outside suture easier.
small artery forceps on each and ligate them one by one,
using a 2/0 or 3/0 suture (or smaller for children & babies). Continue with the first continuous Lembert suture which
To save suture material you can leave the haemostats you left hanging long on the mesenteric border, and go
untied on the part of bowel to be resected. round till you end at the ante-mesenteric border (11-7O).
Pack away the other abdominal contents, and place one of Tie the 2 ends of the outer continuous suture together and
2 large abdominal swabs under the bowel to be resected. so complete the circle (11-7P). Test the patency of the
Make sure you protect the abdominal wound edges from lumen with your fingers (11-7Q). Massage some of the
contamination. bowel contents past the anastomosis to test for leaks.
If you are worried, place the anastomosis under water and
Divide the bowel on the outside of the crushing clamps squeeze: look for gas bubbles; if there are none,
(11-7E), using a sharp knife to give a clean cut. Empty the your anastomosis is sound.
bowel of its content into a bowl, or using a guarded sucker.
Bring the non-crushing clamps together (11-7F) and evert Close the defect in the mesentery with continuous 2/0 or
them (11-7G). 3/0 suture, taking great care not to occlude the vessels.
Insert a continuous Lembert suture through the END-TO-END ANASTOMOSIS BY A SINGLE LAYER
seromuscular coat of the posterior layer of the bowel SUTURE (GRADE 3.3)
(the one which is furthest from you) starting at the anti-
mesenteric border (11-7H), leaving one end long to act as The important feature about this method is that it uses a
a stay suture (11-7I), and continue till the mesenteric single layer suture.
border, leaving the suture to hang. Do not cut it off, or its
needle: you will use it again! Start the all coats continuous Essentially this method is like the ‘2 layer’ but uses a
inner layer at the anti-mesenteric border with a loop on the single all coats layer, dispensing with the outer
seromuscular layers of both ends of bowel, leaving one seromuscular layer; you need to be very careful to place
end long as a 2nd stay suture (11-7J): you can differentiate the loops of the suture accurately and close enough
this from the first stay suture if you are using the same together. These sutures cannot be made too neatly.
thread by putting a loop on it, and continue by passing
inside the lumen as a single all coats suture (11.5B-C). If the suture line is snug and inverted, stop at this stage.
Continue as a simple over and over suture until you reach If not, complete the anastomosis with a final layer of
the mesenteric end (11-7K). Make sure you get your Lembert 4/0 monofilament seromuscular sutures.
assistant to keep the right tension on the suture and let it This converts the one-layer method into a partial 2 layer
snug down nicely on the bowel wall, so that you cannot method. You should be able to get most of the way round
insert a small artery forceps between the suture points. the bowel, but you may not be able to suture its mesenteric
border.
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BOWEL SUTURING METHODS If you are not happy that you have made a satisfactory
anastomosis (no anastomosis is ever quite 'watertight'),
you can bring up a loop of omentum and suture this
loosely over the place which you think will leak. This is
optional; there are certain occasions when it is very useful,
notably the repair of a perforated peptic ulcer (13-11).
Which parts of the bowel can you safely anastomose to ENTEROTOMY AND CLOSING A BOWEL
which and when? You can anastomose large bowel PERFORATION (11-5M) (GRADE 3.2)
safely if it is empty: give bowel preparation and enemas
beforehand for the elective cases, or empty the bowel as An enterotomy is an opening in the bowel. You may have
described for emergency cases. If the colon is perforated to make one to decompress the bowel (12.4), make a
or gangrenous, and particularly when there is heavy faecal stoma (11.5), to inspect the bowel to see where bleeding is
soiling of the peritoneal cavity, this is not safe especially if coming from (13.4), or to remove ascaris worms (12.5)
you only have catgut. You should then make a or a foreign body (12.15). Make a longitudinal opening in
diversionary colostomy (11.6). the anti-mesenteric border of the bowel.
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Don’t close an inflamed small bowel perforation: a leak METHOD. Bring the clamped loop of bowel close to the
will be certain. Resect the involved segment or drain it! other viscus, and insert stay sutures through the
seromuscular layers only (11-9I). Complete the layer of
Close the hole transversely in 2 layers as if you were interrupted seromuscular sutures (11-9J).
anastomosing bowel. In this way you will not narrow its
lumen. Start with a seromuscular suture just beyond the Clamp the other viscus and open it preferably with
hole, leaving one end long as a stay. Continue this as a diathermy so as to make a stoma equal in size to the small
Connell all-coats suture till you have closed the hole, bowel (11-9K). Trim the loop of bowel if necessary.
and tie a knot again leaving the end long as a stay. Start the inner all coats layer with a Connell inverting
Cover this suture with a continuous seromuscular Lembert suture (11-9L). Continue this as an over-and-over suture to
suture from just beyond the 1st knot to just beyond the 2nd, the other end, and return using a continuous Connell suture
thus inverting the first layer completely. Test the closure for the anterior layer (11-9N).
with your fingers by milking intestinal content past it.
END-TO-SIDE ANASTOMOSIS
(GRADE 3.3)
INDICATIONS.
(1) Constructing a Roux loop
(2);Bypassing an inoperable colon
tumour, septic or tuberculous
adhesions, or as an alternative to
ileocaecal resection.
(3);When there is a big difference in the
size of 2 loops of bowel to be
anastomosed (though the method of
11-8B is better).
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When you reach the end tie the 2 ends of the continuous
all coats suture together and leave the ends 5mm long
(11-9O).
INDICATIONS.
(1) Gastrojejunostomy (13-16)
(2) Cholecystojejunostomy (15-5)
(3) Bypass without resecting bowel.
Clamp the other viscus and incise both bowel and viscus
for about 3cm (11-10B) with diathermy if possible.
Starting with a Connell inverting suture (11-10C),
use absorbable to join the posterior cut edges of the bowel
with an all coats continuous over-and-over suture
(11-10D). When you reach the other end continue as a
Connell inverting suture along the anterior layer of the
anastomosis (11-10E). Finally, complete it and tie the ends
of the suture together, leaving 5mm cut ends. Insert an
anterior layer of Lembert seromuscular sutures (11-10F).
Test the lumen of the stoma with your fingers (11-10G)
and move the bowel contents over the anastomosis to
check for leaks.
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Commercial bags come as one-piece or two-piece systems, A sigmoid colostomy is an alternative to a transverse
with a flange to attach the bag. The advantage of the colostomy. Here again you can make a loop, or adjacent or
two-piece is that the stoma can be examined easily and the end colostomy (as in the Hartmann operation, 12.9)
skin adhesion is not disturbed: they are more expensive
and need a flat surface to stick nicely. They are difficult to
manipulate by the elderly and by those with arthritis.
Different manufacturers’ flange sizes are not usually
interchangeable: pouches of the wrong size which do not
attach to the flange are then useless!
The biggest problems are leaks: it helps to have sealant
pastes and skin barriers, adhesive tape and supporting
belts. Make sure the opening of the bag fits exactly on the
stoma: measure it with a paper template.
Fortunately, most stomas are usually only needed
temporarily.
TYPES OF STOMA
A gastrostomy (13.9) is an opening made in the stomach
for feeding.
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A 'spectacles colostomy' has limbs that are separated by a Check that the mesentery is not twisted or strangulated by
small bridge of skin (11-14E). It is useful: (a) if a patient the rectus muscle. Fix the ileum to the rectus sheath with
needs a colostomy for a long time, and (b) during the some seromuscular absorbable sutures.
repair of a rectovaginal or vesicovaginal fistula, After closing the abdomen, remove the clamp or tape off
when work on the rectum and bladder has to be completed the ileum and trim it clean.
before the fistula can be closed.
Apply a bag, making sure the opening is exactly the size of
An end (terminal) colostomy forms the 'end' of the bowel the stoma, otherwise it will inevitably leak.
after excision of the sigmoid in Hartmann's operation
(12.9) or excision of the rectum. CAECOSTOMY (GRADE 3.2)
INDICATIONS.
A mucous fistula (colostomy) is a stoma of the distal (1) Penetrating injuries of the caecum.
defunctioned large bowel, discharging only mucus. (2) A grossly distended caecum about to burst.
(3);An obstruction proximal to the mid transverse colon,
Closing stomas can be more difficult than making them. if you feel unable to perform a right hemicolectomy.
A tube caecostomy will usually close by itself once the (4);Large bowel obstruction, if the patient is in extremis
tube is removed, but a surgical procedure is needed to and too ill for a colostomy, or if you are inexperienced.
close a loop transverse or sigmoid colostomy,
or ileostomy. Reversing Hartmann's operation is much RADIOGRAPHS. Before you start, make sure exactly
more difficult (12.10). Leaving a stoma permanently may where the caecum is. Look for its gas shadow on the
be safer for the patient, although much less popular. radiograph. It can be surprisingly high. Percuss the
abdomen to make sure.
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INDICATIONS.
(1) Obstruction of the distal ⅔ of the transverse colon.
(2) A penetrating injury of the transverse colon.
(3);Gangrene of part of the transverse colon owing to
strangulation or interference with its blood supply.
(4);To divert faeces prior to repair of a rectovesical or
rectovaginal fistula.
(5);Protecting an anastomosis for sigmoid volvulus after
resection.
(6);To defunction the bowel for Hirschsprung’s disease
(33.7). Fig. 11-13 LOOP COLOSTOMY.
A, make these incisions for a transverse or sigmoid colostomy.
For a transverse colostomy: B, incise the rectus muscle. C, incise the
A transverse colostomy is not difficult to fashion, greater omentum. D, incise the mesentery. E, bring the colon through
and is better than a caecostomy. There are 3 types: the greater omentum. F, push a piece of tube or a glass rod through
(1) A plain loop. the hole, and fix the colon to stop it falling back. G, close the wound.
H, open the colon and suture it to the edges of the skin wound.
(2) An adjacent colostomy. I, complete the colostomy. J, after healing of the wound.
(3) A 'spectacles colostomy' (11-14). After Goligher JC. The Surgery of the Anus, Rectum and Colon. Baillière
CAUTION! Tindall 4th ed 1974 Figs 347-361 with kind permission.
(1) Make the incision well to the right.
(2) It must be high enough to avoid the umbilicus, and not Choose an area of the transverse colon to the right of the
so high that the transverse colon cannot reach it. midline. Trim off the omentum attached to 7-10cm of its
(3) Make it just large enough to take the loop comfortably. anterior surface so as to make a gap in it (11-13C).
(4) Make sure you have picked up the transverse colon and Try to avoid tying any small vessels that may be present.
not the stomach or the sigmoid colon! The transverse Deliver a loop of the transverse colon through this gap.
colon has taeniae (unlike the stomach), and is attached by Make a small window in the transverse mesocolon next to
a short omentum to the greater curvature of the stomach. the mesenteric border of the colon (11-13D).
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Do this by pushing a large blunt haemostat through the SIGMOID COLOSTOMY (GRADE 3.2)
mesentery close to the wall of the bowel, while you open
and close its jaws. Avoid injuring the branches of the INDICATIONS.
middle colic artery as you do so. Pass a rubber sling (1) Wounds of the rectum.
through the window you have made, and grasp both its (2);Chronic inoperable obstructive rectal lesions including
ends with a haemostat. Test the colon for mobility again. carcinoma.
If it is very tense and distended, decompress it. (3);To divert faeces prior to repair of a rectovesical or
CAUTION! You must be able to deliver the loop of rectovaginal fistula repair.
colon you have isolated through the transverse incision (4) To defunction the bowel for imperforate anus (33.6).
comfortably. If you cannot do this, mobilize the colon (5);To divert faeces in uncontrollable faecal incontinence,
more; a poor alternative is to open the colon, and suture especially because of HIV disease.
the bowel edges directly to the abdominal wall skin.
This is a ‘blow-hole colostomy’. To prevent the bowel METHOD. Mark the site for the colostomy beforehand.
from detaching, fix it to the inner abdominal wall with Proceed as for a transverse colostomy (though there is no
4 sutures. If you are still uncertain about its fixation, insert greater omentum to draw the sigmoid through) pulling out
a Foley catheter into the stoma, blow up the balloon a loop of sigmoid colon: this is usually readily mobile.
sufficiently to hold the bowel against the abdominal wall
and apply a little traction on the catheter.
METHOD.
Mark the site for the colostomy beforehand. Make a 6-7cm
separate transverse skin incision above and to the right of
the laparotomy incision (11-13). Divide the anterior rectus
sheath in the same line as the skin. Stretch the rectus
muscle transversely to admit 2 fingers only.
Open the posterior rectus sheath and peritoneum.
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END (TERMINAL) COLOSTOMY (GRADE 3.3) If the bowel forming the colostomy necroses,
and becomes dark purple you probably damaged its
INDICATIONS. mesentery by stretching or compressing it into too small a
(1) As part of Hartmann's operation (12.9). hole. Put a glass tube into the stoma and shine alight onto
(2);A permanent colostomy, as in an abdomino-perineal it to see how deep the necrosis extends. (You can get a
resection of the rectum. better view if you pass an endoscope down the stoma.)
(3);In exteriorization of an ileocolic intussusception (12.7).
If it is more than superficial, return to theatre, enlarge
METHOD. the opening in the abdominal wall, and make a fresh
Mark the site for the colostomy beforehand. Draw out the colostomy by bringing out more bowel, and resecting the
end of the bowel with a clamp or tape attached to avoid necrotic black or purple part. Do not delay doing this,
spillage. Before you close the abdomen, put in a few hoping the bowel will improve: the risk is of further bowel
absorbable sutures between the seromuscular coat of the necrosing and peritonitis resulting.
bowel, and the anterior rectus sheath of the abdominal wall N.B. Take care you distinguish necrosis from melanosis
to reduce the risk of prolapse and to stop the bowel coli, the blackish appearance of bowel from anthracene
falling back into the abdomen after you have closed it! laxative abuse (e.g. senna). This bowel bleeds if you pinch
Make sure that there will be 1½cm of healthy bowel it with forceps; necrotic bowel does not.
protruding beyond the skin. Try to close the lateral space
between the colostomy and the abdominal side wall; If the colostomy retracts, it will contaminate the
then close the abdomen. peritoneum and cause faecal peritonitis if the bowel
separates completely. You then need to re-open the
To open the colostomy, cut off the crushing clamp with a abdomen to correct this. Retraction occurs because of:
sharp scalpel. Control bleeding. Suture mucosa to skin all (1) the mucocutaneous sutures giving way.
round with continuous absorbable sutures which take (2) chronic peristomal skin infections.
a bite of the full thickness of the colon, and run (3) inadequate mobilization of the bowel mesentery.
subcuticularly in the skin. You will find the colostomy will (4);too early removal of the rod supporting a loop
evert itself beautifully (11-14G). Do not attempt to dilate colostomy.
the stoma with 2 fingers! (5);excessive weight gain. Retraction makes it difficult to
get a bag to stick.
If a baby with imperforate anus has a grossly distended
colon, make the incision as before and put gauze swabs If the colostomy stenoses, dilate it gently with sounds,
around the incision edges. Place a purse-string, preferably using a lubricant, not with 2 fingers. It may be that the
over the tinea, and decompress the bowel with a stab fascia or skin is too tight; if so, release it under local
incision at the centre of the purse-string. The bowel will anaesthesia. If it is the result of a severely retracted stoma,
then collapse and become easy to manipulate. refashion it. Check for recurrent inflammatory bowel or
malignant disease at the stoma site.
DIFFICULTIES WITH COLOSTOMIES
If the skin around the colostomy becomes oedematous
If the colostomy 'runs like a river', this is likely to be a and inflamed, necrotizing fasciitis of the abdominal wall
good sign in the early stages, because it means that the has developed because of leakage of faeces into the
obstructed bowel is emptying itself. If it happens later, subcutaneous tissues. Return immediately to theatre to
treat with kaolin mixture with 30-60mg codeine phosphate debride the affected skin and fascia widely, and refashion
tid, and advise against drinking orange juice. a colostomy in a different site.
If the colostomy does not work, put a finger into the If a hernia forms around the colostomy, it will probably
afferent loop to make sure that it has not become occluded. only be a little bulge, and is unlikely to grow big. It has
Twist your finger round gently inside the bowel lumen occurred because the opening for the colostomy is too big
beyond the level of the rectus muscle to irritate the bowel. or the stoma has been placed lateral to the rectus muscle.
If this fails to start it 30-60mins later, get the patient to You may be able to close the colostomy opening better by
drink orange juice and mobilize. If this also fails, put a inserting sutures from fascia to the seromuscular layer of
glycerine suppository into the afferent loop, or instil the bowel, but this is rarely necessary. Occasionally a
enema solution in using a Foley catheter with the balloon hernia comes through at the side of a colostomy: this needs
gently inflated to prevent the irrigation spilling out. revision (18.13).
If it is still not working after 3days, check abdominal
radiographs to see if there is proximal obstruction. If signs of intestinal obstruction develop (12.4),
adhesions may be forming inside the abdomen at the site
If an abscess forms next to the colostomy, where the colostomy emerges, or from the original disease
drain it (preferably under LA) and allow it to drain into the process. They are no different from the adhesions
stoma bag. developing after any other abdominal operation.
Explore the abdomen if there is no improvement.
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CAUTION!
(1) The patient will be hoping for this as soon as possible.
Do not let him persuade you to do it too early.
(2) It is not an easy operation.
(3);Make sure there is a loop colostomy and not an
end-colostomy by examining it carefully with your fingers,
feeling for the afferent and efferent loops.
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Free the parietal peritoneum round the circumference of Start by placing 2 atraumatic sutures through all the coats
the opening. Divide any adhesions that may be present. of the bowel where the proximal and distal colon meet.
Draw the colon gently out of the incision, and place packs Tie the knot in the lumen, and work from each side.
over the wound. Trim away the everted edges of the bowel Finish with a seromuscular continuous Lembert suture
(11-16E). Close it transversely with Connell sutures (11-16I). Test the patency of the lumen with your fingers
(11-16G,H). and return the colon into the abdomen. Repair the defect
of the rectus sheath (11-16J),
and close the stoma opening with
a subcuticular purse-string suture:
this allows a small hole to drain
fluid and prevents infection and
gives a neat scar avoiding
‘dog-ears’.
DIFFICULTIES WITH
COLOSTOMY CLOSURE
If there is a ‘blow-hole
colostomy’, insert a Foley
catheter into the bowel and inflate
the balloon to hold onto the colon
and prevent it falling into the
abdomen and leaking content
during closure.
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METHOD.
Make a small laparotomy in the upper abdomen.
Find the upper jejunum by following it downwards from
the ligament of Treitz. Confirm you have found the
duodeno-jejunal junction by identifying the inferior
mesenteric vein along its left border and feeling it emerge
from its fixed position behind the peritoneum. Take a loop
about 25cm from the duodeno-jejunal junction, and make
an incision on its ante-mesenteric border through the
longitudinal muscle layer for about 8cm. At the distal end
of this make a hole through into the lumen. Insert a
feeding catheter (Ch18 for an adult), or a long Ryle's tube,
through this hole for about 10cm. Close the bowel around
it with continuous absorbable suture (11-17C).
If the bowel wall is thin and you are afraid of tearing it,
make a hole in the jejunum for the feeding tube,
and then create a tunnel to bury it by suturing together the
bowel wall longitudinally over it.
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11.8 Draining & closing the abdomen Normally though you have 2 layers to be closed:
the peritoneum, which is fused to the posterior rectus
sheath and the anterior rectus sheath. Close these layers
After a laparotomy consider if you wish to close the together in a mass closure by the modified Everett method,
abdomen primarily. Leave it open (11.10), if closure which leaves knots within the muscle layer where they
would be too tight because of bowel distension or packs cause no discomfort. An ideal suture is a long-lasting
left in the abdomen, or if you plan a 2nd look laparotomy absorbable monofilament such as PDS (4.6).
(10.1). Occasionally, even if you cannot safely close the Consider leaving the skin open if there is severe sepsis.
fascia, you can close the skin: in this case do so with This will reduce the risk of wound infection in high-risk
interrupted mattress sutures. This is easier to handle cases in the same way as in wounds of other kinds.
post-operatively. Antibiotics are less effective than leaving the skin wound
open for a few days (see below). Otherwise close it
as a separate layer.
LAVAGE.
Before you close the abdomen, make quite sure
that, if it is contaminated, you wash it out
completely with warm water (10.1).
PREVENTING ADHESIONS.
Bring the greater omentum down so that it
underlies the incision. This will help to prevent
adhesions forming between the viscera and the
abdominal wall.
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Make sure the abdominal wall is relaxed: if the patient is CAUTION! If you use interrupted sutures,
pushing, ask the anaesthetist to increase his relaxation, (1) do not take the bites too close to the wound edges,
or if you are operating under ketamine, add diazepam IV. (2) do not make the sutures too far apart, &
Press down on the bowel with a ‘fish’ (11-18A) to make (3) do not make them too tight.
sure you don’t catch a loop of bowel in your suture.
This is a piece of stiff rubber sheet (such as that from a car DELAYED PRIMARY SUTURE FOR POTENTIALLY
tyre inner tube) with a tail on it. Alternatively use a INFECTED ABDOMINAL WOUNDS
specially constructed curved bowel depressor or the handle INDICATIONS. Severe sepsis which contaminates the
end of a Morris retractor. Do not use your assistant’s abdominal wound puts the patient at risk, especially from:
hands as retractors while you are putting in deep sutures! (1) Caesarean Section in the presence of infected amniotic
Put your hand inside after every suture to check nothing is liquor.
caught. Do not put sutures in ‘blind’. (2) Appendicitis.
Insert a longitudinal suture using a 65mm ½ circle needle (3) Perforation of the ileum.
parallel to the linea alba (11-18B), starting at the lower (4) Perforations of the colon.
end of the incision, as a continuous suture on both sides (5) Excision of gangrenous bowel.
(11-18C), after first clearing the fat c.2cm from it. (6) Generalized peritonitis.
Hold the ends of this suture by haemostats inferiorly.
METHOD. Use this where there really is a lot of sepsis
Then place the continuous suture using again a 65mm ½ with litres of purulent fluid in the belly, not just for the
needle, taking care the points are introduced lateral to the localized case. Close the muscles of the abdomen as
longitudinal suture (11-18D) by passing the needle from above. Make the sutures just tight enough to bring the
between the anterior and posterior layers of the rectus muscles of the abdominal wall together and prevent the
sheath out anteriorly, then going from the outer surface of bowel escaping. Test this as you go along by feeling the
the anterior rectus abdominal muscle inwards (11-18E) inside of the wound with your finger, as if it were a loop of
on the opposite side of the wound. Thread the needle bowel trying to escape. Then put a betadine dressing on
through the loop if there is one (11-18F). the wound. Use antibiotics only if the condition you are
operating for demands their use.
Otherwise, tie the knot carefully and securely with At 3-5days, examine the wound. If it is clean, close it
multiple throws so as to bury the knot between the layers. by delayed primary closure. If it is infected, apply
Proceed all the way along the wound like this taking deep hypochlorite, saline or betadine dressings regularly until it
bites and not pulling too tightly (11-18G). Place the is fit for secondary suture, or secondary skin grafting.
sutures about 1cm apart. At the end of the wound come out Occasionally, you will find the wound already healing so
anteriorly, pull one loop through another (11-18H) and tie well, that it will close spontaneously. If so, let it do so.
an Aberdeen knot (4-13), burying the end of the suture
between the layers. CAUTION!
(1);NEVER close the fascia or muscle of the abdominal
Then pull the longitudinal suture taut and tie it, taking care wall with catgut or short-acting absorbable. It will be
not to pull it excessively as the function of this suture is to absorbed too soon, and increase the risk of early bursting
distribute the pressure on the tissue. Too much tightening and later herniation.
will lead to bow stringing. Take care that no bowel loops (2);Do not use braided silk, which increases the risk of
are caught within either suture. sinuses.
(3);Make the sutures just tight enough to bring the edges
The longitudinal suture is an added safeguard in of the muscles together; do not strangle them.
emergency surgery: however, for a clean elective (4);Avoid closing the peritoneum with non-absorbable
procedure, you may omit it. sutures, as there is a higher risk of adhesions.
(5);Take care to pick up the posterior rectus sheath and
If you have made a transverse incision, close the peritoneum in the lower abdomen, as it might retract
peritoneum with the posterior rectus sheath, and then the laterally so be difficult to see; otherwise an incisional
anterior rectus sheath in 2 separate layers. hernia will result.
(6);Do not try to close the abdominal wall and skin in a
If you have made a Pfannenstiel incision (11-4), single layer.
close the sheaths transversely. (7);Do not close the abdomen if bringing the abdominal
edges together is a struggle: the abdominal compartment
SKIN CLOSURE. Now either close the skin with syndrome will result (11.10). Instead, place a vacuum
subcuticular absorbable or with continuous or interrupted dressing over the open abdomen (11-20).
monofilament; subcuticular closure leaves a neater scar
and probably is less prone to infection because the needle DIFFICULTIES CLOSING THE ABDOMEN
does not pass through the outer skin surface. (1) Get the patient fully anaesthetized.
Use skin clips if you have them. Alternatively if the wound (2).Make sure you decompress the bowel (12-4) and make
is very septic, leave it open for a few days for delayed sure a nasogastric tube is in place.
primary skin suture later. (3).Consider whether you should leave the abdomen open
(11.10) rather than closing it.
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AMBULATION. Encourage movement of the legs in bed. POSTOPERATIVE URINE OUTPUT FAILURE
Do all you can to mobilize your patient early.
Dependant immobile legs have a higher incidence of deep If there is no urine output, or only a little, and the
vein thrombosis than raised ones. This is more likely to bladder is not distended, look for:
occur lying in bed or sitting still in a chair than sitting still (1) Dehydration.
in bed. (2) Hypovolaemia.
(3) Renal tubular necrosis resulting in renal failure, caused
by a period of low blood pressure during the operation.
11.10 Non-respiratory postoperative problems N.B. Some urinary suppression is normal for 24-60hrs
after major surgery, as a normal response to stress.
Many complications can interrupt recovery, but you can
prevent most of them. Important problems involve the If there is a little urine of high specific gravity, with
lungs (11.11). Infections are more likely if there is obvious dehydration, infuse 1-2l of saline as rapidly as
cachexia, HIV disease (5.6), or diabetes. you can. If the urinary output does not improve, check the
central venous pressure; only if this shows adequate
In order to recover uneventfully from an abdominal hydration, use a diuretic such as 0·5-1l of mannitol IV,
operation, the bowel must start to work soon. The passage or 40-80mg of furosemide IV. If this produces a diuresis,
of flatus and bowel sounds show that the small bowel is there was severe dehydration causing renal shut-down,
starting to work; the large bowel starts 1-2days later. but which is now recovering. If the kidneys produce no
If all goes well, eating should start in 2-3days. This will be flow, there may be tubular necrosis and renal failure.
delayed after peritonitis, an anastomosis of the stomach or CAUTION! Do not overhydrate a child.
upper small bowel, or because of ileus (12.16), or anorexia (1);Treat him with 30ml/kg of fluid for the first 2hrs,
from any cause, such as burns or severe sepsis. and repeat it over the next 3-4hrs if necessary.
Unfortunately, the common IV fluids provide little energy (2);Before you diagnose anuria, make sure that the Foley
and no protein, and you are unlikely to have the necessary catheter is not blocked and is properly situated in the
solutions of proteins and amino acids for parenteral bladder!
nutrition. However if you can provide some nutrition,
as described below, it may be crucial. Most patients with If there is no urine passed, and the bladder is distended
sepsis are in a catabolic state and so need greatly (dull to percussion), this is urinary retention.
increased levels of nutrition; if you cannot feed them, It is common after perineal operations especially in elderly
they will lose much weight very quickly. men. Try to initiate micturition by getting the patient to
stand by the edge of the bed, and walk about if possible.
POSTOPERATIVE BLEEDING AND SHOCK Open a water tap: the sound of running water may make
Bleeding may be obvious but minimal, or hidden but the urine flow; alternatively, put the patient in a warm
catastrophic. Don’t make the mistake of failing to check for bath: the warm water may help him relax. Stimulating the
signs of circulatory failure (3.5, 11.9). skin of the upper inner thigh may also help. If all this fails,
introduce a urinary catheter.
POSTOPERATIVE VOMITING
If there is vomiting immediately after the operation, POSTOPERATIVE FEVER
turn the patient on his side. It may be due to the Most patients have a mild fever (<37·5˚C) for 1-4days
anaesthetic, especially ether, or to morphine or pethidine. after a major abdominal operation. This is insignificant.
He is likely to recover quickly. If he vomits >8hrs or
copiously at any time, start nasogastric aspiration. If there is significant fever postoperatively,
consider pulmonary collapse (11.11), pneumonia, wound
If there is vomiting after 48hrs, this is likely to be more sepsis (2.10, 11.13), urinary tract infection (especially if
serious, cause severe fluid loss and may result in tracheal you have used a catheter), drug reaction, malaria, further
aspiration. It may be due to ileus, postoperative bowel intra-abdominal sepsis either under the diaphragm (10.2)
obstruction, or rarely acute gastric dilatation. If you do not or somewhere else, septicaemia or septic shock, or deep
replace the fluids and electrolytes IV, severe vein thrombosis.
hypovolaemia and hypokalaemia will ensue.
Start nasogastric drainage to avoid aspiration of vomit. If there is persistent fever, and the general condition is
not improving, suspect that there is sepsis somewhere in
If there is vomiting with a distended, silent abdomen, the abdomen, especially if you operated for peritonitis,
this is an ileus (12.16), which may be due to postoperative there was inadequate lavage of contaminants (pus, faeces
peritonitis (10.1) which also causes pain, fever, and or bile) during the operation, or an anastomotic leak. In
toxaemia. The nature of the previous operation, such as a this case you should re-open the abdomen before 48-72hrs
pelvic abscess or an injury to the large bowel, usually (12.16). Examine the patient carefully every day. Sepsis
suggests its site. Later, watch for a localized abdominal after a clean abdominal operation suggests a serious
collection, especially subphrenic (10.2). If the patient’s problem, which you should deal with earlier rather than
condition deteriorates, think of the abdominal later.
compartment syndrome.
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If there is, after 3-5days, also a raised diaphragm and This results in further abdominal distension, fall in urine
fluid in the costophrenic angle on a chest radiograph, output, pressure on the diaphragm, hypoxia and shock.
there is a subphrenic abscess until proved otherwise (10.2). ACS is a common life-threatening condition which is often
Get an ultrasound scan (38.2K). If there is also diarrhoea not recognized, and often complicates abdominal sepsis.
with the passage of mucus, a pelvic abscess (10.3) is It can also happen in burns, especially of the abdominal
probably present. The passage of mucus is a particularly wall, and after laparoscopic insufflation of the abdomen
valuable sign. with gas.
Avoid 'blind' antibiotic treatment unless the condition is
critical. It may merely mask the problem which will You can diagnose ACS by emptying the bladder and then
become worse later. Attempt to drain an abscess under instilling 50ml (or 1ml/kg for children <20kg) of saline or
ultrasound guidance. Try to get to the abscess warm water into it through a clamped catheter, and hold
extra-peritoneally if at all possible. Do not contaminate a the fluid bag up vertically. Let the meniscus settle and wait
clean area of the abdomen with pus from an abscess which at least 1min to allow for detrusor muscle relaxation;
was walled off before! measure its height above the pubic symphysis with the
patient lying supine at end-expiration. It does not give a
If there is no evidence of peritonitis, no abscess on reliable reading if there is a neurogenic or contracted
ultrasound, and you have no good idea of where the bladder. A more reliable method, useful for continuous
sepsis is coming from, do not launch into a difficult monitoring, is illustrated (11-19).
repeat laparotomy.
INTRA-ABDOMINAL PRESSURE MANOMETER
If there is obvious peritonitis, sepsis from a source
unknown, or details of previous surgery are unsure,
perform a re-laparotomy.
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If the pressure is >27cm water (20mmHg), ACS is You must, if ACS is confirmed, re-open the abdomen
confirmed. urgently, and leave it open (laparostomy). Avoid this
N.B. These measures may not be accurate in the scenario by leaving it open in the first place. Do this by
presence of ascites, pregnancy, abdominal packs, obesity, placing a sterile plastic (11-20A) over the bowel and
active abdominal contractions or a neurogenic bladder! tucking this at least 10cm laterally under the abdominal
wall edges, adjusting it so that no excess pressure is
VACUUM ABDOMINAL DRESSING exerted by the plastic. On top of the plastic, place layers of
gauze or sterile sponge (11-20B), and in the midst of these
place 1-2 suction tubes (11-20C).
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COMPLICATIONS.
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POSTOPERATIVELY, adequate analgesia is a big help. CAUTION! To be effective a 'huff' must be long and
Encourage proper deep breathing, moving about in bed, controlled, using the abdominal wall, and not spasmodic.
and getting up as soon as possible. The noisiest 'huff' is not necessarily the best.
Position is important; avoid the semi-recumbent 'slumped' PERCUSSION AND VIBRATION. Percuss the thorax
position, because this restricts movement of the over a towel or blanket with your cupped hands for periods
diaphragm, and promotes the collapse of the lower lung of about 1min. Then rapidly shake the chest during
lobes. Encourage sitting up with a back support. expiration. Relax during inspiration, and follow this with
Insist on early mobilization by the 2nd day, if you can, some deep breathing. Repeat this 2-3 times.
even if there is an IV line, catheter or chest drain to trail
around. Encourage the exercises already learnt. POSTURAL DRAINAGE will be useful if there is much
An 'incentive spirometer' is very useful. fluid in the bronchi. Listen carefully to the chest, and
examine the chest radiograph. Decide where the secretions
COUGHING. Distinguish between an effective deep are worst, and arrange the patient so that this affected part
productive cough (which is what you want) and a noise in is uppermost, using the appropriate position (11-24).
the throat, which is useless. Several short expiratory 'huffs' Encourage deep breathing for 10mins, vibrate and slap the
before coughing will help to loosen the secretions. chest for 10mins, then repeat the breathing. If there is
Suggest taking a deep breath after each cough, and not to established collapse or infection repeat this bd/tds.
cough continually without pausing.
If the patient is too ill for the hips to be raised, lay him
If there is an abdominal wound, it is essential to bend on his side. If the secretions are viscid, ideally he needs
the knees, hold the wound, maybe with a pillow, inhalation therapy to 'loosen' them prior to physiotherapy:
and then to take a deep breath and cough. Give reassurance steam with Friar's balsam or saline with mucolytics from a
that the wound will not split open (if your closure is nebulizer.
adequate!). If you can, use vibration during coughing.
HUFFING. A 'huff' is a rapid forced expiration without a Fig. 11-24 POSTURAL DRAINAGE. Positions which allow gravity
cough. Huffing, when the lungs are in full inspiration, to promote the drainage of secretions from particular parts of the
lung. Study the chest radiograph, and decide which position will be
will dislodge secretions from the larger airways. best. Positions correspond to the following segments: A, left upper
Huffing, when they are half full, will dislodge secretions apical 1. B, left upper posterior 2. C, right upper anterior 3.
from the smaller airways. So encourage huffing in both D, left superior lingular 4a. E left inferior lingular 5a. F, right middle
phases, with periods of relaxation and abdominal breathing medial 5. G, right lower apical 6. H, right lower medial 7.
I, left lower anterior 8. J, right lower lateral 9. K, right lower
between them. Do this every hour from the day of posterior 10. L, left lower posterior 10.
operation; make checks bd for the 1st 48hrs. Kindly contributed by Lynne Wilson
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11.13 Abdominal wound infection If the wound smells putrid, suspect an ANAEROBIC
INFECTION. Treat with oral metronidazole and
A laparotomy wound usually remains tender for 7-10days chloramphenicol. If there is abdominal tenderness
after an operation. If it is abnormally tender and indurated, near-by, suspect peritonitis and re-open the abdomen;
associated with fever, it is probably infected. otherwise check for development of a faecal fistula
Infection may also be elsewhere: in the abdominal cavity, (11.15). Remember if you have inadvertently caught bowel
in the chest, or elsewhere. Sometimes the site of infection in a suture closing the abdomen, this is how the problem
may be unclear. usually firsts presents.
Be guided by the severity of the symptoms. More severe If you see necrotic muscle or fascia, when you remove
anorexia, fever, and malaise, should all make you suspect skin sutures, debride the dead tissues urgently and lay
an abdominal abscess, for example. Consider whether a open the wound widely. Sepsis can spread very quickly
wound infection is a sign of deeper trouble. and be fatal (6.23).
If many of your wounds become infected, look at your
sterile procedures and leave any but completely clean If the wound is tense, swollen & bruised, with old blood
wounds open (11.8). exuding from between the sutures, suspect a haematoma.
Under sedation, remove a few of the skin sutures, and
POSTOPERATIVE WOUND INFECTION wash out old blood and clot with water.
Lift out more clots with a swab. Irrigate the wound with
If the wound is red, painful, and tender, and discharges hydrogen peroxide, and leave it open. If it is clean after
pus, it is infected, so start by removing 1-3 skin sutures on 5days, consider secondary suturing.
the ward. This will show you the extent of the infection.
Take a Gram stain of the pus. If it seems to be deeper, but If the wound discharges a little brownish fluid which
is still extraperitoneal, use sedation with pethidine, smells mousey, suspect GAS GANGRENE (6.24). This is
ketamine or diazepam, and press the sides of the wound, commoner than you probably think. Obvious gas in the
and probe suspicious areas with sinus forceps. Do not open tissues is uncommon, so that gas gangrene is often missed.
up the deeper layers of all infected wounds from top to Remove all of the skin sutures, make a Gram film of the
bottom, or remove the deeper sutures. The peritoneum will exudate, and look for Gram+ve bacilli. Treat aggressively
probably have healed in spite of the infection, but the with IV benzyl penicillin 10MU qid for 5days and with
sutures in the fascial layers will probably pull away. metronidazole 1g PR or IV tid. Debride the wound,
If pus flows adequately, drainage should be adequate. remove any dead tissue, and make sure you isolate this
Irrigate the wound with ¼ strength hydrogen peroxide, patient from other patients.
or hypochlorite solution. It’s best to use a 10ml syringe
with a 24G needle attached: break off the needle from the If the wound discharges chronically, there is probably a
plastic hub: the resulting apparatus will produce the ideal foreign body in situ. This is most likely a non-absorbable
spray. Pack it with dry gauze, or gauze soaked in a mild suture: infiltrate LA, widen the sinus and use a crochet
antiseptic, and change this 1-3 times daily. You can speed hook to remove the suture knot. If the discharge persists,
up the cleansing of a wound by applying a suction there may be a fistula (11.15) or a swab left inside the
dressing; commercial vacuum sponge dressings are abdomen! Take a radiograph (most abdominal swabs
available but expensive. You can make your own by should have a radio-opaque marker), and re-explore the
simply placing a fenestrated drainage tube, attached to a abdomen carefully. Bowel may be caught in the swab, and
suction device, between layers of gauze and sponge, need resecting en bloc (11-7). If there is neither foreign
and sealing the whole assembly against intact skin with body nor fistula, check the glucose & HIV status.
adhesive (‘opsite’ is best). The seal must be air-tight, and
you therefore need to make sure the surface is quite dry 11.14 Burst abdomen (Abdominal dehiscence)
before trying to stick any adhesive. Use a suction pressure
of 50-125mm Hg.
An abdominal dehiscence may occur because you should
CAUTION! not have closed the abdomen in the first place!
(1) Make a wide enough opening to release the pus. A burst abdomen results because either:
(2) Test the glucose and HIV status if the wound infection (1) your suture breaks,
occurs after clean surgery. (2) your knots slip, or
(3) Do not resort to antibiotics unless there is cellulitis (3) your suture cuts out through unhealthy tissues.
present:
The abdomen is likely to burst if:
If the surrounding area is inflamed, there is cellulitis. (1).You have sutured the fascia with absorbable suture,
(6.22) Treat this with IV gentamicin (if you suspect especially if this is of low quality or out of date, or quickly
Gram-ve organisms), or cloxacillin (for Gram+ve absorbed, as with sepsis.
organisms). (2).Your knotting technique is faulty.
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Open it down its whole length by removing all the skin 11.15 Intestinal fistula
sutures. You will soon find out what has happened.
If you confirm a burst abdomen, remove all sutures from An intestinal fistula is an abnormal track, usually lined by
the fascial layers. Gently separate the parietal peritoneum granulation tissue, between the bowel and the skin.
and the underlying bowel and omentum. Take care you do Fistulae are unusual but serious complications of
not damage bowel. Check if there is any evidence of intra- abdominal surgery, and in HIV, tuberculosis,
abdominal sepsis, and wash out the abdomen, and deal actinomycosis or Crohn’s disease arise spontaneously.
with its cause. They may result from a neglected strangulated hernia.
Beware of postoperative fistulae:
If there is any tension when you try to pull the
abdominal wound edges together, measure the width. (1);After you have divided adhesions for intestinal
Do not try to force the abdomen closed under tension: obstruction, especially if you have opened the bowel by
an abdominal compartment syndrome will result (11.10). mistake, and closed it inadequately, or if it is obstructed
There are 3 options but unless you have diathermy the first distally.
2 will be too bloody to be safe: (2);After an anastomosis done inaccurately, or in the
presence of tension, a poor blood supply, or local disease.
Option 1: Make a long relieving incision inside the (3);If bowel is caught in the sutures, when you close the
abdomen longitudinally (11-25B) between the anterior abdomen.
axillary and mid-axillary lines from the costal margin to (4);After appendicectomy especially when the base of the
the iliac crest, preferably with diathermy. appendix was inflamed (caecal fistula).
(5) If you use diathermy close to the bowel.
If you go through the transversus abdominis and internal
SUDHA (25yrs), a young housewife had an operation in a district
oblique muscles only, without cutting the external oblique, hospital for 'appendicitis' through a McBurney incision. Five days after
no lateral hernia will form. You will gain 2cm for each the operation the wound discharged large quantities of pus, and then
side. If you need more, dividing the external oblique in liquid faeces and gas. She was fed on a low-residue diet, and the skin
addition at a position not directly above the previous round the fistulous opening was painted and protected with zinc oxide
paste. Absorbent dressings were changed tid and her distal colonic
incision will give you another 1cm each side; dividing the obstruction due to constipated faeces was treated with glycerine
subcutaneous fascia in addition will give a further 1cm suppositories and a plain water enema. The fistula healed in 2wks and she
each side. You will therefore be able to close a defect 8cm went home.
wide without tension; for a bigger defect, use a vacuum LESSON Some fistulae will close on non-operative treatment.
dressing (11.10).
The mortality rate of a high output fistula (>1000ml/24hrs)
Option 2: Divide the anterior rectus sheath longitudinally is 70%, and a low output one (<200ml/24hrs) is 30%. The
in the midline and slightly laterally separating it from the repair of a fistula is one of the most difficult operations in
muscle bulk (11-26C); then advance both sheaths towards surgery. Do not be tempted to operate!
the midline and close them with one continuous
#1 non-absorbable suture. If intestinal content discharges from the main wound,
or the site of a drain postoperatively, there must be a
Option 3: Place a vacuum dressing over the open bowel perforation. If the patient says that gas comes out,
abdomen, leaving it as a laparostomy: this requires you to this confirms it; if you are in any doubt, get the patient to
decompress the bowel, return it to the abdominal cavity, swallow some diluted methylene blue dye, and watch for it
and cover it with omentum onto which you place the to appear in the wound or in the dressings. The speed at
dressing and suction drains (11.10). which it comes out may give you some idea of whether the
perforation is high in the GI tract.
If there is no tension, and no sepsis present, If there is a localised discharge of bowel content, insert
re-suture the abdominal wall with #1 interrupted steel or
a fine soft catheter into the track and inject 10-20ml of
monofilament sutures. Suture from within outwards water-soluble contrast medium (take some plain
through the peritoneum, posterior rectus sheath, rectus abdominal films: a fistulogram) and you may be able to
muscle, and anterior rectus sheath, but not through the
delineate from where the fistula arises, though static films
skin. Hold all the sutures out on haemostats until you have
are difficult sometimes to interpret.
placed the last one.
Perform an ultrasound scan (38.2K) to detect any fluid
collections in the abdomen.
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Any patient needing admission to hospital with acute 12.2 Causes of intestinal obstruction
abdominal pain has ‘an acute abdomen’ but you have to
distinguish who has a serious illness which may be fatal if Intestinal obstruction will be one of your major challenges.
you do not operate, and who has a self-limiting complaint. It is a common abdominal emergency, and in some
You also must distinguish between peritonitis (10.1) communities the most common one. Some patients with
and intestinal obstruction. Localized peritonitis may cause simple obstruction resolve spontaneously, for example
obstruction; intestinal obstruction can quickly lead to those with ascariasis (often) or tuberculous peritonitis
peritonitis if the bowel blood supply is cut off. (often) or non-specific adhesions (often if early, less often
if late).
When you operate, you may only need to divide adhesions,
or massage a ball of ascaris from a child's ileum on into
the colon. But if you find that a segment of small bowel is
gangrenous, you will have to resect it and consider joining
the remaining ends. You cannot always safely do this in
the presence of sepsis or soiling, especially with large
bowel if it is loaded with loose faeces, because such an
anastomosis may leak. So you may have to construct a
stoma (11.6) or leave the bowel temporarily tied off if the
patient is very sick indeed, and join up the bowel at a
2nd look laparotomy (10.1) at 48hrs when the condition has
improved. Unfortunately, a patient with intestinal
obstruction often presents late, when he may be severely
dehydrated, hypovolaemic, oliguric, and shocked.
Common causes.
Incarcerated or irreducible external hernias
(especially inguinal and femoral).
Volvulus of the sigmoid colon.
Ascariasis.
Intussusception.
Adhesions or bands
(following previous surgery, or abdominal sepsis).
Adhesions or fibrosis due to abdominal TB.
Simple constipation (including faecaloma).
Uncommon causes.
Volvulus of the small bowel.
Fig. 12-1 INTESTINAL OBSTRUCTION. Carcinoma of the large bowel.
A-C, small bowel obstruction. In A, the obstruction is high, there is Carcinomatosis of the peritoneum.
frequent vomiting, no distension, and intermittent pain, which is not
of the classical type. In B, the obstruction is in the middle of the small Amoebic granuloma or stenosis.
bowel. There is moderate vomiting, moderate distension, and Intra-abdominal abscess (including retained swab).
intermittent pain of the classical, colicky, crescendo type with free Bilharzioma.
intervals. In C, obstruction is low in the small bowel. Vomiting is late Mesenteric thrombosis.
and faeculent, and distension is marked. Pain may or may not be
classical. D-E, large bowel obstruction. In D, the ileocaecal valve is Kaposi Sarcoma of the small bowel.
competent, and prevents distension spreading to the small bowel, Trichobezoar, phytobezoar (or other foreign body).
so that there is a closed loop. In E, the valve is incompetent, Intestinal paracoccidiomycosis.
so there is reflux into the small bowel which distends.
After Dunphy JE, Way LW. Current Surgical Diagnosis and Treatment.
Lange 2nd ed 1975 Figs, 33-5, 34-5. with kind permission.
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SITA (8yrs) presented with vague abdominal tenderness and few other PREVIOUS OPERATIONS OR PERITONEAL SEPSIS.
signs. She was not well, and the only striking sign was a pulse of Adhesions and bands can follow any operation or septic
148/min. 12hrs were wasted while she was observed, before a laparotomy process in the abdomen. (The scars may be difficult to see,
was done and 1m of gangrenous bowel was resected. especially in an obese person or after laparoscopic
KRISHNA (45yrs) presented with abdominal distension, colicky pain,
and vomiting. She was examined by a medical assistant who noted pain surgery!) In a woman enquire especially about a past
in her right lower quadrant and a 'lymph node' in her right groin, history of PID (23.1).
and diagnosed appendicitis. He rang up the doctor, who came in, made a
cursory examination, and proceeded with an appendicectomy, using a EXAMINATION
'gridiron' incision. Her appendix was normal. Later, she had to have an
emergency operation for a strangulated femoral hernia. DISTENSION AND HYPER-RESONANCE. If there is
LESSONS (1) Strangulation can be difficult to diagnose. Tachycardia is a colic and vomiting, the bowel is obstructed until you have
useful sign. (2) ''When acute abdominal pain presents, one maxim I proved otherwise. Distension is not an essential part of the
enjoin, pray do not miss that tiny lump, in one or other groin.'' (Zachary clinical picture. The earliest signs of it are a little fullness
Cope)
in the flanks, or an increased resonance to percussion.
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If the percussion note over the abdomen is 'tympanitic', If, in a child, you feel an ill-defined mobile mass
there are distended gas-filled loops of bowel. (or masses), usually in the umbilical region, sometimes
in the iliac fossae, it is probably a mass of ascaris worms.
If distension is conspicuous and other signs are
minimal, suspect large bowel obstruction. If it is extreme, If there is a large, slightly tender, mobile sausage-
suspect sigmoid volvulus, or Hirschsprung’s disease. shaped mass, some of the bowel may be caught in an
intussusception. If the mass is rounder, it may be bowel
If you are not sure if the distension is caused by bowel infarcted due to torsion.
obstruction or ascites, examine for shifting dullness.
Remember that fluid and gas in a distended bowel can If the mass changes its position from one day to
cause shifting dullness, but that it is less obvious than with another, and is accompanied by colicky pain, this is
ascites. probably recurrent intussusception, a mass of ascaris
worms (12.5), or constipation.
If you are not sure if true distension is present or not,
particularly in the obese, measure the girth at some fixed If you feel an ill-defined lump or lumps in the right
place, and see if it increases. Also see if the trousers or lower quadrant, this may be ileocaecal tuberculosis or
skirt fit comfortably. carcinoma. You may also feel more central lumps caused
by caseating tuberculous lymph nodes.
OBSTRUCTIVE BOWEL SOUNDS. Listen for these at
the time pain appears, while you are taking the history. If there is a tender indurated mass, suspect that the
This is essential if you are going to pick up the critical sign obstruction is due to intraperitoneal sepsis (10.1),
of intestinal obstruction during the 30sec during which lymphoma or tuberculosis.
peristaltic waves make a ladder pattern on the abdominal
wall, accompanied by a rush of high-pitched tinkles and If you feel hard impacted compressible masses in the
splashes. If you miss this opportunity it may not return for colon and rectally, they are masses of faeces, and may be
15mins. So, if the patient loses interest in the conversation, causing the obstruction (not uncommon in the old and
and grimaces with pain, listen quickly. If you hear runs of debilitated).
borborygmi (audible rumblings), or a chorus of tinkling
high-pitched musical sounds at the same time that he If there are one or more masses especially at the
grimaces with colic, there is almost certainly obstruction umbilicus and also ascites and cachexia, this is probably
present. These are very useful early signs. disseminated carcinoma.
N.B. Do not mistake them for the peristaltic rushes of
gastroenteritis, or normal hyperactive bowel sounds. RECTAL EXAMINATION must never be forgotten!
If you find fresh blood and mucus on your finger, or on
VISIBLE PERISTALSIS. In a thin patient, look for waves the toilet paper, there is probably an intussusception,
of peristalsis passing across the abdomen. If he is very thin a strangulating lesion higher up, or carcinoma of the large
this may be normal, especially in a young child. bowel. Occasionally, you may feel the tip of the
intussusception or see it appear out of the anus.
A TENDER MASS AT ONE OF THE HERNIAL Do not confuse this with rectal prolapse (26.8).
ORIFICES. If you find a painful tender mass, this is an
incarcerated or strangulated hernia, until proved otherwise. If you feel a hard mass of faeces,
Always examine the inguinal and femoral orifices. suspect that constipation may be causing the obstruction.
CAUTION! Ask about dietary habits, and causes listed above.
(1);You can easily miss a strangulated femoral or
umbilical hernia, especially under an apron of fat in an If the rectum is empty and even 'ballooned',
obese person: it may not be tender or painful. you may be dealing with a pseudo-obstruction.
(2);Rarely, a hernia may have been reduced 'en masse'
(18.3) by the patient or medical personnel! If you feel a tense, tender, possibly fluctuant mass
bulging into the pouch of Douglas, it is probably a pelvic
ABDOMINAL TENDERNESS is not a prominent feature abscess. You may feel it more easily bimanually, with
of uncomplicated obstruction. Obvious tenderness over your other hand exerting pressure suprapubically (10.3).
part of the abdomen suggests bowel ischaemia. If there is
peritonitis, this means the bowel is definitely necrotic. If you find a hard mass in the recto-vesical pouch
(a 'rectal shelf'), it is probably malignant. Tumour deposits
AN OLD LAPAROTOMY SCAR suggests that the cause here may be well-defined hard lumps, or a 'shelf' caused
of an obstruction may well be a band, an adhesion, or an by tumour growing into the surrounding tissue.
area of stenosis, but this may not necessarily be the case.
HAS THE BOWEL STRANGULATED?
A PALPABLE ABDOMINAL MASS is unusual, You may not be certain about this until you perform a
apart from a mass at a hernial orifice. Feel carefully, here laparotomy. Strangulation is easy to diagnose when it is
are some of the masses you might find: advanced, unless it is so advanced that there is septic
shock. Try to diagnose it early.
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Individually, the features below are not diagnostic, To distinguish large and small bowel shadows,
but the bowel has probably strangulated if several of the remember that:
following features are present: (1) Fine folds or partitions, (valvulae conniventes), extend
(1) Sudden onset of symptoms. right across a distended jejunum which is more central in
(2).Severe continuous pain: this is the result of bowel the abdomen.
ischaemia or irritation of the parietal peritoneum. (2) The ileum has no folds distally, and few proximally.
If there is minimal discomfort and absence of pain (3) The caecum is a rounded mass of gas.
between waves of hyperperistalsis, the bowel is probably (4).The haustral markings of obstructed large bowel are
not strangulated, but only obstructed (unless it is sealed off rounded and much further apart than the valvulae
in a hernial sac or is an intussusception). conniventes of the jejunum, and do not cross its full
(3).A fast pulse: this is perhaps the most reliable sign; diameter.
if the pulse is < 88/min, there is unlikely to be strangulated (5).The large bowel is more peripheral in the abdomen,
bowel present. whereas the small bowel is more central.
(4).Fever: this suggests strangulation, or sepsis.
Simple obstruction does not cause fever! Free gas in the peritoneum is usually a reliable sign of
(5) A low or falling blood pressure. perforation. You will see it better under the diaphragm in
(6).Localized tenderness, or rebound tenderness; this is a an erect chest film, and under the abdominal wall in a
sign of peritoneal irritation, and can be caused by lateral supine film. (Free gas may occur from gas-forming
inflammation, blood in the peritoneal cavity, organisms in the peritoneal cavity.) On an abdominal film,
or strangulation. Tenderness may be masked by loops of look for air both outside and inside the bowel wall, and air
normal bowel over the strangulated area, so its absence is outlining the lateral wall of the liver.
not significant.
(7).The passage of blood or blood and mucus rectally: Gas in the small bowel is always abnormal, except:
this is typical of intussusception, but you may see it (1) in the duodenal cap,
whenever the blood supply of the bowel is impaired. (2) in the terminal ileum (rare),
(8).Signs of generalized peritonitis, (tenderness, guarding, (3) in children <2yrs.
and absent bowel sounds), prostration, and shock.
CAUTION! Never administer barium contrast media by
ABDOMINAL RADIOGRAPHS IN INTESTINAL
mouth in intestinal obstruction.
OBSTRUCTION
Take films in the erect and supine positions. They can
usually give you the diagnosis, its site and chronicity,
and sometimes its cause, for example, intussusception
(12.7).
While the patient is lying down, take a supine AP film. Fig. 12-3 INTESTINAL OBSTRUCTION.
If he is not well enough to sit up by himself, support him Patient A has distended loops of small bowel. Note the different
in the sitting position while you take an erect film. patterns of the jejunum and ileum, the jejunum has 'valvulae
conniventes' (transverse bands across it), whereas the ileum is more
This will be more useful than the alternative, which is a featureless. The caecum and ascending colon are distended, but there
lateral decubitus film, taken from the side while he is lying are no signs of the transverse colon or rectum. (A barium enema
down. Its purpose is to show fluid levels, and maybe gas showed a carcinoma just beyond the splenic flexure).
under the diaphragm. Patient B's large bowel is distended down to the sigmoid colon,
but there is no rectal bubble. This is typical of distal large bowel
When you examine the films, first see if there is a obstruction; there was a carcinoma of the sigmoid colon.
distended large bowel shadow, and especially a caecal These are supine films, so there are no fluid levels, but the valvulae
shadow. If there is, the large bowel is obstructed. and haustra show up well.
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Fluid levels in the small bowel are always abnormal OTHER INVESTIGATIONS A high Hb or haematocrit
except where there is no distension. Elsewhere, fluid levels are some indication of the severity of dehydration.
in the small bowel indicate: Urea and electrolyte measurements are very helpful.
(1) mechanical obstruction, Expect a potassium deficit.
(2) paralytic ileus, or
(3) gastroenteritis. Ultrasound is usually unhelpful, but if there is a mass,
Look for them in erect films. The larger and more it can show if this is solid, or contains worms, or gives the
numerous they are, the lower and the more advanced the classic double ring appearance of intussusceptions.
obstruction.
DIFFICULTIES IN DIAGNOSING INTESTINAL OBSTRUCTION
Gas in the large bowel is normal, but not if the bowel
shadow is hugely distended. If there is excruciating abdominal pain, massive
abdominal distension, and circulatory collapse,
If there are fluid levels in the large bowel, they may be: the possibilities include:
(1) normal (if there are only a few), or (1) Volvulus of the sigmoid with gangrene.
(2) caused by gastroenteritis. (2) Ileosigmoid knot (12-14).
(3) Volvulus of the small bowel or caecum.
If the large bowel is also distended there is: (4) Perforation of a peptic ulcer presenting late.
(1) a mechanical obstruction, (5) Generalized peritonitis leading to ileus.
(2) paralytic ileus, or (6) Typhoid fever with perforation.
(3);some other cause for the dilatation, such as amoebic (7) Acute pancreatitis.
colitis. You may not be able to diagnose which of these there is
until you operate. Rapid resuscitation and urgent surgery is
If there are distended loops of large and small bowel necessary, but try to exclude pancreatitis first.
irregularly distributed with gas in the rectum, suspect
paralytic ileus. If there are obvious abdominal signs, but the patient
looks comparatively well, (and he has not been
If there is no gas in the caecum (which normally contains vomiting), suspect large bowel or incomplete small bowel
some gas), suspect that the small bowel is completely obstruction.
obstructed.
If there are the other signs of obstruction, but loose
If there are distended loops in the small bowel and stools are passed with or without flatus, there may be:
minimal air in the colon, suspect partial small bowel (1) An incomplete large bowel obstruction.
obstruction. (2) A pelvic abscess.
(3) A Richter's hernia (18.1).
If there is gaseous distension of the large bowel with
minimal small bowel distension, suspect large bowel If there is a history of several days of fever, anorexia
obstruction or the Ogilvie syndrome. and localized abdominal pain, followed by colicky pain
and the other symptoms of obstruction, suspect that
If there is much gas in the caecum (which may be huge), obstruction has followed intraperitoneal sepsis. Distension
the large bowel is obstructed. As the pressure builds up, may mask the abdominal findings, but you may be able to
the small bowel often starts to distend, because the elicit deep tenderness and induration in the right lower
ileocaecal valve is incompetent (in ⅔ of patients). quadrant, suprapubically, rectally, or, in a woman,
vaginally.
If you see a mottled opacity in the right lower
abdomen, suspect a bezoar (13.12) If the abdomen is distended and associated with
vomiting but no typical colicky pain of obstruction,
If you see a really massive gas bubble, the stomach may suspect ileus rather than obstruction, especially if there is
be dilated, or there may be volvulus of the sigmoid colon toxaemia and dehydration. Obstruction appears
(12.9) or of the caecum and ascending colon (12.12). spontaneously, whereas paralytic ileus usually follows
some good reason for it, such as local or general
If there is a gas in the rectum and rectal examination is peritonitis, a previous operation, or an intraperitoneal
normal clinically, obstruction is unlikely; but if the large injury or haemorrhage.
bowel is hugely distended this suggests pseudo-
obstruction. If signs of obstruction develop after surgery, you will
find it difficult to know if the obstruction is mechanical or
If the large bowel is relatively empty, and the fluid due to the paralysis caused by ileus (12.16).
levels in the erect film pass obliquely upwards from the
right iliac fossa to the left hypochondrium, like a
stepladder, they suggest volvulus of the small bowel.
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12.4 The management of intestinal Do not embark on complicated operations which need
obstruction much dissection unless you are experienced and have good
back-up. Even then, always remember that a long
operation in an acutely ill patient is not a good idea.
Operation is mandatory for ischaemic bowel; simple
mechanical obstruction may resolve without operation, Open the abdomen with the greatest possible care: you can
but if it fails to improve after 48hrs, operate. The detailed so easily perforate the bowel and flood the abdomen with
indications for operating are listed below. Operate at the small bowel fluid. Distended loops of bowel will bulge
optimum moment after you have rehydrated a patient, through the incision. Deliver them on to the surface,
but do not operate if the condition is hopeless. and do not try to examine the depths of the abdomen until
you have done so: they will continually obscure your field.
Rehydrate rapidly over a few hours. If you rehydrate
energetically, you should be able to operate within 4hrs, Because distended loops of bowel are so difficult to work
and certainly within 6hrs. If you suspect strangulation with, decompress them. Doing so makes distended bowel
obstruction, try to operate within 2hrs, and rehydrate as much easier to handle, makes the abdomen easier to close,
best you can before doing so. If the patient is conscious reduces the risk of anastomotic leak if you have to resect
with a normal blood pressure and is passing urine, bowel, and reduces the risk of post-operative vomiting and
he is probably fit for operation. aspiration. The danger of decompression is that it
At the same time pass a nasogastric tube and drain the inevitably contaminates the peritoneum a little, unless you
fluid and gas from the dilated stomach and upper small use the retrograde method (via a nasogastric tube).
bowel. This will stop vomiting, and may reduce the But carefully opening distended bowel outside the
distension. Most importantly, it will reduce the danger of abdomen, hanging over its edge, with the proper
aspiration of stomach contents during induction of precautions causes much less contamination than an
anaesthesia. uncontrolled burst, which is the probable alternative.
So, if bowel is greatly distended, decompress it.
PREOPERATIVE PREPARATION
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If the patient is thirsty, and the lips and tongue are dry, N.B. Always operate if there is even a suspicion of
dehydration is mild: use at least 4l of fluid. strangulation obstruction.
METHOD. Continue nasogastric suction and IV infusions.
If there are also sunken eyes and loss of skin elasticity, Make careful observations. If you continue to restrict
dehydration is moderate: use about 6l. fluids orally for more than a few days, try to add at least
8·5MJ (about 2,000Kcal) of energy to the daily intake.
If there are also oliguria, anuria, hypotension, If possible, administer this as 50% dextrose into a central
& clammy extremities, dehydration is severe: use about vein. When the nasogastric aspirate has reduced, instil
8l. 15-30ml gastrografin, if you can, and see if this promotes a
bowel action.
If there is also weakness and disorientation, fluid loss is
probably >8l. Do not be afraid to infuse up to 4l for the If you suspect simple constipation, instil a phosphate or
first hour. Set up a CVP line, if you can. soap-and-water enema. If the faeces are rock hard and fail
to move, remove them manually under GA. A ‘Murphy
In the elderly or those with cardiac problems, check the skid’ (normally used to dislocate the hip) is a useful
lung bases for crepitations, and the jugular venous pressure instrument to help you do this. Advise a short course of
or the CVP. IV fluid replacement and diuretics may be laxatives and a high-fibre diet: an instruction sheet is
necessary. useful to give to patients. Chopped rice husks are ideal.
Do not use liquid paraffin: aspiration causes severe
If the bowel strangulates, its veins block before its pneumonitis, and if used with illicit drug ‘body packers’
arteries, so that blood is lost into the lumen, so transfuse it can cause the packets to dissolve and the opiate carried
1 unit of blood per 50cm of strangulated bowel. to be rapidly absorbed.
If you have corrected the hypovolaemia as shown by an If you suspect oesophagostomiasis (especially in
adequate urine output, or a normal CVP, but there is Northern Ghana & Togo), use albendazole 10mg/kg od for
still hypotension, this is probably due to septic shock. 5days.
Signs of improvement are:
URETHRAL CATHETERIZATION. This is necessary (1) Reduction in the gastric aspirate to <500ml/day
for a very ill patient to measure the urine volume hourly. (2) Reduction in abdominal distension.
If the patient is not very ill, its risks may outweigh its (3) Return of bowel sounds to normal.
advantages. If an adult passes 35-60ml/hr, the kidneys are (4).Less pain. No tenderness.
being adequately perfused, and the blood volume is (5).Finally, flatus & the passage of stools.
becoming normal. For a man, use of Paul's tubing is often
better. Do not insert a catheter if no-one will record the DECOMPRESSION
urine output! However, if there is large bowel obstruction OF LARGE BOWEL
and you plan to operate in the pelvis, it is important that OBSTRUCTION (12.9)
the bladder will remain empty to give you more room to
POSITION FOR
operate. DEFLATIION
SIGMOIDOSCOPY
ANTIBIOTICS. Use perioperative antibiotics (2.9):
chloramphenicol 50mg/kg IV qid or gentamicin 3mg/kg
IV od plus metronidazole 7·5mg/kg tid
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If you do not have a sigmoidoscope, or its light does not CAUTION. Do not use neostigmine in asthmatics,
work, you may succeed in deflating the colon with a soft epileptics, pregnancy or breast-feeding mothers, or if the
rubber tube while in this position. The sigmoidoscope blood pressure is low. Have atropine 06mg IV ready as
usually travels 20-25cm before it reaches the point where an antidote if bradycardia results.
the colon is twisted, but you may not be able to reach this N.B. Fashioning an ileostomy or colostomy is not
point. If you do, look at the mucosa carefully. If it looks helpful.
normal through the sigmoidoscope, hold the ’scope firmly,
and pass a large (Ch36 or 12mm) well-lubricated soft B..OPERATIVE TREATMENT FOR INTESTINAL
rubber tube through it. With a gentle rotatory movement, OBSTRUCTION (GRADE 3.4)
ease the tube past the twist into the high-pressure area of INCISION.
the dilated sigmoid. Do not use force or you may perforate A midline incision, ⅓ above the umbilicus and ⅔ below it,
the bowel! is usually best. Start with a 10cm incision and enlarge it up
or down as necessary. You will probably find that the
If you succeed in deflation, you will be rewarded by much posterior rectus sheath and the peritoneum will appear as
flatus and some loose faeces. Both you and the patient will 2 distinct layers, now that the abdominal wall is distended.
recognize that you have relieved the obstruction. Have moist packs (laparotomy pads) ready. Put them into
Withdraw the sigmoidoscope, taking care not to pull out warm water and then wring out most of the fluid.
the flatus tube when you remove the sigmoidoscope! Use them to cover any bowel that bulges out of the wound,
Using LA, suture the flatus tube to the anal margin, and and to wall off any fluid that spills.
leave it in place for 2days. It may continue to discharge
liquid faeces, so attach an extension tube to it, and lead If there is an old scar, open the abdomen at one end of it
this into a bucket beside the bed. If drainage stops, wash to avoid a loop of bowel which may be adherent (11.2).
out the tube. Do not leave the tube in for more than 72hrs, This is safer than making a parallel incision, which may
or it may cause pressure necrosis. lead to necrosis of the abdominal wall between the
CAUTION! 2 incisions.
(1) Do not anaesthetize the patient or use a heavy sedative.
Pain during or after sigmoidoscopy is a useful indication If there is a strangulated external hernia, make the
of trauma or gangrene. appropriate incision (18.6,8).
(2);If the sigmoid is gangrenous, trying to deflate it is CAUTION!
dangerous; you may perforate it. (1).Open the abdomen with the greatest care (11-2).
(3);Do not pass a sigmoidoscope using force or without Use your fingers! Distended loops of bowel will be
seeing where you are going: you may push it through the pressing up against the internal abdominal wall, and the
colon. smallest nick of a scalpel will go straight into the bowel.
(4);Wear an apron and theatre boots, because a huge You can so easily cut the thin wall of the distended colon
quantity of flatus and fluid may rush out. Extinguish any and cause a fatal peritonitis.
cigarettes in the vicinity and stand well back! (2).Note which parts of the bowel are distended; you will
need to know this later, to decide where the obstruction is.
If you fail to pass the sigmoidoscope far enough,
consider whether there might be a carcinoma. HANDLING THE BOWEL.
Try the knee-elbow position if you have been using the left If it is very distended, decompress it before you do
lateral position. anything else, especially if there are multiple dense
adhesions which prevent you lifting out the bowel from the
If you see any discoloration through the sigmoidoscope, abdominal cavity. If it is less distended, use a moist swab
or any blood-stained fluid, or the patient cannot to lift the dilated loops from below gently out on to the
tolerate the procedure, suspect strangulation and prepare surface of the abdomen.
for an immediate laparotomy. Never pull on the bowel: it will tear! Handle bowel with
the greatest care. If you handle it roughly you will prolong
If the fluid which runs out is bloody, assume that the the period of postoperative ileus. Be especially careful of
sigmoid has an area which is non-viable. Prepare for an the caecum. It is often greatly thinned, and if it does burst,
immediate laparotomy. (A smear of blood is not a soiling will be particularly dangerous.
sufficient indication.) Do not let loops of the bowel get dry: cover them with
moist packs. If they are heavily laden with fluid, ask your
METHOD: USE OF NEOSTIGMINE. assistant to support them.
This is only indicated for pseudo-obstruction, so perform a If you make a very superficial cut only into the
sigmoidoscopy as above to exclude volvulus or other seromuscular wall of a loop of bowel, leave it alone.
causes of large bowel obstruction. The sigmoidoscopy Close a deeper injury (you will notice the mucosa pouting
may help to deflate the colon partially. Administer 2mg out), with a purse string suture or by sewing it up
neostigmine IV slowly. Monitor the patient carefully. transversely in two layers, while trying to keep spills to a
The bowel will usually deflate immediately. minimum.
Repeat neostigmine after 1hr if the effect is only partially If you soil the abdomen with faeces, suck them out
successful. immediately. Irrigate the peritoneal cavity thoroughly with
liberal amounts of warm fluid.
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DECOMPRESSION FOR INTESTINAL OBSTRUCTION The Poole’s sucker has a guard with several holes.
It blocks less easily than a needle, but the risks of a spill
Be safe, and decompress the bowel if there is any risk of are greater. It always blocks eventually. Removing it,
rupturing it: unblocking it, and reinserting it may be necessary,
(1).if it gets in your way unduly, but is likely to cause a spill. (A Yankauer sucker does not
(2).if dense adhesions prevent you lifting it out of the have a trocar, so it is difficult to use without spilling.)
abdomen, or CAUTION! After you have inserted a sucker,
(3).if it prevents you closing the abdomen. do not remove it unless you have to. If you have to remove
it to clear it, pack off the peritoneal cavity to avoid
If you have to open the bowel, pack off the remaining spillage, and discard any contaminated packs.
abdomen with moist swabs in order to limit contamination
with bowel content. Alternatively you can use a large Foley catheter; insert it
Make sure your suction is connected and working well. (with extra side holes cut close to the balloon) connected
to the sucker. Suck the bowel empty. Then blow up the
There are 5 ways to decompress the bowel: balloon and 'milk' it along the bowel, sucking as you go.
If it blocks, inject some saline and start again. Withdraw it,
(1) RETROGRADE DECOMPRESSION is the method of sucking as you go, then close the purse string.
choice, provided the bowel is not too oedematous and
friable. It is useful for the entire small bowel. Start at the (4).USE OF THE SAVAGE DECOMPRESSOR.
jejuno-ileal junction, and milk the contents proximally Insert a purse string suture on the antimesenteric border of
between your straight index and middle fingers into the the bowel as before, make an enterotomy incision in the
stomach. Palpate this from time to time if it gets full, in centre of this, and push the decompressor with its trocar
order to dislodge trapped air and thick fluid blocking the through. Withdraw the trocar and close the proximal
nasogastric suction tube. You may need some firm opening of the decompressor with its threaded cap.
pressure on the proximal jejunum. When you have emptied With your thumb on the vent to control the degree of
enough fluid out of the jejunum, massage the fluid suction, start sucking out gas and fluid. Make sure that
from the ileum into it and repeat the process. intestinal fluid, which may come gushing out of the suction
As you decompress, ask the anaesthetist to keep aspirating vent, pours into a bowl outside the abdomen!
fluid from the stomach. Pass the decompressor proximally and distally, carefully
This is usually the best method, but make sure that suction threading the distended loops of bowel over it as you suck.
through a large bore nasogastric tube is working properly, To minimize clogging the holes, remove your finger from
or the fluid may spill and your patient may aspirate it! the vent from time to time. This will reduce the suction
It may prove difficult or impossible if the bowel content is and let the food particles fall away. Or, more effectively,
very thick, as in distal small bowel obstruction or large reintroduce the trocar. When you have decompressed
bowel obstruction. Do not use this method in children enough bowel (there is no need to decompress it all),
where the anaesthetist has put in an uncuffed endotracheal remove the decompressor, close the purse string, and put it
tube. in the 'dirty basin'. Reinforce the purse string with a
second layer of sutures, 3 mm beyond the first, going
(2).NEEDLE PUNCTURE. You can use a specially through the seromuscular layer only.
prepared spinal needle. This will remove gas, but is soon
blocked by food particles when you try to remove liquid. (5).FORMAL DRAINAGE.
A spinal needle, connected to a rubber tube, is especially Mobilize a suitable segment of bowel and make sure it can
useful for the sigmoid colon and the caecum, which are hang outside the abdomen; pack off the peritoneal cavity
often distended only with gas. Its advantage is that there is and other organs with swabs, and hold the bowel with
no need to insert a purse string after removing the needle. Babcock forceps. Preferably place two non-crushing bowel
Pack off the colon well. Push the needle through a taenia clamps across the bowel and make a 1cm enterotomy on
coli, and advance it longitudinally between the muscle the antimesenteric surface between them. Release one
coats for 3cm. Then angle it inwards through the circular clamp in turn and allow the bowel content to drain into
muscle to reach the lumen. Keep its point in the gas and large bowls held carefully to catch the fluid, as you
clear of the fluid. If it blocks, pinch the rubber tube massage the fluid from each end towards the hole you
connected to the needle, then pinch it again distally. have made. Then close the hole in 2 layers (14.3).
This should provide enough pressure in the needle to free
it. If you insert the needle obliquely, there is no need to This is the best method if you have to resect bowel
close the hole, which should not leak. anyway: drain the bowel contents from the open ends of
bowel before anastomosis (11.3).
(3).POOLE’S SUCTION. Select a site in the bowel,
and empty it of its content by manual massage externally, Measure the fluid you have aspirated to see how much has
and then place two non-crushing bowel clamps on either been lost. Record this in the notes.
side of the emptied portion. Insert a purse string suture on
the antimesenteric border, and make an incision in its
centre into the lumen of the bowel, and push the Poole’s
sucker through. Release the proximal clamp.
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If you find a loop which feels 'tethered', and you cannot Now turn your attention to closing up: do this with
lift it into view, it is probably the site of the obstruction. particular care as a 'burst abdomen' is a major risk (11.14).
Expose this area well, by appropriate retraction, Distension may also recur, hopefully only temporarily.
by packing bowel away, and by lengthening the incision. Remember to bring the omentum down over the bowel to
If the bowel is firmly stuck in the pelvis, don’t try to separate it from the abdominal wall; this will often prevent
dissect it out when you can’t see properly: it is then best to adhesions, and is especially important if you have made an
pinch it firmly, and extract it with your fingers, knowing anastomosis.
you will have to resect that portion. Be sure you have Close the abdomen by Everett's method (11.8)
decompressed the proximal bowel before you do this!
If the abdomen is difficult to close, decompress the small
If the obstruction is difficult to find, remember that it is bowel into the stomach, and again empty it by aspiration
more likely to be in the small bowel. through the nasogastric tube. If necessary use the 'fish'
(12.5). If this fails, leave the incision open, and fix a
If you are not sure if a piece of bowel is large or small, vacuum dressing in place (11.8)
remember that large bowel has taenia coli running over its
surface. If you have had to resect bowel, or the peritoneum has
been soiled, wash out the peritoneal cavity with warm
If you do not know which piece of bowel is proximal sterile water.
and which is distal, pass your hand down to the root of
the mesentery, and remember that it runs obliquely If there has been significant soiling, leave the skin edges
downwards from left to right. Follow the bowel to its end. unsutured for delayed primary closure (11.8).
If you really are lost as to which way the bowel goes, POSTOPERATIVE CARE
you have no alternative except to deliver the obstructed FOR INTESTINAL OBSTRUCTION
loops until you reach the duodenum proximally, or the Continue nasogastric suction until flatus is passed,
obstructed focus distally. Check if the bowel is viable the distension is becoming less, the bowel sounds are
(11.3, 11-6). returning, and the nasogastric aspiration is ≤500ml daily of
CAUTION! Do not try to rely on the standard light-green fluid, which is the normal gastric secretion. (If
differences between ileum and jejunum. Obstructed bowel the aspirate is persistently large, but flatus is being passed,
loses some of its characteristic features. withdraw the drain 10cm: it might have slipped into the
duodenum) Commence free oral intake when faeces has
If you cannot find or release the cause of the been passed.
obstruction, and yet the bowel is grossly distended,
decompress it preferably as near proximal to the Continue to keep an accurate fluid balance chart. Measure
obstruction as possible. Search the length of the bowel the urine output, and when necessary the CVP. An adult in
again, including in the pelvis, for missed pathology. the tropics loses at least 3l of fluid a day (skin 1l. lungs
Could this be a pseudo-obstruction? Or a Chagas 0·5l. urine 1·5l). Replace this with 1l of 0·9% saline and 2l
megacolon? Or a toxic megacolon from amoebiasis or 5% dextrose. In a hot humid environment increase these
ulcerative colitis? volumes by 50% after the first 24-48hrs. Monitor the urine
output: this should be at least 1·5l by the 3rd postoperative
If you find a mass within the bowel, but not attached to day.
its wall, it is probably a foreign body (gallstone, bezoar, or
other ingested foreign body): make a transverse Replace the fluid you aspirate from the stomach in
enterotomy and remove the obstruction. addition. You can usually replace it with IV 0·9% saline or
Ringer's lactate.
SPECIAL METHODS. See elsewhere for: obstruction due
to bands and adhesions (12.6), inguinal hernias (18.6), As soon as a postoperative diuresis starts (at 24-60hrs)
femoral hernias (18.7), other hernias (18.10 to 18.14), replace the potassium loss. Basic needs are about
ascariasis (12.5), intussusception (12.7), volvulus of the 40mmol/24hrs. But if IV fluids are still needed after 48hrs,
small bowel (12.8), sigmoid volvulus (12.9), volvulus of up to 80mmol of potassium a day may be necessary,
the caecum (12.12), and abdominal tuberculosis (16.1). depending on the volume of secretions lost. Replace this
loss, either as a 1M solution added to the IV fluids, or as
CLOSING THE ABDOMEN AFTER INTESTINAL Ringer’s lactate ([K+]=4mM), or as Darrow's solution
OBSTRUCTION ([K+]=34mM) or as half-strength Darrow's ([K+]=17mM).
Before you close the abdomen, have a last look at the DIFFICULTIES WITH INTESTINAL OBSTRUCTION
bowel, check the anastomosis (if you have made one), and If you do not know what to do about an obstruction,
look for bleeding, and at the length of the proximal bowel and the situation looks very complex,
(if you have decompressed this) for damage or leaks. consider bypassing the obstruction by anastomosing a
Wash the abdominal cavity thoroughly. Handle the bowel distended to a collapsed loop. Or, if you cannot do this,
carefully. bring out the proximal loop of bowel as a stoma.
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If the large or small bowel is not viable, but you are not
sure how to make a safe anastomosis, exteriorize the
bowel. Bring the non-viable bowel out through a stab
wound which is big enough to accommodate it.
Suture its margins, at a point where it is healthy, to the
skin of the wound, so that it won't slip back inside.
Close the laparotomy wound carefully. The stoma will be
of rather generous proportions, sticking out of a short
wound in the flank. Then cut off the non-viable bowel
about 3cm from the skin to form a double barrelled stoma.
You will have to replace orally the large volumes of small
bowel fluid lost from an ileostomy or jejunostomy (11-12).
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ABDOMINAL RADIOGRAPHS show multiple fluid PREPARATION. Correct any dehydration present.
levels on an erect film, and you may see the worms (12-7). Insert a nasogastric tube.
They may not be the cause of the symptoms. Radiographs
are not necessary if you can make the diagnosis clinically. INCISION. Make a transverse or midline incision and
inspect the bowel.
ULTRASOUND will demonstrate a mass filled with If the mass of worms has thinned, devitalized, or
worms which you can see moving. Ascites is a bad sign. eroded the bowel, or it is intussuscepted or twisted,
resect it. Decompress the remaining bowel and milk out all
DIFFERENTIAL DIAGNOSIS includes the other the worms you can feel. Instil piperazine intraluminally
common causes of intestinal obstruction in childhood. along the whole length of bowel and perform an
Suggesting intussusceptions: a more regular sausage- end-to-end anastomosis. Try to cover your enterotomy
shaped mass, the passage of blood and mucus rectally, closure or anastomosis with omentum in order to prevent
and tenderness which is more acute. any remaining live ascaris worms migrating through.
CAUTION! If you have difficulty, do not be tempted to
Suggesting an appendix abscess causing obstruction: perform a bypass operation above the level of the worms.
the mass is not mobile, tenderness is more acute; a
swinging temperature and toxaemia. If there is severe contamination, leave the skin open
(11.8).
Suggesting Hirschsprung’s disease: long-standing
gaseous abdominal distension with chronic constipation. If the bowel is healthy and you find a ball of worms
N.B. Tapeworms do not cause obstruction. blocking it, try, if possible, to break up the ball and milk
the worms avoiding tearing the serosa, through to the
NON-OPERATIVE TREATMENT caecum, where they will be safely expelled. If they are in
FOR ASCARIS OBSTRUCTION the terminal ileum, this should be easy. If they are more
proximal, do not try to milk them up into the stomach:
INDICATIONS. The child's general condition is good, they may then climb the oesophagus and be aspirated into
the colic is intermittent, and the vomiting is mild. the bronchus.
There are no signs of peritoneal irritation.
POSTOPERATIVE ‘DE-WORMING’.
METHOD. Introduce 15-30ml of gastrografin through the Do not ‘de-worm’ the child until 48-72hrs after all signs of
nasogastric tube and clamp it for 4hrs: this often obstruction have gone, and there are no palpable masses
dehydrates and disentangles the worms. of worms. Then use a single dose of piperazine citrate 4g,
CAUTION! which will paralyse the worms so that they pass rectally.
(1).Do not try to ‘de-worm’ a child with partial or Or, use mebendazole 100mg bd for 3days.
complete obstruction. Wait until the obstruction has gone.
(2).Do not use purgatives: they may precipitate DIFFICULTIES WITH ASCARIS OBSTRUCTION
intussusception or volvulus. If you cannot milk the worms downwards, and the wall
of the bowel is healthy, try injecting 15-30ml of
LAPAROTOMY FOR ASCARIS OBSTRUCTION (GRADE 3.4) gastrografin into the lumen of the bowel proximally: this
might break up the mass satisfactorily. Otherwise, isolate
INDICATIONS. A laparotomy is not often needed. the mass carefully with abdominal packs. Resect the
Absolute indications are: affected portion of bowel; then try to remove all the
(1).Signs of perforation, which is caused by pressure remaining worms in the bowel by milking them down
necrosis from the obstructed mass of worms, which may through the open bowel ends. Most of them will probably
lead to migration of a worm into the peritoneal cavity. be in the upper small bowel. If you can remove all of
(2).Signs of peritonitis associated with intussusception, them, there will be no chance of them working their way
volvulus, appendicitis or, rarely, diverticulitis of a Meckel through a suture line later. Nonetheless, make a careful
loop. anastomosis (11.3).
(3).Persistent abdominal pain with a tender palpable mass.
(4),Jaundice which you think might be caused by a worm If you have difficulty milking all the worms out of the
in the bile duct (15.6). retroperitoneal duodenum or the rest of the bowel,
construct an enterostomy (11.6). When bowel function has
Relative indications are: re-commenced, instil gastrografin into the bowel lumen.
(1).Toxaemia out of proportion to the severity of When you are satisfied that all the worms have been
obstruction. expelled, close the stoma. If you are unable to construct an
(2).Persistence of a worm mass at the same site, or its enterostomy, leave a nasogastric tube in place till signs of
fixity. obstruction have gone and then use piperazine as above;
(3).Rectal bleeding especially associated with abdominal beware of worms migrating proximally and down into the
pain. bronchus! Check the airway by a laryngoscopy at the time
(4).Increasing bowel distension or increasing evidence of of extubation to see if there are any worms present.
free intra-peritoneal fluid.
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INCISION. Open the abdomen with great care. DIFFICULTIES WITH INTESTINAL ADHESIONS
Always dissect under direct vision: so get good exposure, If bleeding obstructs your view, apply gentle pressure
and keep the field dry. Do not use diathermy close to the with a warm moist pack. Leave it alone for a few minutes,
bowel wall: it too easily causes necrosis. and dissect somewhere else. Place a small figure-of-8
suture on a bleeding point if bleeding persists: do not use
If there is a previous midline or paramedian incision, diathermy!
excise the scar and reopen the abdomen through it, unless
this is difficult. Start above or below it in an area which is If you strip the serosa with some of the muscle layer,
free of adhesions. Put a finger into the incision and explore leave it. Apply a warm pack, and suture any bleeding
the deep surface of the old scar. Work slowly with a sharp points.
scalpel and detach the adherent bowel from under it.
Do not make a midline incision parallel to a previous If distended loops of bowel obscure your vision, and you
paramedian incision, because the intervening skin may cannot release these, it is safer formally to decompress the
necrose. If you have to enter the abdomen through the site bowel (12.4) instead of tearing it accidentally.
of multiple adhesions, dissect them away with the utmost
care and patience. If the bowel has completely stuck to the If you do open the bowel, apply non-crushing bowel
abdominal wall, be prepared to excise a piece of the clamps either side of the perforation, clean up any spillage
adherent peritoneum when necessary, rather than damage and pack around the affected bowel. You can use this
the bowel. opportunity to decompress it of its contents (12.4).
If the opened bowel is still stuck, free it completely before
If there is a transverse or oblique incision, reopen this trying to clamp it, otherwise you may cause more damage.
incision. Then finish releasing all the adhesions you need to free up.
Then close any perforation transversely carefully in two
FREEING THE ADHESIONS. layers. If the edges of the defect are ragged, trim them
Look for the site of the obstruction, which may be a band neatly, so that you only use full-thickness bowel for
with a knuckle or loop of bowel caught under it. This has a closure: make sure that there is no obstruction distal to the
95% chance of being in the small bowel and a 75% chance point of repair! If there is, a fistula is sure to form.
of being in the ileum. Use the 'push and spread technique' If you make more than one hole in the bowel, aim to resect
with blunt tipped Metzenbaum's or McIndoe's scissors the affected portion as one piece if possible and make a
(4-9B, 12-8D). Use the outer sides of the blades to spread formal anastomosis, unless you will have to sacrifice too
the tissues. If you work carefully, you can define tissues much bowel. If there is much soiling, make a temporary
when they are matted together, by opening up tissue enterostomy (11.6) and have a second look 48hrs later.
planes, and without injuring anything. You will see what is
bowel, and what is an adhesion, and will be able to cut in If loops of bowel are firmly stuck down in the pelvis
greater safety. Work away at one site and then at another usually in a female from PID or from TB, try carefully to
until the adherent loops unravel. Go very gently and be pinch them off the pelvic wall from behind. If you fail,
patient! bypass them with an entero-enterostomy (11.4). This is a
Alternatively, use the 'pinching technique'. Pinch your safe way out of a difficult problem, provided that too long
index finger and thumb together between two loops of a length of small bowel is not bypassed. Choose an easily
adherent bowel. Do not pull on the bowel: it may rupture; accessible loop of bowel proximal to the obstruction, and
rather, try to lift it out from underneath. Grip the bowel anastomose it side-to-side with a collapsed loop distally.
firmly with moist gauze, and release it periodically, to help Some of the absorptive surface of the bowel will be lost,
you to identify what you are cutting, and to control but this will be life-saving. If necessary, another operation
bleeding. can be done later when the condition has improved: you
When you have divided a band, you will want to know if may well then find the adhesions are much less of a
the trapped bowel is viable or not: do this using the criteria problem.
described (11.3, 11-7). If you can squeeze bowel contents
past a kink in the bowel, you can probably leave it safely.
Make sure you decompress the bowel proximally (12.4).
12.7 Intussusception
If the obstructed part of the bowel is non-viable or
strictured, resect this portion and make an end-to-end Telescoping of the bowel into itself takes several forms:
anastomosis (11.3), remembering to decompress the bowel (1);Ileocaecal, ileocolic and ileorectal, which occur in
content before you do so. children, especially with ascaris but also in adults.
Do not necessarily try to divide every adhesion you find. (2);Caeco-colic,
Freeing adhesions can go on indefinitely, and can be (3) Colo-colic,
dangerous. If there are adhesions between loops which are (4);Ileo-ileal, generally occuring in adults as a result of
not causing obstruction, leave them alone. lymphadenopathy, especially with HIV disease,
CAUTION! Work slowly and carefully. Making a hole amoebiasis, schistosomiasis or polypoid tumours.
in the bowel wall increases greatly the postoperative
morbidity, especially the risk of a fistula (11.15) and
further adhesions.
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METHOD. If you split the serous and muscular coats of the last few
If the outer layer of the intussusception looks viable, centimetres of the bowel as you reduce it, do not worry.
try to reduce it by manipulation. If the intussusception has This usually happens. Provided the mucosa is intact and
not gone beyond the splenic flexure, manual reduction the bowel is not gangrenous, it will heal.
should not be too difficult. An area of residual thickened bowel is common and not an
But if it has reached the sigmoid colon, or if it has been indication for resection. Do not perform an
present >24hrs, it is likely to be non-viable. appendicectomy, unless it is inevitably included in the
bowel resection.
CAUTION!
(1) Complete all the reduction by squeezing.
(2) Do not pull the proximal end.
(3);Reduce the last dimple, or the intussusception may
recur.
(4);Make sure the apex is viable, because this is the part
which is most likely to become gangrenous.
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In theory, treatment is easy: untwist the bowel. One of If you have difficulty untwisting the bowel, decompress
your difficulties will be to make the diagnosis, when all it first. Introduce the suction nozzle into a distended loop
you see at laparotomy are distended loops of small bowel. through a purse string suture, and decompress it
proximally and distally. Do this routinely if the bowel is
Manipulating distended bowel is dangerous, whether or obviously non-viable.
not it is strangulated. If a loop ruptures, survival is in
doubt because of septic flooding of the peritoneal cavity If the bowel is viable, decompress it by massaging the
that results. There is about a 30% chance of death when fluid proximally (12.4).
bowel is gangrenous but in a survivor, volvulus rarely
recurs. If you are not sure if the bowel is viable or not, assess it
(11-6). Wait for at least 10mins before you make a
decision.
ABDOMINAL RADIOGRAPHS early on show a few Continue nasogastric suction and IV fluids postoperatively
loops of distended small bowel with one or two fluid till flatus is passed. You may need to transfuse blood.
levels on erect films; later you will see the regular
horizontal step-ladder pattern, and many fluid levels,
although by this time the patient is usually moribund.
12.9 Sigmoid volvulus
CAUTION! When a strangulated closed loop is
distended with blood, there may be no fluid levels, A long sigmoid colon distended with the gas of a high-
so that the radiographs appear normal. fibre diet is more liable to twist on its mesentery.
This is the commonest cause of large bowel obstruction in
LAPAROTOMY FOR SMALL BOWEL VOLVULUS. much of the world, particularly in the African continent,
(GRADE 3.4) and is sufficiently characteristic to allow you to diagnose
Make a midline incision. You will find purple, congested, it easily. Occasionally, it resolves spontaneously.
haemorrhagic, distended small bowel full of food and If sigmoid volvulus persists, ischaemia results and the
fluid. A collapsed caecum shows that the obstruction is in colon becomes gangrenous and may perforate.
the small bowel. Sigmoid volvulus is however less dangerous and more
common than small bowel volvulus (12.8).
Try to reach the base of the mesentery. Approach this by
first putting your hand down into the pelvis, and then up In a patient, normally male, with his first episode of
along the posterior border of the abdominal wall. volvulus, the colon may not be thickened, and the blood
Often, the whole of the small bowel is twisted, except the vessels thin. However, usually there have been many
first few centimetres of the jejunum and the terminal undiagnosed episodes of volvulus; the long mesentery is
ileum. Rotate the whole mass until the volvulus is undone. scarred, its vessels are enlarged, and the bowel wall is
If you find a band near the ileo-caecal valve, dividing it thickened as in Chagas disease (12.13). Occasionally, in
may help you to reduce the volvulus. Take great care younger adults, the small bowel is pulled round with the
doing this so you do not inadvertently puncture the bowel sigmoid and an ileosigmoid knot (compound sigmoid
and spill large volumes of bowel contents! volvulus) (12-14) results.
Deliver the bowel, untwist it, and cover it with warm moist
abdominal swabs. Assess its viability.
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Classically there is initially difficulty passing flatus. Start gentamicin with metronidazole perioperatively.
This is followed over a few days by increasing gaseous On the 5th day perform a laparotomy to resect the sigmoid
abdominal distension, tympanitic (like a drum), colon.
but without much pain or tenderness. There may be so
great distension, that breathing is severely impaired. N.B. The main danger in using a sigmoidoscope is that
Vomiting is unusual, except when the colon presses you may perforate a gangrenous loop of bowel and cause
severely on the stomach. The general condition is usually catastrophic spillage of faecal material into the peritoneal
good: drinking is possible and dehydration not severe. cavity. This will depend on the acuteness of onset and
The contrast between the satisfactory general state, and the delay in presentation.
huge abdomen is striking.
If the twist in the sigmoid is >180º, symptoms and signs LAPAROTOMY FOR SIGMOID VOLVULUS
will be more acute, with severe colicky pain, perhaps some (GRADE 3.4)
bloody loose stool, abdominal distension, prostration and
circulatory collapse. Likewise a patient whose volvulus INDICATIONS
persists will show similar signs of peritonitis. (1) Failure to reduce the volvulus with a flatus tube.
(2) The presence of bloody diarrhoea or infracted mucosa
ABDOMINAL RADIOGRAPHS are usually immediately on sigmoidoscopy.
diagnostic: in the erect film, there is a huge appearance of (3).Perforation of the colon at sigmoidoscopy or by
gas like an inverted 'U' reaching from the pelvis to the passage of a flatus tube.
upper abdomen, inclining right or left, often with smaller (4) Signs of peritonitis.
fluid levels proximal to the loop (12-12A). A supine film (5) (Elective procedure after successful deflation)
may show three dense curved lines converging on the left
sacroiliac joint. The middle line is the most constant, RESUSCITATION. Resuscitate vigorously. There may be
and is caused by two walls of the distended loop lying large volumes of fluid lost into the sigmoid. If there is a
pressed together (12-12B). compound volvulus, 2 or even 4 units of blood may be
needed.
DIFFERENTIAL DIAGNOSIS.
(1) Carcinomatous obstruction of the left colon or rectum. If respiration is very laboured because of enormous
(2) Caecal volvulus. abdominal distension, you can buy time by puncturing
(3) Megacolon. the colon percutaneously and introducing a Foley catheter
(4) Neglected short segment Hirschsprung’s disease. into the colon to decompress it, provided you have already
(5) Pseudo-Obstruction started IV fluid resuscitation.
Suggesting carcinoma of the colorectum: a change from METHOD. Use the Lloyd-Davies stirrups. Catheterize the
a normal bowel habit to constipation over a much longer bladder. Add gentamicin 80mg and metronidazole 500mg
period; a smoothly distended abdomen without obvious IV when you start the operation if they have not been
coils of colon; palpation of a rectal tumour; radiographs given already. Make a generous midline incision.
showing caecal distension, and not the characteristic signs You will see an enormously distended loop of colon.
of sigmoid volvulus. Gently lift it out of the abdomen from below.
CAUTION! Open the tense distended abdomen with
Suggesting a caecal volvulus: radiographs show a huge the greatest care: it is easy to perforate the bloated
appearance of gas centrally in the abdomen unlike the sigmoid!
appearances in 12-12A,B. Pack the sigmoid off well and decompress it (12-6B).
Suggesting megacolon: long history of constipation with If the sigmoid loop is of normal colour, gently introduce
no acute signs. the rectal tube into it. Ask your (suitably clothed) assistant
to get under the drapes and pass it further up the rectum.
Suggesting pseudo-obstruction: gas in the rectum. As he does this, guide it manually past the twist.
The loop will deflate and allow you to untwist it. Get your
MANAGEMENT. assistant to suture the tube to the anus so that it acts as an
If the bowel is viable, you should be able to relieve internal splint.
obstruction by decompression with a flatus tube passed Alternatively, find the pedicle and see which way it
through a sigmoidoscope (12.4). This will relieve the is twisted. Using both hands, try to untwist it.
immediate symptoms, but it is not sufficient treatment, This will be safe provided it is not gangrenous.
because the volvulus has a >30% chance of recurring. The loop seldom rotates by more than 360º. If you succeed
After a 2nd attack it has a 60% chance of doing so. in untwisting it, flatus will discharge through the rectal
If you succeed in relieving the volvulus, prepare for a tube. If you cannot find the pedicle and do not know which
definitive procedure. It will recur if the interval is too long: way it is twisted, twist it first one way and then the other.
so give adequate warning. If you proceed to sigmoid
colectomy, recommence oral fluids and provide bowel
preparation with magnesium sulphate (or other laxatives)
and rectal washouts on the 3rd and 4th day.
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What you should do next depends on your experience: If you are not sure if the colon is viable or not,
(1) If you are not at all experienced, deflation alone proceed with resection if you can. Do not leave non-viable
without resection will be wiser. The problem of the patient colon in the abdomen!
returning to have an interval resection is, however,
a very real one. You can reduce this risk (but not abolish In all these operations you will have to mobilize some of
it) by fashioning a temporary tube colostomy to fix the the descending colon by incising the peritoneum 2cm
colon to the abdominal wall. lateral to it, followed by blunt dissection.
(2).If an anastomosis is out of the question, you may
perform a mesosigmoidoplasty. Fixing the colon to the If the loop is obviously gangrenous, assume that the area
lateral abdominal wall by means of a colopexy results in of the twist is likely to be even more unhealthy. Pack it off
too many cases of recurrence to be worthwhile. (it may pop like a balloon). Clamp the bowel proximal and
(3) If you are experienced, resect the sigmoid colon loop distal to the twist. Very cautiously decompress it (12-6B),
and perform an end-to-end anastomosis. making sure you drain bowel content outside the abdomen.
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CAUTION! Remember that the inferior mesenteric Unless you have special small bowel clamps which can
vessels and ureter may take a looping course near the pass through the opening, you are liable to spill bowel
sigmoid colon (12-13A). Shine a laterally placed light content at this stage; it is best to tie a strong ligature round
behind the bowel to reveal the mesenteric vessels and the end of the bowel (tight enough to prevent spillage of
divide them well out towards the bowel wall, so that you faeces, but not too tight to cause ischaemia).
avoid injuring the left ureter or the superior rectal vessels. The exteriorized bowel must lie comfortably; if it doesn’t,
mobilize more of the descending colon.
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EXTERIORIZATION (GRADE 3.5) If the lower limit of the gangrene on the ileum is close
Proceed as for the Hartmann’s operation. Carry the to the ileocaecal valve, you may need to resect the
dissection back to the point where the proximal and distal ileocaecal segment as for intussusception (12.7).
colon are viable. Bring the sigmoid colon outside the
abdomen, through a separate incision. Wash out the If you decide to make a stoma, fashion an ileostomy
abdomen with warm fluid and close the main laparotomy rather than a colostomy distal to a small bowel
incision (11.8). anastomosis. Rarely, one loop is viable: if it is the small
Place a small crushing clamp just beyond the two ends bowel, leave it alone; if it is the sigmoid, perform a
where the colon is not viable. Apply non-crushing clamps resection.
proximally and distally, and divide healthy bowel between
the crushing and non-crushing clamps, and remove the
gangrenous loop. If possible, make a colostomy (11-14),
and suture the everted colon mucosa to the skin.
N.B. In practice, the distal end is usually too short to
pull out as a stoma, so you will be forced to perform a
Hartmann’s operation.
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PREPARATION. Administer magnesium sulphate Perform an end-to-end anastomosis. Put stay sutures at the
(Epsom salts) 10g orally (or other available laxatives) the left and right edges, holding both ends together. Start the
evening before the operation, and again early in the anastomosis at the back (posteriorly) in the middle instead
morning on the day of operation to clear the bowel. of the antimesenteric border with two separate long-acting
Meanwhile provide plenty of oral fluids to avoid absorbable or silk sutures, placing the knots outside the
dehydration. Start metronidazole 400mg tid, and restrict bowel wall, and leaving the ends left long (12-15C).
intake to oral fluids only on the evening before operation. Continue these as a continuous seromuscular Lembert
On the day before the operation wash out the proximal suture and work round on the outside towards the left and
loop, and administer an enema up the rectal stump. right sides in turn. Starting at the same point inside the
Cross-match 2 units of blood. Add gentamicin 240mg IV lumen in the middle posteriorly, insert an all-coats over
when you start the operation. and over inner layer long-acting absorbable suture,
working round towards left and right as before (12-15D),
METHOD. Use the supine position and put the legs in and continue as an inverting Connell suture finishing at the
Lloyd-Davies stirrups. Catheterize the bladder. front (anteriorly). Then complete the outer layer
Tilt the head down to give you better access to the pelvis. seromuscular suture to bury the inner layer.
Excise the previous wound. Using scissors and gentle
blunt dissection, carefully separate any adhesions between Check the soundness of the anastomosis and the size of the
the bowel and the abdominal wall, and between loops of lumen by pinching it between your thumb and finger
bowel. (11-7Q). You can further check the anastomosis by filling
the pelvis with water and blowing air up through the anus
Pack off the small bowel inside the upper abdomen with a bladder syringe. There is a leak if you see bubbles
(a three-bladed abdominal or universal Dennis-Browne in the water!
retractor is useful for this, 4-5). Infiltrate lignocaine with Remove the stay suture hitching up the bladder.
adrenaline (1:200000) around the colostomy to reduce Close the pelvic peritoneum over the anastomosis and
bleeding. Hook up the bladder to the pubic symphysis with close any defect through which a loop of small bowel
a temporary stay suture. might prolapse, preventing its fall into the pelvis.
Start by finding the distal rectal stump: if you fail to do so, DIFFICULTIES REVERSING HARTMANN'S OPERATION
you will not have disturbed the proximal colostomy, and If you cannot bring the ends of the bowel together
can close up, and try again later. Put a long blunt easily, mobilize more of the descending colon proximally
instrument into the rectum through the anus to help by incising the lateral peritoneal reflexion further, and
identify the stump. raising more of the mesentery. You can always bring the
bowel ends together if you mobilize enough mesentery.
Then start to dissect it out (the non-absorbable suture You may, rarely, need to mobilize the splenic flexure;
placed earlier will also help to find it). Dissect across the make sure you fix the colon to the posterior peritoneum to
top and about 5cm down each side (12-15B). Remove the prevent it twisting on an axis from the transverse colon to
instrument in the rectal stump and cut it across 1cm from the rectum.
its blind end, so a clean bowel lumen becomes visible.
Do not be tempted to leave a swab in the distal rectum: If the ends of the bowel are different sizes (the proximal
you may forget it or be unable to retrieve it end is usually bigger), place the sutures on the wider end
postoperatively. further apart from each other, so that you meet at the same
place on each lumen.
Make an elliptical incision around the colostomy; dissect
down to the rectus sheath. Control bleeding carefully so If the lumen is too narrow, or there is a ‘dog-ear’ at the
you can see where you are. Free the bowel from the anastomosis, undo it and start again. If you leave it,
anterior and posterior rectus sheaths; a finger inside the obstruction or a leak are inevitable.
stoma will help show you where to dissect without cutting
into the bowel lumen (11.6). If there are adhesions to the If there is a small leak, evidenced by bubbles from
stoma site, free them from the proximal colon from inside insufflations of the anus, at the anastomosis, identify the
the abdomen; apply a non-crushing clamp across it from defect carefully, and invaginate it. Re-check if there is still
inside just adjacent to the abdominal wall, and amputate it. a leak. If so, try again, but if there remains a leak, undo the
Mobilize the proximal descending colon by incising its anastomosis and start again.
lateral peritoneal reflection, and using a ‘swab on a stick’
to peel the bowel away from its attachments (12-15A). If the ends of the bowel bleed, press them firmly for up to
5mins. If there is a bleeding vessel beside the bowel, clip
Mobilize it sufficiently, so that it reaches the distal stump and tie it.
without tension. This may mean mobilizing the splenic
flexure. If you cannot get access to the rectal stump to make an
anastomosis by hand, extend the incision, make sure you
have good abdominal relaxation, the small bowel is packed
out of the way, and get another assistant to retract.
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(b) If the tumour is not resectable (12-16B), bypass the If you have made an anastomosis which you think may
obstruction with a side-to-side ILEOTRANSVERSE leak, make a defunctioning proximal colostomy in
ANASTOMOSIS (GRADE 3.4) (11-10, 12-16H). addition. This won’t have any effect on the risk of an
anastomotic leakage, but will make it less dangerous for
(c) If the colon is obstructed: the patient.
(1);If the condition is good and you are experienced,
perform a right hemicolectomy, as in (a). (b).If the tumour is not resectable (12-16D),
(2);If the condition is poor or you are inexperienced, make make a defunctioning right transverse loop colostomy
a bypass, as in (b). This might thereby mean missing the (11-13): this is preferable to a sigmoid colostomy which
opportunity of a curative resection, however. may later be encroached by spreading tumour
If the tumour is between the mid transverse colon and (c).If the colon is obstructed:
the sigmoid colon (12-16C): (1);Resect as above in (a) and make a colostomy
(a),If the tumour is resectable, resect the involved proximally and a mucous fistula distally, or,
bowel with its associated mesentery, leaving a margin least (2);Perform a Hartmann's operation: resect the sigmoid,
5cm proximal to the tumour. Perform an end-to-end bring out the proximal bowel as an end-colostomy,
anastomosis (12-16M). The bowel ends must have a good and close the rectal stump (12.9, 12-16N). If you are
blood supply. If not, resect more bowel, but not more confident with bowel anastomoses, you can clean out the
mesentery. The extent of this operation varies from being a bowel by decompressing it proximally, or doing an
LIMITED COLECTOMY (GRADE 3.2) to being a LEFT intra-operative wash-out (12.9), and make a primary
HEMICOLECTOMY (GRADE 3.5). Try to remove the anastomosis; make sure you test it afterwards by filling the
tumour and its lymphatic drainage area to make a pelvis with water and blowing air up the rectum (12.10).
satisfactory oncologic resection, but do not compromise
the patient’s survival by being too heroic! If necessary, If the tumour is in the middle or lower rectum
try to get a more experienced colleague to perform a wider (12-16E):
resection if that would be possible. (a).If the tumour is resectable, you should not have
Beware of the left ureter, which is easily reflected with the proceeded unless you can perform an anterior or
descending and the sigmoid mesentery (12-13A) and the abdomino-perineal resection of the rectum, or, better,
spleen, if you need to mobilize the splenic flexure. a rectal resection with a colonic pull-through and colo-anal
Make the anastomosis in 2 layers, as for small bowel, anastomosis. Biopsy the tumour through a proctoscope or
preferably with a non-absorbable suture for the outer layer. sigmoidoscope if this was not already done. If the tumour
Make sure the anastomosis is not under tension. is stenosing and likely to obstruct, make a sigmoid loop
colostomy (11.6).
(b) If the tumour is not resectable (12-16D), bypass the
obstruction with a side-to-side COLO-COLIC (b).If the tumour is not resectable, make a sigmoid loop
ANASTOMOSIS (GRADE 3.4) or make a defunctioning colostomy (11.6) unless you think he will die before he
right transverse loop colostomy (11-14, 12-16I) becomes obstructed.
(c) If the colon is obstructed: (c).If the colon is obstructed, make a transverse
(1);If the condition is good and you are experienced, colostomy, if you think he could have definitive surgery
proceed as (a) provided the bowel ends have a good blood later, or a sigmoid loop colostomy if this is unlikely.
supply and you can satisfactorily clean the bowel.
(2);Instead, as this is rarely possible, resect the bowel and CAUTION! If there are liver metastases or a fixed
bring the two cut ends out as a double-barrelled colostomy tumour, think hard before you make a colostomy.
(11-12D, 12-16J). Close this electively later. The patient may live a few more months, but dying with a
colostomy will be miserable, especially if colostomy care
If the tumour is in the sigmoid or upper rectum is poor. If the tumour is not resectable, it is better to
(12-16E): perform a bypass operation, an ileotransverse or colo-colic
anastomosis. This is possible for lesions of the ascending,
(a).If the tumour is resectable, resect the SIGMOID transverse, or descending colon, but not the distal sigmoid
(GRADE 3.4) or upper rectum, leaving 5cm margins clear or the rectum.
of the tumour, as for a sigmoid volvulus (12.9). Beware of
the left ureter. You may need to mobilize the proximal If a bypass is impossible, however, a colostomy is better
colon to make sure it reaches the distal end without than dying in obstruction.
tension. Perform an end-to-end anastomosis (12-16M).
If access to the anastomosis is difficult, start it at the back LAVAGE. When the operation is over, wash out the
(posteriorly) in the middle with 2 separate sutures knotted peritoneal cavity with warm fluid; do not insert drains.
together and work round towards the left and right sides in
turn, finishing at the front (anteriorly). If you cannot make
a safe anastomosis, bail out and fashion a colostomy and
mucous fistula or perform a Hartmann’s operation (12.9).
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Rarely, the caecum, ascending colon and ileum may all In South America, almost 20% of the adult rural
twist. This can only happen if they are all free to rotate as population may be infected by the parasite trypanosoma
the result of a rare anomaly of the mesentery. This is more cruzi which are deposited in insect faeces on the skin and
common during pregnancy. Twisting causes sudden severe introduced into the circulation by scratching. The parasite
pain, and vomiting. The abdomen distends and becomes is carried by a bug, triatoma infestans, which lives in
tender centrally and in the right lower quadrant. cracks in walls and in thatch, and can be killed by
Signs of strangulation develop quickly. insecticide spraying. A neurotoxin released and
inflammatory reactions cause destruction of the Meissner
ABDOMINAl.RADIOGRAPHS show a huge appearance and Auerbach neural plexuses in the colon resulting in
of gas which is not where the caecum should be, but is uncoordinated peristalsis especially in the distal colon;
central, or even in the left upper quadrant where it may this is exactly the same picture as in Hirschsprung’s
mimic the stomach. Unlike a sigmoid volvulus (12-12B), disease in the baby.
this radiological appearance does not have 2 limbs The result is tenesmus, progressive constipation, difficulty
descending into the pelvis. evacuating flatus, abdominal distension and spurious
diarrhoea. Faecal loading may result in sigmoid volvulus
(12.9). The usual picture is a megacolon. Trypanasoma
may also affect the heart and oesophagus giving a picture
like achalasia (30.6). HIV may cause reactivation of
dormant infection, so you should screen for HIV.
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The result is, in both cases, peritonitis as bowel organisms If an intra-abdominal abscess is causing obstruction,
translocate through the ischaemic bowel wall. This may be drain the abscess: this will usually be enough to relieve the
difficult to distinguish from pancreatitis and amylase obstruction. If there is a retained swab, it may have eroded
levels may be raised. into bowel. Remove it carefully, and examine the bowel
very carefully for perforations; if you find it is damaged,
ABDOMINAl.RADIOGRAPHS. do not try to repair holes but perform a formal resection.
Featureless bowel gives no clue towards the diagnosis
initially, but thickened bowel wall with air within the wall If you feel a solid object at the point where the
develops later; occasionally you can see air in the distended loops join the collapsed ones, decompress the
intrahepatic portal veins! obstructed bowel proximally and apply non-crushing
clamps to the empty segment. If you can easily move the
MANAGEMENT. Often you only discover the problem at solid object to another site in the bowel where the mucosa
laparotomy. will not have been ulcerated, do so. Isolate the segment
If bowel is frankly necrotic, resect the affected portion. with packs and make a longitudinal incision in its
antimesenteric border. Remove the foreign body and repair
If the bowel is suspicious, apply warm packs, and if after the bowel transversely. If it is a gallstone, it has come
5mins the bowel remains suspicious, lavage, close the through a fistula from an inflamed gallbladder. Extract the
abdomen and plan an elective re-laparotomy after 48hrs. stone, look for a second one if the first is faceted,
Administer heparin. A defunctioning ileostomy is no real and leave the gallbladder alone.
benefit.
If it is a food bolus that has impacted in the small bowel
If there is patchy necrosis, resect affected portions, but especially if there is a gastrojejunostomy (13.7),
try to limit the number of anastomoses to 2 or 3 at try to break it up and massage down into the caecum.
maximum; you may have to sacrifice normal bowel to do If you fail, perform an enterotomy as above. Sometimes
this. If you are uncertain about the blood supply around an narcotics smugglers ingest PACKETS OF DRUGS and
anastomosis, make an ileostomy or plan a re-laparotomy these obstruct. Be careful not to spill their contents as
after 48hrs. sudden absorption of cocaine, for example, may be fatal.
If there is an obvious embolus in a mesenteric artery, If you find a tumour in the small bowel causing
try to remove it using a Fogarty embolectomy balloon obstruction, look for other such tumours (especially
catheter after isolating the artery segment with bulldog purplish Kaposi sarcoma lesions). Resect the affected
clamps, if the bowel is still viable. If you fail, resect the portion of small bowel.
non-viable bowel.
If there are many inflammatory adhesions between
loops of bowel, do not try to resect bowel. This may be
Crohn’s disease. Take a biopsy of a node to check for TB.
Continue nasogastric suction and IV fluids till the
12.15 Other causes of intestinal obstruction inflammation settles.
You are unlikely to make the diagnosis of rarer causes of If there is atresia of the jejunum in a neonate (33.2),
intestinal obstruction before operation; even to the much of the proximal bowel is diseased, and it is
experienced surgeon, the abdomen is full of surprises. inevitably hugely distended compared to the distal bowel.
Here are some guidelines: Check for more areas of atresia distally by injecting saline
into the distal bowel. Resect as much proximal bowel as
If there is widespread carcinoma, avoid a stoma. possible and perform an end-to-back anastomosis, opening
Try to perform a bypass operation (12.11). the distal bowel on its antimesenteric border.
If you find an inflammatory swelling in the caecum If an internal hernia is obstructing the bowel,
or colorectum, it may be an amoeboma (14.5), it will probably be of the closed loop variety.
a bilharzioma, actinomycosis, paracoccidiomycosis (14.1), You can usually divide the obstructing structure quite
Crohn’s disease (14.2) or TB (16.3). You may not be able safely, but be careful with a hernia into the recess formed
to make a diagnosis without histology, so take a biopsy. by the paraduodenal fold at the duodeno-jejunal flexure,
If there is incomplete obstruction, continue nasogastric because you can easily cut the inferior mesenteric vein.
drainage and IV fluids postoperatively, providing medical If bowel is strangulating through a hole in the mesentery,
treatment for whatever is most likely in your region. do not cut the neck of the constricting ring, or it will
If there is complete obstruction, perform a colostomy or probably bleed severely. Instead, decompress the
bypass, take a biopsy of inflammatory tissue taking care distended loop (12-6), withdraw it, and close the defect in
not to perforate bowel, and start medical treatment. the mesentery, carefully avoiding its blood vessels.
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If there is an inflammatory mass or abscess around However, you should re-operate if there are signs of
colonic diverticular disease, drain it. If inflammation is peritoneal irritation (which could be due to a leaking
severe or extensive, or there is evidence of perforation or anastomosis, iatrogenic bowel damage, haemorrhage or
spillage (you will be able to smell it!), perform a proximal new infection), or some mechanical obstruction unrelated
defunctioning colostomy, and leave a drain. Do not try to to the original operation. An ultrasound may detect a
resect the inflamed colon, unless you are experienced! localized abscess (38.2K, but this will usually take 5days
to form).
If there is radiation damage to bowel, it will not hold Do not wait too long; if there is no improvement within
sutures well. Bypass the obstruction. 48-72hrs of a laparotomy for serious sepsis, perform a
second-look laparotomy (10.1), especially if the patient is
If there is a submucosal haematoma in the ileum, and HIV+ve. You will be able to wash out further sepsis, clean
the patient was taking anticoagulants, administer out any cavities you have missed, check for viability of
Vitamin K 10mg IM stat and leave the haematoma alone. bowel or leak from anastomoses.
Rest the bowel by nasogastric suction.
NJOROGE (10yrs) had a splenectomy for a ruptured spleen.
On the 3rd postoperative day he was clearly not well. He had obstructive
bowel sounds, some colicky pain, and a moderate amount of fluid was
coming up the nasogastric tube. He was immediately operated on and an
intussusception was found. LESSON Do not wait too long before you
12.16 Ileus & obstruction following reopen an abdomen; be guided by the whole clinical picture.
abdominal surgery Early mechanical obstruction such as this is rare; ileus is more usual.
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If distension progresses from Day 1 and is still present If normal bowel function starts, and then stops again,
on Day 5 but the abdomen is not tender, there is or there is vomiting or distension, or you aspirate
probably a simple ileus. The normal postoperative progressively more fluid, even >3l/day, suspect
muscular inactivity usually starts to resolve after 72hrs, mechanical obstruction. If at the same time there is
but may last 7-14days or more in the presence of infection, diarrhoea, there may be a pelvic abscess, or uncommonly
metabolic imbalance, impaired renal function or severe staphylococcal enterocolitis, or a partial obstruction,
general illness. which allows some fluid to pass and obstructs the rest.
Maintaining the fluid balance will be difficult.
NONOPERATIVE TREATMENT.
Fig. 12-18 INTESTINAL OBSTRUCTION AND PARALYTIC If this is in the small bowel or is a small leak in the
ILEUS. The passage of intestinal contents down the bowel can be large bowel, close it with interrupted non-absorbable
prevented by a mechanical obstruction, or by a functional sutures, and exteriorize that portion of bowel, or fashion an
disturbance of the motility of the bowel (paralytic ileus). enterostomy.
The physiological effects are much the same in both and are shown
here. Adapted from a drawing by Frank Netter, with the kind permission
of CIBA-GEIGY Ltd, Basel Switzerland. If this is in the proximal jejunum, introduce a feeding
tube in the distal part of the bowel. You can also put a tube
If the recovery was good until day 5, and then inside the bowel proximal to the leak, and drain this into
distension starts, there is probably a mechanical the bowel distal to the leak: make sure you anchor this
obstruction, especially if there is colic, 'tinkling' bowel tube firmly, and make it pass outside the abdomen so you
sounds, distension, vomiting, but no fever. The tinkling can monitor what is passing through it.
bowel sounds may be intermittent, so you may have to
listen for a long time. If there is a large leak in the colon, resect the affected
portion, close the distal stump and bring the proximal
If, at day 5, the abdomen is silent and painless, with colon out as an end-colostomy (like a Hartmann’s
fever and a raised white count, this is probably an ileus. operation: 12.9).
Suspect residual septic fluid collections and get an
ultrasound scan (38.2K). Aspirate fluid and test for bile If there is minimal contamination within 48hrs of the
with a urine dipstick: if present, this strongly suggests a previous operation, you will be justified in repairing the
bowel leak, needing an urgent re-laparotomy. leak with interrupted transverse invaginating sutures.
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EXAMINATION.
Tenderness in the epigastrium may be the only physical
sign. Look for other signs suggesting other diagnoses:
tenderness over the gallbladder (cholecystitis),
Fig. 13-1 COMPLICATIONS OF PEPTIC ULCERATION.
hepatomegaly (cirrhosis/hepatoma), oral candidiasis A, anterior perforation of a duodenal ulcer. B, penetration into the
(oesophageal candidiasis), pancreatitis and epigastric liver or pancreas. C, haematemesis and melaena. D, pyloric
hernia. obstruction. Note the hyperperistalsis and undigested food in the
stomach.
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If you are looking for a source of bleeding, This is the difficult part for the patient, so be encouraging
and the patient is haemodynamically stable, either wash and do not get impatient. If he coughs, suction secretions
out the stomach with 500ml/hr tepid water till the and straighten out the curve of the scope: you are too far
nasogastric aspirate is clear, or administer 250mg anterior. If he fails to swallow the endoscope after 3-4
erythromycin IV over 20mins and perform the OGD attempts, pull it out and try again, making sure your
30min later, or use both methods of preparation. controls and orientation are correct.
In an elderly or sick patient, attach a monitor (or have an (If you are passing the endoscope on an anaesthetized
assistant to check pulse and blood pressure) and add patient lying supine, you can use a laryngoscope to guide
oxygen by nasal prongs. the tip down into the oesophagus.)
Quickly introduce the mouthguard between the teeth, As you go down the oesophagus, suck out any secretions
asking him to bite on it: do this before he becomes too and look at the mucosa; note any irregularities, deposits of
drowsy with the sedative, especially if you use ketamine. whitish candida, redness or stricturing. You will need to
Turn him onto the left lateral position, with the head and blow in a bit of air if you have used the suction.
neck supported comfortably on a pillow. Ask the assistant You will see the oesophago-gastric junction as the mucosa
to hold the mouthguard in place, and put her left hand turns from pale pink to red; where this is in relation to the
behind the head and right arm over the patient’s chest to diaphragm is not really relevant: the degree of
restrain him gently (13-3). oesophagitis is.
Just as you pass the cardia, blow some air in and turn the
scope slightly down and left (as the oesophago-gastric
junction is at a slight angle), and blow air into the stomach
so you can see its lining.
Do not advance if you can’t see! If the view is red (unless
the lumen is full of blood), the endoscope tip is against the
mucosa, so withdraw it and blow air in.
Holding the endoscope with the left hand, with the thumb
free to manipulate the viewing controls, and the index and
middle fingers on the suction and blowing buttons,
pass the lubricated tip gently through the mouthguard.
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ENDOSCOPIC VIEW OF THE STOMACH Pass the endoscope round the duodenal angle, but do not
force it because if the duodenal cap is distorted from old
scarring, this is where you can perforate it! You rarely will
need to go past the 2nd part of the duodenum, and anyway
then you will need a side-viewing endoscope.
Now scan the areas you have missed on the way in (13-7):
gently withdraw the endoscope and look carefully at the
first part of the duodenum, and then at the pylorus.
An ulcer shows as a yellowish sloughy area,
Fig. 13-5 ENDOSCOPIC VIEWS OF THE STOMACH.
which may bleed slightly on touching with the endoscope
A, angulus view. B, pylorus view. tip. You can use this moment to take biopsies for
After Cotton PB, Williams CB. Practical Gastrointestinal Endoscopy, helicobacter near the pylorus and examine the mucosa of
Blackwell 2nd ed 1982 p.29 Fig 4.16 the stomach. Make sure you look at the fundus by
retroversion of the endoscope looking towards the cardia
You should see a small pool of gastric juice in the where you will see the black tube of the instrument
posterior part of the body of the stomach: suck this out and coming through. As you pull the instrument out, you will
blow air in. You then will notice a ridge ahead be able to see the cardia close up; look again at the
(the incisura, or angulus) above which is a view of the oesophagus and pharynx as you come out.
lesser curvature:
Below this is the antrum, leading to the pylorus. DIFFICULTIES WITH OGD
You may be surprised by the very short distance there
seems to be between the incisura and the pylorus such that If the patient becomes distressed, check the monitor and
the endoscope tip may ‘jump’ out of the pyloric opening add oxygen by nasal prongs. If this fails, withdraw the
back over the incisura into the body of the stomach. instrument and try again later. If he is agitated because of
You need then to try to pass the endoscope tip through the alcohol misuse, diazepam may make him worse: use 50mg
pylorus which appears as a black hole; this may seem like pethidine IV.
driving a truck with your hands off the steering wheel into
a moving tunnel entrance! (13-5) If you have done an inadvertent bronchoscopy, he will
Be patient: do not suck or blow air in excessively because usually be coughing profusely. Withdraw the instrument,
this may irritate the patient. If he is very lively, hyoscine and suction at the same time, and when he has recovered,
20mg IV will reduce spasm at this stage. Keep one hand try again to introduce the endoscope into the oesophagus.
on the endoscope controls and the other on the instrument
tip and wait till the pylorus opens; then quickly pass the If severe abdominal or chest pain develops, abandon the
endoscope tip through. It will tend to slip past against the procedure: There is either a perforation or a myocardial
bulb of the duodenum, and so need withdrawing a little: infarction. Resuscitate appropriately (13.3)
If you get lost, or only see red, blow air in so you can
orientate yourself. If you find yourself seeing the
instrument coming through the cardia, he will start
belching. Withdraw the endoscope tip and turn it towards
the left, and advance again provided you can see where
you are going! You should find the incisura and then find
the pylorus. Remember there may be gross pathology to
confuse you: achalasia, large diverticulum, duodenal
Fig. 13-6 ENDOSCOPIC POSITIONS IN THE STOMACH. deformity, pyloric stenosis, previous surgery,
A, in front of pylorus. B, against duodenal bulb. C, against
duodenum. After Cotton PB, Williams CB, Practical Gastrointestinal e.g. a gastrojejunostomy, or congenital malrotation (with
Endoscopy, Blackwell 2nd ed 1982 p.30 Fig 4.23 or without dextrocardia!)
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If there is excess food residue, the patient may not have PROCEDURES
starved or he may have an outlet obstruction; if you can Biopsy. (GRADE 1.5) It is best to use a forceps with a
ride the endoscope above the food you may be able to see central spike; check that the biopsy forceps is working,
a cause. However, there is a risk of regurgitation and the correct width, and long enough and thread it through
aspiration, so do not persist and try again after nasogastric the biopsy channel. Do not force it through at the tip:
suction. Beware: food particles and thick candida can it may not pass if the endoscope is very retroverted or of
block the endoscope channels and damage them. course if it is too big! Take specimens under direct vision
If you can’t withdraw the endoscope, check that the by instructing an assistant how and when to open and close
viewing control ratchet is free and manipulate them so the the forceps, and shake them directly into a container with
instrument is straight. Check that the patient is not biting formalin. You will need to take at least 3-6 specimens.
on the endoscope! Frustratingly, many biopsy forceps will work outside the
instrument but not when passed through the biopsy
APPEARANCES ON OGD channel when the cable is damaged: this happens easily if
Oesophagus. Early OESOPHAGITIS has a fine vascular the endoscope case is closed on top of it, so take care to
pattern of the mucosa disappearing with oedema; it then store these delicate accessories carefully.
becomes red and friable, bleeding on contact. Patches of
exudate and frank ulceration with a yellow slough then Dilation. (GRADE 2.3) Balloon dilators can be used for
result, usually in the long axis of the oesophagus. oesophageal and pyloric strictures. If you don’t have these,
A MALLORY-WEISS TEAR is a longitudinal 5-20mm dilators which you can pass over a guide wire are an
split in the mucosa. A BENIGN STRICTURE is alternative. This is a great advantage over rigid
symmetrical and smooth, usually with normal mucosa oesophagoscopy under GA as patients are generally frail,
proximally. A MALIGNANT STRICTURE is wasted and dehydrated. However, if you are not
asymmetrical with exuberant abnormal mucosa and raised experienced you may need longer than diazepam alone
ulcer edges but a gastric carcinoma may infiltrate under will allow; add ketamine or pethidine.
the mucosa from below. CANDIDIASIS looks like white Pass the guide wire under direct vision via the biopsy
spots or plaques which may become diffuse: these do not channel through the stricture. You need good suction to
wash off with a jet of water. VARICES are bluish mounds clear the debris above the stricture to find the opening:
in the long axis of the oesophagus. DIVERTICULA and do not force the wire if it snags against tumour, a hiatus
FOREIGN BODIES are obvious. ACHALASIA shows no hernia or a pseudo-diverticulum. With the tip of the guide
abnormality except excessive food residue which may look wire nicely beyond the stricture, gently withdraw the
like candidiasis. endoscope, pushing the wire in as you pull the instrument
Stomach. The redness of GASTRITIS may not have out. When it becomes visible at the mouth, ask your
clinical significance and biopsies may be more helpful. assistant to hold it firmly, and remove the endoscope.
GASTRIC ATROPHY is seen as greyish white patches Dilators are either of increasing size (Eder-Puestow type)
and associated with intestinal metaplasia. Erosions start as or of stepped graduation (Celestin type); pass them over
umbilicated polyps and then develop into smooth-margin the guide wire past the stricture and then withdraw them.
GASTRIC ULCER. Irregular margin, base and Warm the Celestin type in boiling water to make it
surrounding mucosa suggest a GASTRIC CARCINOMA. flexible; use the Eder-Puestow type as bougies in
However, a submucosal malignancy will not show any increasing size from Ch21 to 40. When you have passed
mucosal changes. Biopsy all gastric lesions for a correct the dilator, introduce the endoscope again to check the
diagnosis. stomach.
Duodenum. Persistent deformity of the pyloric ring If the patient has severe pain, cannot swallow or has
indicates current or past ulceration; a DUODENAL subcutaneous emphysema or peritonitis afterwards,
ULCER appears as a break in the mucosa with an you have probably perforated the oesophagus (30.7),
oedematous smooth raised edge and yellowish slough in or pylorus.
the centre. You can highlight lesions more easily by
spraying the surface with a little methylene blue or Such dilation will unfortunately not help in achalasia
ordinary ink, with an injection device passed through the (30.6), which needs a special balloon distended to
biopsy channel. Minor changes of ‘duodenitis’ are of 300mmHg.
doubtful significance.
Bleeding ulcers. During endoscopy you may see active Oesophageal stenting (GRADE 2.3). Make sure you have
bleeding or evidence of recent bleeding; the Forrest measured the position of the malignant stricture.
classification gives you an idea of who is likely to re-bleed After successful dilation, you can pass a prosthetic tube,
and therefore who needs intervention: well lubricated, over the dilator of appropriate size and
guide this together with an introducer (which can be
Type RISK OF RE-BLEED home-made) into the correct position. The prosthetic tube
IA Pulsatile arterial haemorrhage 100% must have a distal flange or rim to prevent upward
IB Oozing haemorrhage >50% displacement. Remove the dilator and guide wire whilst
IIA Vessel seen >40%
holding the tube in place with the introducer.
IIB Clot over bleeding point >20%
IIC Haematin-covered flat spot 10% Then pass the endoscope through the introducer to check
III No signs 5% the position of the tube; if all is well, disconnect the
introducer with a twisting motion and withdraw it.
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N.B. If you have self-dilating stents, these are a big When you see an actively bleeding vessel in a duodenal
improvement on the basic fixed tube described. ulcer, you can inject 1ml of absolute alcohol, adrenaline or
hypertonic saline adjacent to the bleeding point.
The problem is that you may not actually see the bleeding
point if the stomach is full of blood, so make sure you
have passed a nasogastric tube beforehand and sucked it
out.
If you have the more sophisticated equipment, you may be
able to clip a bleeding vessel.
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DIFFERENTIAL DIAGNOSIS.
13.3 Perforated gastric or duodenal ulcer The main diagnostic difficulty is pancreatitis or
appendicitis, which is important because the first needs no
operation and the second needs a different incision.
Classically, when a peptic ulcer perforates, it floods the
peritoneum with the acid contents of the stomach, and Suggesting perforation: referred shoulder pain, usually
results in sudden agonizing pain. The patient can often tell on the patient's right, the absence of fever (this develops
you the exact moment the pain began; it is constant, late in a perforation), shock (when generalized rigidity is
it spreads across the entire upper abdomen and later all the result of appendicitis, shock is unusual), and >1l of
over, and is made worse by deep breathing or movement. stomach aspirate.
Usually, he lies still in excruciating pain,
and breathes shallowly without moving the abdomen. Suggesting pancreatitis (15.13): referred back pain,
He is pale, sweating, usually with a fast pulse and is the absence of fever, shock, and a history of alcohol
hypotensive but has a normal temperature, ingestion.
and an abdomen which is not distended.
Suggesting appendicitis (14.1): central abdominal pain
Typically, it has a board-like rigidity, unlike that in any initially moving to the right iliac fossa, fever, a small
other disease, which may be so complete that you cannot stomach aspirate of mucoid or bile-stained fluid.
elicit tenderness, except when you examine him rectally.
Suggesting oesophageal perforation (30.7): vomiting for
After 3-6hrs the pain and rigidity lessen, he feels better any reason with sudden severe epigastric and lower
and a 'silent interval' begins. Then, at about 6hrs, signs of retrosternal pain, or spreading between the shoulders.
diffuse peritonitis develop, accompanied by abdominal
distension and absent bowel sounds.
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Draw this downwards, and ask your assistant to hold it; If the stomach and duodenum are normal, feel gently
at the same time ask him to hold the liver upwards with a downwards towards the appendix, and pelvic organs in a
deep retractor. Put an abdominal pack between the female. Then look at the small bowel from end to end.
retractor and the liver to protect it. If necessary, get the If this is normal, examine the gallbladder, pancreas and
help of a second assistant. If access is difficult, enlarge the finally the colon.
incision.
Suck away any fluid, looking carefully to see where it is To close the perforation, place 0 or 2/0 long-acting
coming from. Search for a small (1-10mm or more) absorbable sutures on an atraumatic needle superior and
circular hole on the anterior surface of the duodenum, inferior to the hole (13-11B); then tie these sutures over an
looking as if it has just been drilled out. Feel it. The tissues omental fold onto the stomach or duodenum thus covering
around it will be oedematous, thickened, scarred, and the hole (13-11C). A hole so covered is unlikely to leak.
friable.
Do not try to bring the ulcer edges together: if the sutures
If the duodenum is normal, look at the stomach, cut out, the hole will be much larger than before.
especially its lesser curve. If the hole is small, there may With a large hole, you can use the omentum actually to
be more to feel than to see. Sometimes, a gastric ulcer is plug it, but this does not safely close perforations >2cm
sealed off by adhesions to the liver. Remember that a diameter (see below). Check if the hole is sealed by
gastric ulcer may be malignant: take a biopsy if this does passing some dye (e.g. diluted methylene blue) down the
not make closure difficult. You should not attempt to nasogastric tube, and confirming no dye is leaking out.
excise a malignant gastric ulcer as an emergency unless it
is very small. Look quickly if there is a second perforation. Wash out the peritoneal cavity. This is absolutely critical,
Open the lesser sac through the lesser omentum. and may be more important than closing the hole.
Feel the posterior surface of the stomach. An ulcer high up Tip a litre of warm fluid into the peritoneal cavity,
posteriorly may be difficult to find. Feel for it carefully, splash it about well, and then suck it out again.
and if you still cannot find it, pass diluted Methylene blue Repeat this several times till the draining fluid is clear,
dye through the nasogastric tube and watch where it comes and try to wash out every possible recess in the upper
out. abdomen. Mop the upper surface of the liver.
POSTOPERATIVELY.
Nurse the patient sitting up straight in bed. Breathing will
then be easier, chest complications less likely, and any
exudate will gravitate downwards. Continue with
nasogastric suction and IV fluids (11.9). Replace the
gastric aspirate with IV saline (4.9). Chest physiotherapy
is vital if he is asthmatic, a smoker, immune-compromised,
elderly, or if there is widespread soiling in the abdomen.
Treat him with antibiotics for helicobacter as >80% of
perforated ulcer patients have it. Start an H2-blocker or
proton-pump inhibitor immediately (dilute crushed tablets
with water and introduce this via the nasogastric tube, and
then clamp it for 1hr) and continue oral treatment for
6wks.
Fig. 13-11 CLOSING A PERFORATED PEPTIC ULCER. If the ulcer is huge, leaving only a small part of
A, retract the stomach and expose a perforation on the anterior of duodenum normal, closing it will be impossible or result
the duodenum. B, place interrupted stay sutures of 0 or 2/0 silk or in stenosis; mobilize the duodenum by dividing the
absorbable on an atraumatic needle adjacent to (but not through) the
peritoneal attachment along its convexity (the Kocher
perforation, C, in order to pull a fold of omentum over the hole.
Kindly contributed by Gerald Hankins. manoeuvre) as much as you can, and insert an omental
plug as above.
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Then pass 2 Ch16 Foley catheters, one into the stomach In all these conditions the patient vomits bright or altered
and one to the 2nd part of the duodenum, securing them blood ('coffee grounds'), or he passes melaena stools,
with a purse-string suture, and inflating the balloon so that or occasionally bright blood, if the bleeding is brisk,
no fluid leaks out. Bring both tubes out through separate from the rectum. Your task is to:
stab incisions in the abdominal wall, label them clearly, (1) resuscitate the patient,
and secure them firmly. Perform a gastrojejunostomy (2) make the diagnosis,
(13-16). (3) assess the risk status, and
Keep the patient nil orally till his nasogastric aspirate has (4) control bleeding.
settled, and then try oral fluids with some dye.
If this comes out through the stomach Foley drain, wait Try to make the diagnosis epidemiologically and
and try again later. Eventually the area of ulceration will clinically, especially if you do not have a fibre-optic
close by scarring. gastroscope, or you cannot do barium studies (38.1).
The important distinction is whether or not bleeding is
If there is concurrent bleeding, there is probably a large from gastro-oesophageal varices, because you will not
circular or ‘kissing’ ulcer: try to undersew the bleeding want to operate on these, whereas you may need to operate
vessel first. You will need to make a large Y-shaped for most of the other causes. A large spleen is a most
incision including the perforation and then try closing it useful sign. Ultrasound will demonstrate portal venous
making a V-type pyloroplasty (13.5, 3-12). distension (38.2A). Endoscopy is very helpful (13.2).
If this is impossible, use an omental plug, with a However, even the best surgical centres cannot find a
retrograde tube duodenostomy and feeding jejunostomy as cause for the bleeding in about 10% of cases. You may
above. need plenty of blood for transfusion.
If there is also gastric outlet obstruction, which is not UPPER GASTROINTESTINAL BLEEDING
relieved by the pyloroplasty you perform on closure, add a
gastrojejunostomy (13.8). HISTORY. A history of peptic ulceration is suggestive
only. Confirmation is often lacking. There is at least a 25%
If an ‘hourglass stomach’ perforates, it is from stricture chance that the patient has a peptic ulcer and no
due to acid ingestion (13.10); perform a Polya gastrectomy symptoms. Has he been taking NSAIDs, or steroids?
(13.10). These can cause haemorrhagic gastritis and ulcers.
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Suggesting haemorrhagic gastritis (mucosal erosions): OUTCOME. Several things can happen. A gastric ulcer or
the recent ingestion of alcohol or analgesic tablets. gastro-oesophageal varices are more likely to continue to
Use the history and physical signs to form some estimate bleed than a duodenal ulcer.
of how much blood has been lost, and over how long. Melaena alone is not as serious as haematemesis,
Decide if the blood loss has been mild, moderate, but beware of continuing melaena and unaltered blood in
or severe. Anaemia on arrival suggests chronic blood loss. the stools, which indicate persistent bleeding.
Suggesting a duodenal or gastric ulcer: a history of
epigastric pain and dyspepsia, and especially NSAID use. (1);Bleeding may stop either before admission, or with
the above treatment, and not occur again (75% chance).
RESUSCITATION. Cross-match 2-4 units of blood
depending on the severity of the bleeding. Sedate (2);Bleeding may continue moderately, but responds to
the patient heavily with diazepam 5mg qid IV, transfusion. Small melaena stools or small bloody vomits
or chlorpromazine 25mg, or use ketamine. Avoid continue, so that the haematocrit drifts downwards.
morphine. The resting pulse may only be 90/min, but the least
exertion may send it up to ≥120/min. Non-operative
If the patient is in shock, set up 2 IV infusions of 0·9% treatment is dangerous if this continues for >72hrs or you
saline or Ringer's lactate, with large-bore cannulae. If there have transfused >5 units of blood.
is severe bleeding, infuse 1-4l of fluid rapidly, or more,
until the blood pressure returns to 100mmHg. (3);Bleeding may stop completely and start again in a
You may need at least 3 units of blood and possibly many few hrs, or a day or two later. This also is dangerous.
more. If you have a colloid plasma expander, infuse 1-2l (After 3days, however, re-bleeding is unlikely.)
while you wait for blood.
(4);Bleeding may continue severely, with vomiting of
If you do not have blood, nor enough blood, do not bowlful after bowlful of fresh or clotted blood, each bleed
hesitate to infuse large quantities of saline or Ringer's being accompanied by a wave of weakness and sweating.
lactate: the great need is for fluid to fill the vessels, but The passage of large tarry stools persists. A rapid fall in
remember then that your threshold for operative Hb 8hrs after an initial bleed indicates continued bleeding.
intervention will be lower. Try to keep some blood in
reserve in case bleeding resumes. MANAGEMENT depends on the risk status.
If you think gastro-oesophageal varices are unlikely, Remember Moshe Schein’s dictum:
pass a large nasogastric tube. This will tell you if bleeding “When the blood is fresh and pink, and the patient is old,
is continuing, and whether the blood is fresh or altered. it is time to be active and bold;
If you aspirate clots, irrigate the stomach to wash them When the patient is young and the blood is dark and old,
out. Then run into the stomach 200ml ice-cold saline you can relax and put your knife on hold.”
(Schein M, Rogers PN, (eds). Common Sense Abdominal Emergency
containing 8mg noradrenaline and leave it for 30mins; Surgery, Springer 2nd ed 2005 p.139)
aspirate and repeat this for 4hrs or until bleeding stops.
Beware that you don’t make the patient hypothermic! For the low risk patient, put him to bed, treat him with
antacids, H2 antagonists, or PPI inhibitors whichever is
MONITORING. available: the best are, alas, the most expensive.
Measure and chart the pulse, the blood pressure, and the Later, if possible, perform endoscopy, or a barium meal.
peripheral circulation ½hrly. A rising pulse or a sustained
tachycardia are more important than isolated readings. For the high risk patient, (the indicators are:
Monitor the urine output, and, if possible, the central haematemesis as well as melaena, pallor, loss of
venous pressure if the patient is very ill. Measure the consciousness, age >45yrs, BP <100 mmHg, pulse
haemoglobin and haematocrit as a baseline. >120/min), management depends on whether you suspect
Continued bleeding is suggested by: persistent nausea, varices (13.7) or not (13.5). Ideally every patient with an
tachycardia, pallor, restlessness, bright red fluid aspirated upper gastro-intestinal haemorrhage should have an
through the nasogastric tube, and the rapid fall in Hb or its endoscopy. Unless you have good suction, however,
failure to rise in spite of transfusion (a useful sign). you will not be able to see much. Look for adherent blood
Monitor glucose levels in liver disease, and liver function clots in an ulcer, a visible vessel ‘standing up’ in the ulcer
tests if possible. Correct coagulation problems if present. base, or active oozing or spurting from a vessel.
Endoscopy gives you the chance, if necessary,
ENDOSCOPY (13.2). This is most useful, if you can do it, of sclerotherapy for varices and injection or clipping of
but it will be almost impossible during heavy active vessels in bleeding ulcers (13.2), but this is quite
bleeding unless you have very effective suction, specialized practice and needs the technology and some
and resuscitation facilities where you plan to perform the experience.
endoscopy. Once it has settled, it will allow you to inject Remember Helicobacter pylori is almost always present
gastro-oesophageal varices (13-9), or inject around a where ulcers bleed, so use antibiotics (13.3).
bleeding point in a duodenal ulcer.
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13.5 Surgery for a bleeding peptic ulcer Be much more ready to operate on the patient who is
bleeding repeatedly, moderately or severely, needing
There is about a 25% chance that conservative or >4 units of blood.
endoscopic treatment is going to fail. At this point you will The bleeding point may be difficult to find, and when you
have to decide whether or not to operate in the hope of have found it, blood may obscure it, so that controlling it
saving life. The patient needs surgery in the case of will be difficult. You will need a generous gastrotomy,
bleeding outcomes (2, 3 or 4), described previously (13.4); a good assistant, a good light, and good suction.
without surgery, there is about a 50% chance of death,
especially if he is >45yrs. If you operate skilfully, the Expect respiratory complications (11.11), and wound
chances of death are only about 10%. In spite of the breakdown (11.14).
limitations of your services, about 90% of your patients
with severe bleeding should live, most of them as the SURGERY FOR A BLEEDING PEPTIC ULCER (GRADE 3.5)
result of your efforts. One of your main difficulties may be
to get enough blood: in this case operate earlier rather than PREPARATION. Make sure a large bore nasogastric tube
later! is in place, blood and clots are suctioned out of the
stomach, and blood is ready: you may need 4 units or
The purpose of emergency surgery is to save life, more. Try to restore the blood pressure, but do not pour in
so decide when your patient is more likely to die if you do fluids at one end only for him to bleed from the other end!
not operate than if you do. Try, especially, to judge the Keep the systolic BP around 80mmHg. Get 2 assistants to
best time to operate, but do not put off the decision! help you.
When you do operate, try to find where the blood is
coming from, and stop it. Obviously there is a big INCISION.
advantage if you can perform emergency endoscopy.
Doing an operation which will prevent bleeding recurring Make a high midline incision extending up to the
is a lesser priority, because you may be able to arrange for xiphisternum. Open the abdomen, and insert a self-
a definitive operation later. retaining retractor in the abdominal wall. Insert a deep
retractor under the liver, so that your assistant can retract it
Remember though that surgery should be a controlled risk upwards. Gently draw the greater curve of the stomach
whereas further haemorrhage is an uncontrolled risk. downwards.
If you have seen an adherent blood clot, or a vessel
‘standing up’ in an ulcer base on endoscopy, re-bleeding is Suggesting peptic ulceration: a scarred, deformed first
very likely. If the patient is not suitable for surgery, or for part of the duodenum or a puckered, thickened,
some reason you decide not to operate, do not give up: hyperaemic area on the stomach, especially on the lesser
continue ice-cold saline/noradrenaline lavage. curve. There may be nothing to feel if a posterior ulcer is
eroding into the pancreas, or the liver.
A gastric ulcer has stopped bleeding when the aspirate is
no longer bloody. If this has not happened after 4hrs, Suggesting bleeding gastro-oesophageal varices: a firm
abandon this method. If there is a duodenal ulcer, blood or hard, shrunken, irregular liver, and dilated veins on the
may not be returned in the nasogastric aspirate, so you will stomach. If you find this, and there are no signs of an ulcer
have to rely on the pulse and peripheral circulation to also, think about an oesophageal transection, and treat the
know when bleeding has stopped. varices (13.7). Treat for schistosomiasis if this is common
in your area.
If you can effect endoscopic injection (13-9), N.B. Sometimes a patient has varices and an ulcer.
try this first!
If there is no obvious bleeding site, feel every part of the
If you decide to operate, open the stomach and stomach between your thumb and forefinger, and go right
duodenum. If you find a bleeding duodenal or gastric up to the gastro-oesophageal junction. Open the lesser sac
ulcer, the simplest way to stop it bleeding is to undersew by dividing the greater omentum between the lower edge
it. of the stomach and the colon. Feel the whole posterior
surface of the stomach.
Perform a pyloroplasty: just remember not to close a
pylorotomy longitudinally otherwise gastric outlet If you still cannot find the source of the bleeding,
obstruction will result. and there is melaena, check the small bowel first.
Surgery for gastrointestinal bleeding is difficult. Blood might be coming from anywhere from the duodeno-
The 2 common mistakes are: jejunal flexure to the caecum. If you are not sure if the
(1) To choose the wrong type of patient to operate on. contents of the bowel are blood or bile insert a needle
(2);To operate at the wrong time: if you wait too long, obliquely and aspirate. Look for a bleeding leiomyoma or
you risk the patient's life, but if you operate too soon, gastro-intestinal stromal tumour of the stomach or small
the risk may be equally great, especially if you operate intestine, Kaposi sarcoma or a bleeding Meckel's
before you have restored the blood volume. diverticulum. Then check the colon for ileocaecal
tuberculosis, carcinoma, amoebic colitis, and
intussusception.
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If, even after you have done this, you cannot find the If there was a haematemesis and you cannot find any
source of the bleeding after a haematemesis, abnormality: put the tip of the sucker, or a swab on a
the chances of the patient surviving are small unless you holder, into the second part of the duodenum, to make sure
continue to try. If you have not been able to perform an that there is no bleeding from a post-bulbar ulcer.
endoscopy beforehand, do so now. You may not be able to If you still cannot find any cause for the bleeding,
see your way clearly because of a lot of blood clots in the try to pass the flexible endoscope through the duodenal
stomach: in this case, unless there is continued massive opening distally.
bleeding and you simply do not have enough time to do If you find an acute ulcer, a solitary erosion, no longer
this, evacuate the blood clots by water irrigation using a bleeding, or multiple small bleeding erosions,
wide-bore tube through a small high gastrotomy. close the duodenal opening with a pyloroplasty.
Then pass the endoscope through this same opening, Postoperatively, advise against NSAID drugs.
fastening it tight with a purse-string suture to make it
air-tight in order to look for the bleeding site. (You can use
a rigid cystoscope to do this, if you have no flexible
endoscope).
If this is unhelpful, or you are faced with catastrophic
haemorrhage, open the stomach and duodenum.
There is no substitute for having a good look.
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If bleeding continues, put ligatures transversely across the If bleeding started after a severe episode of vomiting,
pancreatico-duodenal artery above and below the centre of from some other cause, such as a drinking bout, suspect
the ulcer, taking care not to damage the pancreas or bile that there is a tear in the oesophagus at, or just above,
duct in the process. the gastro-oesophageal junction (the Mallory-Weiss
syndrome), which almost never requires surgery (30.7).
If the ulcer is in the distal duodenum, mobilize it,
and make a small duodenotomy, and undersew the If you tear the oesophagus (which should never happen!),
bleeding point as before. repair the tear with a gastric patch bolstered by a
fundoplasty (30-6). Leave the nasogastric tube in position,
PYLOROPLASTY (GRADE 3.4) and feed the patient through this later.
DIFFICULTIES WITH GASTROINTESTINAL BLEEDING If you cannot close the pyloroplasty without tension,
mobilize the duodenum by dividing its attachment to the
STRESS ULCERATION & HAEMORRHAGIC GASTRITIS posterior peritoneum laterally, after drawing down the
can occur after a burn, head or other injury, major surgical hepatic flexure of the colon. (This is the Kocher
operation, or after alcohol or NSAID medication. manoeuvre.)
These are usually superficial erosions in the stomach or
typically in the second or third parts of the duodenum. If the spleen starts to bleed during the operation,
They are usually multiple, shallow, and irregular. you have probably pulled too hard on the crus.
They usually give little pain, and severe bleeding is likely Pack around the spleen and wait to see if bleeding stops.
to have been the first sign. Minor harmless gastric Then finish the rest of the procedure, and if there is no
bleeding is common after an alcoholic binge. Ulceration of more bleeding, carefully remove the pack. If further
this kind may ooze severely, so that there are melaena bleeding ensues, depending on your experience,
stools for several days. Treat with antacids ½hrly, and try a either replace the pack and perform a 2nd look laparotomy,
noradrenaline in saline lavage (13.4) and, if possible, or proceed to splenectomy.
IV cimetidine 400mg for 1hr repeated after an interval of
4-6hrs. (Alternatively use a continuous infusion at If peptic ulcer symptoms recur, try to do an endoscopy
100mg/hr over 24hrs, maximum 2·4g od.) to confirm this. You will have to resort to medical
Add tranexamic acid 1g IV and then 8hly. treatment, especially with proton-pump inhibitors or
misoprostol (13.1). Make sure you have eradicated
Do not operate unless the situation is critical. In this case, Helicobacter pylori. Exclude hypercalcaemia and the
you need to devascularize the stomach by ligating both Zollinger-Ellison syndrome (gastrinoma, usually of the
gastro-epiploic arteries as well as the left and right gastric pancreas).
arteries near the gastric wall. This effectively means an
emergency gastrectomy! The chances of the patient dying
are high, whatever you do.
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You can gently pick up the stomach with Babcock forceps If the child vomits frequently during the first 24hrs,
to help you find the pylorus, but do not try to pick up the wash out the stomach to remove the excess mucus.
pyloric swelling with forceps as it will tear.
Hold the swelling between the thumb and index finger of If the child is not taking enough fluid by mouth to
your left hand. Keep your left middle finger against the maintain an intake of 100ml/kg/day, infuse 5% dextrose
distal extremity of the swollen pyloric muscle. Turn this so in half-strength saline IV.
as to expose its antero-superior border.
If the child continues to vomit after 48hrs, you may not
Cut 1-2mm deep through the circular muscle along the have divided the hypertrophic pylorus adequately.
length of the pylorus (33-3F). Start on the top of the If necessary, operate again. Wait however for 1wk to see if
swelling and continue just proximal to the white line he is able to feed; but remember that it is better to operate
(the junction of the pylorus and duodenum); at this point earlier than allow him to become severely malnourished
(the distal end of the swelling) the wall of the bowel
suddenly becomes extremely thin. At this point, make your
incision more oblique, or even V-shaped, and keep your
cut very superficial. Extend the incision along the whole
length of the thickened pylorus and onto the stomach 13.7 Bleeding gastro-oesophageal varices
(the proximal end is less clear, because the stomach wall is
also thickened). Spread its circular muscle using a Bleeding from gastro-oesophageal varices will be a
haemostat with its concave curve upwards, without formidable challenge; stopping the bleeding may prove
harming the submucosa, which should bulge out of the impossible. If there is advanced cirrhosis, the prognosis
incision. Still using the tip of the haemostat, separate the may be so bad, and you will use up so much blood, that
fibres distally on the duodenal side, under the white line, you may not feel it is justified using all your precious
so as to divide all the circular fibres without perforating resources on this one patient.
the duodenal mucosa (33-3G).
Whilst spreading the muscle, continue to mark and protect Because oesophageal veins communicate with the portal
the duodenum with the middle finger of your left hand. and systemic venous system, they tend to dilate when there
is elevated pressure in the portal venous system.
CAUTION! The common causes are:
(1) Do not cut the white line at the site of the pyloric vein, (1) cirrhosis of the liver,
or you may open the duodenum. (2).periportal fibrosis due to Schistosoma mansoni
(2) Do not sew up the muscle incision. infection,
(3) Make sure you have made an adequate myotomy. (3) non-cirrhotic portal fibrosis,
(4) Check for escape of bile or air by massaging air from (4) portal vein thrombosis.
the stomach distally, or inject air via the nasogastric tube,
whilst holding the pylorus under water. Death is from loss of blood and liver failure.
The final cause of death may be hepatic encephalopathy,
If you find you have opened the duodenal mucosa, due to the failure of the liver to detoxify metabolites from
close it with a 4/0 or 5/0 absorbable suture, taking care not blood absorbed in the bowel, either because its cells have
to occlude the lumen: you may also suture omentum to failed, or because blood has been shunted from the liver.
cover the hole made by incising the muscle layer. Liver failure commonly complicates cirrhosis, but not the
If you have made a V-incision, you can use the distal part other causes.
to cover the perforation as a transposition flap. Your aim is to:
(1) stop the bleeding,
If a vessel bleeds, press with gauze for a few minutes; (2) restore the blood volume,
if this fails transfix it with 4/0 multifilament. (3) prevent encephalopathy.
Do not use diathermy as this may damage the mucosa.
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ACTION.
Get the patient to swallow 200ml ice-cold water
and if this halts bleeding, repeat after 2hrs.
Administer Vitamin K 10mg IV od for 3days,
correct hypoglycaemia, and add 10mg
propranolol IV over 10min or 20 units
Vasopressin in 200ml saline or 5% dextrose over
20min. This may give rise to the side-effects of
abdominal cramps, headache, and palpitations.
It will also raise the blood pressure for a short
time.
N.B. Vasopressin loses its activity in the heat,
so, if there are absolutely no abdominal cramps,
it may well be inactive. Arrange endoscopic
sclerotherapy (13-9) if possible.
If bleeding continues, insert a Sengstaken tube
for 24hrs, then deflate the balloon. If bleeding
recurs, repeat the drugs and re-inflate the balloon.
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METHOD.
Make a left subcostal incision, and carefully expose
the oesophago-gastric junction. You may need to
clear the oesophagus of large vessels by ligating
them individually: take your time! Mobilize enough
of the oesophagus to be able to get a sling round it.
Retract the posterior and anterior vagus nerves out
of the way if possible.
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13.8 Gastric outlet obstruction Before the last drop has left the funnel, lower it over a
bucket (to prevent air entering). The stomach contents
will run out. Repeat the process, this time using 1l water.
Scarring from a chronic duodenal ulcer, TB or ingestion of Go on doing this until the fluid returns clear. Finally, leave
caustic sometimes causes pyloric obstruction (stenosis). 500ml inside the stomach. Repeat this daily, for 3days,
Obstruction may also be caused by carcinoma of the distal or until he is fit for surgery, whichever is later.
stomach (13.10). The patient may come to you saying that Do not perform the wash out on the day of operation!
he has been vomiting for days or weeks. He may only CAUTION! Check the volume of water you have run in
vomit once a day or he may say that he vomits 'everything and out: a marked discrepancy indicates the stomach has
he eats'. The vomit may contain food that he ate days perforated.
before. Or, he may not actually vomit, but merely feel RADIOGRAPHS are useful if the diagnosis is in doubt.
abnormally full and bloated after only small amounts of Take an erect abdominal film, and look for a large fluid
food. He may be burping, and he may have taught himself level in the left upper quadrant. A drink of barium will
to vomit to relieve the symptoms. He loses weight. produce a mottled shadow showing that the gastric outline
Continued vomiting depletes the extracellular fluid, and is much enlarged. Little or no barium passes the pylorus.
causes hypochloraemic alkalosis, and hypokalaemia; Do not administer a large quantity, because it may be
eventually he becomes dehydrated, wasted and oliguric. difficult to wash out, and the patient may vomit and
aspirate.
Try to confirm the diagnosis either by endoscopy (13.2)
or Barium meal. A biopsy is necessary to differentiate REHYDRATION may be necessary over several days to
between malignant and benign causes. TB may need deep restore the extracellular fluid volume. Treat with 0·9%
‘well’ biopsies. Rarely there is a pyloric web. saline or Ringer's lactate. If necessary, correct the
Very occasionally, the stomach is distended by a huge potassium loss with up to 80mmol of potassium od, or use
bezoar (13.11) or by chronic binge eating (bulimia). Darrow's solution ([K+]=34mM). Be guided by the volume
and specific gravity of the urine output.
To relieve the obstruction, if you cannot perform a
endoscopic dilation (13.2), a gastrojejunostomy is the GASTROJEJUNOSTOMY FOR PYLORIC STENOSIS
answer: this is anastomosing the jejumum side-by-side to (GRADE 3.4)
the gastric antrum. As the pylorus is usually badly scarred, INDICATIONS.
or infiltrated by tumour, do not perform a pyloroplasty. (1).Pyloric obstruction causing dehydration and weight
loss, or other long-standing obstructive symptoms as
In infants, hypertrophic pyloric stenosis is a different described above.
entity altogether (33.4). In Chagas disease, the myenteric (2).Duodenal ulceration with sufficient scarring to
plexus may be involved, giving rise to achalasia of the contraindicate pyloroplasty; combine it with a truncal
pylorus (30.6): this results in pyloric obstruction without vagotomy.
any visible stenosis. You can perform a pyloromyotomy (3).As a palliative procedure for stenosis caused by an
(as in the infant) to deal with this. antral carcinoma or gastric outlet obstruction by pancreatic
carcinoma.
EXAMINATION. Lay the patient down and look for
visible gastric peristalsis, as the stomach struggles to EXPOSURE.
empty itself through a narrowed pylorus. Look for slow Make an upper midline incision. If you find a large thick
waves moving from the left hypochondrium towards and walled stomach, the diagnosis of pyloric stenosis is
beyond the umbilicus. Rock the patient from side to side. confirmed. Ask your assistant to retract the liver upwards
You may hear a succussion splash even without a with a deep retractor, and to draw the stomach downwards
stethoscope. You may also hear it if you depress the at the same time. Make sure there is enough room, because
epigastrium sharply with your hand; (beware: a splash traction may tear the spleen.
may be normal after heavy drinking or a large meal). Is the cause malignant? If there are hard nodules,
enlarged hard lymph nodes, and perhaps an ulcer crater,
PREPARATION just proximal to the pylorus, suspect a gastric carcinoma.
WASHOUTS will empty the stomach, remove debris, and If there is a mass in the head of the pancreas pressing
provide some relief of colic. With luck, the inflamed and on the duodenum from behind, suspect a pancreatic
oedematous pylorus will open up. Washouts will also carcinoma. Biopsy a node, and perform an anterior
reduce the risk of postoperative infection. gastrojejunostomy.
Is the cause benign? If there is:
Find a funnel, a large (Ch36, 10mm diameter) stomach (1);Puckered scarring on the front of the first part of the
tube or a catheter, and a longer piece of rubber connecting duodenum, perhaps with adhesions to surrounding
tube the same size. With the patient prone with the head structures.
supported over the end of the bed, pass the well-lubricated (2);An indentation on the posterior wall of the stomach
stomach tube through the mouth and encourage him to extending into the pancreas to which it is fixed, suspect a
swallow it. Connect the stomach tube via the other tube to chronic peptic ulcer, or tuberculosis.
the funnel. Hold up the funnel and pour in 500ml of tepid Carcinoma rarely affects the first part of the duodenum,
water (250ml in a child). so that lesions there are almost certainly benign.
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GASTROJEJUNOSTOMY
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If there is malignant gastric outlet obstruction, CAUTION! Check that you really have found the
perform a gastrojejunostomy, proximal enough to avoid stomach, and not the transverse colon by mistake!
the tumour (13.10). If you have opened the colon, close the perforation in two
layers (14.3), and continue the operation unless there was
DIFFICULTIES WITH CHRONIC DUODENAL ULCERATION massive soiling.
If medical treatment fails, or is too expensive, you may be Make a small stab incision lateral to the midline and use a
able to help a poor patient by operating. If there is haemostat to pull a Ch20 or Ch24 Malecot or Foley
uncontrollable pain and dyspepsia, or if the quality of life catheter through it. Make the gastrostomy high on the
has been spoilt over the years by nagging pain, heartburn, anterior wall of the stomach, midway between its greater
and indigestion, there may be still a place for a truncal and lesser curves, and as far from the pylorus as you can.
vagotomy and gastrojejunostomy or pyloroplasty. Hold the stomach with two pairs of Babcock's forceps, and
draw it upwards and forwards into a cone.
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POSTOPERATIVELY. Treat the patient sitting upright in 13.12 Gastric foreign bodies
bed, and make sure he gets vigorous chest physiotherapy.
There is no evidence that a nasogastric tube is helpful Most ingested foreign bodies will pass through the pylorus
postoperatively. Do not put one in after the operation, and exit via the anal canal, although their passage is often
because you may perforate the anastomosis with it! missed unless stools are examined assiduously.
However, large, long, sharp or multiple objects may
DIFFICULTIES WITH GASTRECTOMY impact at the pylorus. Most of the time these do not result
If there is significant bleeding after gastrectomy, in gastric outlet obstruction, but may cause obstruction in
place a pack, press and wait 5mins. Look at the spleen: the small bowel. They may not pass if there is pyloric
if it is badly damaged, remove it (15.17). stenosis from another cause. Occasionally they may cause
bleeding or even perforation, especially alkaline disc
If you cannot close the duodenal stump, insert a Ch20 batteries, or potassium tablets.
Foley catheter to produce a controlled fistula.
Bezoars are concretions of ingested material:
trichobezoars, principally hair (chewed by long-haired
girls), or phytobezoars, (unripe persimmons or citrus
13.11 Gastric stricture fruits). These form a glutinous mass in the stomach which
eventually can occupy the whole organ, and cause
Swallowing a corrosive causes damage to the oesophagus obstruction, as well as bleeding, anaemia, weight loss,
(30.3) but ingestion of concentrated acid causes intense mimicking malignancy.
spasm of the pylorus, allowing the corrosive acid to pool
in the body of the stomach. This produces an intense INDICATIONS FOR EXTRACTION OF GASTRIC FOREIGN
inflammatory reaction and subsequent scarring, resulting BODIES
in a stricture of the terminal portion of the body of the (1) Impacted foreign bodies at the pylorus,
stomach or antrum. If you use antacids in the acute (2) Haematemesis and/or melaena,
situation, the acid is neutralized in a highly exothermic (3) Multiple foreign bodies accumulating in the stomach,
reaction which burns the gastric mucosa further. (4) Danger of or actual gastric perforation,
The resulting stricture may take months to develop; (5) Danger of toxic absorption of chemicals (e.g. heroin)
the vomiting of gastric outlet obstruction is frequently
preceded by heartburn, epigastric pain and anorexia. SPECIAL TESTS.
Later carcinoma develops in the scar. Plain abdominal radiographs will show metallic objects;
remember to take these films just prior to any attempt at
EXAMINATION. removal, because foreign bodies are notorious in moving
Look for a gastric splash in a grossly cachectic patient who on! A bezoar may show up as a mottled density, but is
has a history of acid ingestion. often not seen on Barium studies because the contrast
infiltrates into the bezoar.
Endoscopy confirms the diagnosis.
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MANAGEMENT.
Try passing a nasogastric tube to deflate the stomach:
this will buy you time in a chronic or incomplete case.
At laparotomy you may have difficulty seeing the stomach
as it is tucked away in the left hypochondrium;
you will need to decompress the distended twisted
stomach by a needle or small-bore suction tube before you
can untwist it.
Simple gastrostomy (13.9) fixes the stomach, but this is
not usually a permanent solution.
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(3);The diagnosis is particularly difficult, but no less Removing an appendix is usually easy, but is sometimes
important, if the patient is very young, very old, fat or very difficult:
pregnant. (1) The appendix may be difficult to find.
Occasionally you may see a patient with appendicitis with (2) It may be difficult to deliver, if it is stuck deep in the
an appendix scar, or even with a history of having had an wound and is obscured by bleeding.
appendicectomy! He may have been misled, or the scar (3) The caecum may be fragile.
made for a different reason. If the signs indicate surgery is (4) You may find totally different pathology.
required, do not hesitate!
Finally: if signs are equivocal, it is reasonable to
administer gentamicin and metronidazole and review the
situation periodically.
EXAMINATION
PULSE AND TEMPERATURE. In the early stages the
pulse is normal, and the temperature nearly so. If the pulse
is raised, the appendix is probably phlegmonous.
A steadily rising pulse is always serious. If there is rigor or
high fever within 24hrs of the onset of symptoms,
appendicitis is most unlikely.
If you press gently in the right iliac fossa, and then quickly
release your hand, this may produce a sudden pain.
Fig. 14-1 REMOVING AN APPENDIX through McBurney's incision
This is not so reliable if the patient is fat or pregnant.
(if the diagnosis is in doubt a low midline incision is better). This is rebound tenderness, and is a sign of early
A, McBurney's point and the position of the incision. B, split the peritoneal irritation. It is impossible to have guarding but
external oblique aponeurosis. C, split the internal oblique and no rebound tenderness! A kinder way of eliciting this sign
transversus muscles. D, open the peritoneum between 2 haemostats.
This drawing also shows how you can, if necessary, extend the
is to test for tenderness to light percussion. This is not so
incision medially by incising the anterior rectus sheath, painful and is a better sign.
and retracting the rectus muscle. E, pass a ligature through the
mesoappendix. F, transfix the appendix base, and remove it. Try to feel a child’s abdomen when he is asleep, or resting
G, various positions where you may find the appendix: 74% behind
the caecum, 22∙5% in the pelvis. It is seldom anywhere else.
on the mother’s lap. If he resents any attempt to examine
Partly after Maingot R, Abdominal Operations, HK Lewis 4th ed 1961 the abdomen, there is probably something seriously wrong
p.811 Figs. 2,3. with kind permission. inside it. Examine him repeatedly at intervals of 1hr,
until you have enough evidence to justify a laparotomy.
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GUARDING is a sign of local peritonitis. Lay your hand DIFFERENTIAL DIAGNOSIS OF APPENDICITIS
flat on the abdomen, and gently flex your knuckle joints. IN EITHER SEX.
If there is tightening over the right fossa, the sign is +ve, This is a long list, but the most important possibilities are
especially if the patient winces with pain. Remember to the first two, because surgery will make the patient worse:
look at his face not your hand! Tenderness is relieved by
flexing the hip, but worsened by flexing the hip against Suggesting an upper respiratory infection, a viral
resistance (10-2). infection (mesenteric adenitis), or tonsillitis: upper
respiratory symptoms, tachypnoea and alar flaring,
RIGIDITY is a comparatively late sign, and shows that generalized muscle aches. All these can cause central
infection has reached the anterior abdominal wall. abdominal pain in a child. Watch and examine repeatedly,
Generalized rigidity is a sign of generalized peritonitis especially the pulse, and if this does not settle, get a chest
(10.1). It is less marked in the obese, emaciated, radiograph.
very old, very young, or those with HIV disease.
Advanced peritonitis becomes less tender as the volume of Suggesting gastroenteritis: diarrhoea, perhaps with
ascitic fluid increases. vomiting. The pain will be colicky, the tenderness poorly
localized, and there may be pus cells in the stool.
AN APPENDIX MASS may be palpable if the symptoms Be sure to do a pelvic examination, if necessary several
have lasted >2-3days. With obesity, or a very low pain times, because a pelvic appendix abscess may be
threshold, it will be difficult to feel. Distract the patient’s developing. Try to get an ultrasound scan (38.2).
attention while you palpate.
The mass is ill-defined and is probably an ‘abscess’ if: Suggesting amoebiasis: a history of diarrhoea with blood
(1) it is tender, and especially mucus: look for amoebae in the stools
(2) there is a high fever, (14.5).
(3) there are features of intestinal obstruction. Confirm the
presence of pus by aspirating with a wide-bore needle. Suggesting typhoid: a history of fever, diarrhoea,
and diffuse abdominal pain for c.3wks, suddenly becoming
Do not assume a mass in the right iliac fossa is an acute (14.3).
appendix mass: it may be an adnexal mass, an
intussusception, a mass of ascaris worms, an amoeboma, a Suggesting ileocaecal tuberculosis: chronic pain which is
caecal carcinoma, a lymphoma, an ileocaecal tuberculoma, sometimes colicky, with a general deterioration in health,
an ileal phytobezoar, a bilharzioma, or due to especially with HIV disease (16.1).
actinomycosis or angiostrongyliasis. Check the history!
Suggesting a perforated peptic ulcer (13.3): the pain,
RECTAL (OR VAGINAL) EXAMINATION: which is now in the right iliac fossa, started suddenly in
never forget this to feel for tenderness or a mass: the upper abdomen; there may be a history of chronic
the inflamed appendix may be dangling in the pelvis. dyspepsia. Enquire for shoulder tip pain.
A rectal examination will often distinguish salpingitis, and Get an erect chest radiograph and look for gas under the
a right-sided ectopic gestation. Slowly pass your diaphragm.
half-flexed, well-lubricated index finger into the rectum
(use your little finger in a child <10yrs). When it is Suggesting iliac adenitis (6.16): a tender fluctuant mass in
completely inside, keep it still for a moment. Wait for the the lower quadrant, and a marked flexion contracture of
patient to relax, then gently press anteriorly, posteriorly, the hip. Look for the primary source of the infection in the
and on each side on the pelvic peritoneum with the tip of legs or perineum.
your finger.
CAUTION! Do not let the patient confuse the Suggesting septic arthritis of the hip (7.18): intense pain
discomfort of you putting your finger into the anus, on any movement of the hip, which is kept flexed.
with the pain of you pressing on the pelvic appendix. Aspirate from the joint to detect pus.
Wait with your finger in the rectum until the initial
discomfort has settled, then rotate and flex the tip of your Suggesting a urinary infection: frequency and pain on
finger and note the response. micturition, with central lower abdominal tenderness and
little guarding. These symptoms can also be caused by
SPECIAL TESTS. appendicitis, if the appendix lies against the bladder.
A leucocytosis is a useful sign if present, but a normal Examine the urine.
white cell count may be present in advanced appendicitis
with HIV disease. Alone, without other signs, it is not Suggesting ureteric colic: severe intermittent colicky pain
enough to warrant exploration. radiating into the groin without fever. Test the urine for
red cells: these are most often present if there is a stone in
Ultrasound is helpful in detecting free fluid (38.2A), a the ureter.
mass or lymphadenopathy (38.2G), or the appendix
swollen and non-compressible with a diameter >6mm, but
a diagnosis should not rely on an ultrasound report alone.
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APPENDICETOMY (GRADE 3.1) Split the external oblique muscle aponeurosis in the line of
This describes the operation where appendicitis is early, its fibres, which is the same as that of the skin incision,
and inflammation is located to the right iliac fossa. over its whole length. Resist the temptation to extend the
Where this is not the case, and especially when you find a incision too far medially. Get an assistant to retract.
mass when the abdomen is relaxed under GA, or are not Hold the edges of the oblique aponeurosis aside with
certain of the diagnosis, particularly in a woman, haemostats, and you will see the fleshy fibres of the
perform a formal laparotomy through a mid-line incision internal oblique running transversely, and a little upwards.
(10.1) because access is better and you can wash out the Insert a closed pair of blunt scissors between them and use
abdomen more satisfactorily: this is crucial. the 'push and spread technique' (4-9) to separate them.
Then extend the incision with your fingers. Replace these
by retractors, to expose the transversalis fascia and
peritoneum. Pick these up as a single layer and separate
them in the same way. Open the peritoneum between
haemostats (11-2), making sure you have not inadvertently
picked up bowel.
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CAUTION!
(1) If the mesoappendix is very inflamed, do not apply
artery forceps but pass a ligature round it.
(2) Be patient and gentle when you try to remove a tense,
unruptured, gangrenous appendix: if it is on the point of
bursting, try to deliver it intact. (If it bursts, you will
greatly increase the chances of infection.)
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INDICATIONS. A tender mass which is increasing in size If you find greenish fluid in the peritoneal cavity,
with a history of appendicitis, or more rarely following it has probably escaped through a perforated duodenal
appendicectomy 3-4days previously, especially if there is ulcer, and tracked down the right paracolic gutter. Make an
increasing pain, pyrexia, and toxaemia. upper midline incision and close the perforation (13.3).
THE EXTRAPERITONEAL APPROACH is best. If the caecum is much thickened, suspect amoebiasis,
If the abscess is dull to percussion, there is no bowel tuberculosis, or actinomycosis. Insert a drain and treat with
between it and the abdominal wall. It has probably stuck to metronidazole. Take a biopsy of adjacent tissue or lymph
the abdominal wall, so that you can easily drain it under node.
LA. You may be able to do this satisfactorily by aspiration
under ultrasound guidance; this is preferable to surgery but If you find an appendix mass or the appendix is
may mean more than one aspiration to empty the abscess. inflamed, but is so tied down by adhesions that it is
difficult to remove safely, insert a drain and close the
Try to enter the abscess, but not the peritoneal cavity. wound.
Mark the point of maximum tenderness and fluctuation
with a felt pen. Anaesthetize and incise the skin and If the base of the appendix is necrotic, amputate it
muscles at this point. Try to enter the abscess as far because you cannot tie it. This will leave a defect in the
laterally as you can. The muscles will be soggy and base of the caecum: if the margins are healthy, insert a
oedematous, but you can split them in the usual way, purse string suture around the edge of the defect and invert
by pushing in a haemostat and opening it. Push a finger in it. If the edges are unhealthy, and will not take a suture,
laterally and backwards to make sure that the drainage make sure you have good enough exposure (if necessary,
track is big enough. extend the incision) and remove more of the caecal base
Suck out pus, break down any loculi, and feel for and till you reach healthy tissue and close the bowel formally.
remove any faecoliths. Then push a large corrugated Secure some omentum over the repair, insert a drain
rubber drain well in. Suture this to the skin and shorten it adjacent to it, close the muscles of the abdominal wall,
gradually after the 3rd day. Remove it completely when it but leave the skin open. The alternative, a formal
is no longer draining anything. laparotomy and an ileocaecal resection (12.7), is a
formidable procedure, and unless you are experienced may
CAUTION! Do not try to remove an appendix from the give you more problems.
bottom of a large abscess cavity with much friable tissue
that bleeds easily. Drain the abscess and leave the If the appendix is buried in a mass of adhesions and
appendix in place. pockets of pus, avoid spreading the infection. Enlarge the
incision, lift its medial side forwards, isolate the mass with
If you cannot adequately drain the pus (or there is warm packs, suck out the pus, and remove the appendix if
none present), perform a formal laparotomy through a this is not too difficult. Otherwise, leave it, lavage the
midline incision. abdomen thoroughly and put in a drain.
INTERVAL APPENDICECTOMY If you have treated an If you lose the appendix stump or appendicular artery,
appendix mass conservatively or an abscess by drainage, enlarge the incision and withdraw the caecum into the
and left the appendix in, there is only occasionally a need wound once more to find the culprit. If this fails, open the
for an interval appendicectomy. However >80% of abdomen formally by a midline incision.
appendices in this situation fibrose or disappear by
autolysis. Finding the appendix may actually be very If you find a tumour in the caecum, make a midline
difficult. It is probably not indicated in HIV disease. incision and perform a right hemicolectomy (12.11).
If symptoms of right lower abdominal pain recur,
however, appendicectomy should be carried out. If initial If you find a tumour in the appendix tip, it is likely to
histology showed tuberculosis or schistosomiasis in the be a carcinoid. No further treatment is necessary apart
appendix mass, and proper treatment was provided, from the appendicectomy, unless there are metastases in
interval appendicectomy is unnecessary. the liver.
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If the appendix looks normal, look for other pathology: If the temperature rises in the 2nd week, accompanied by
(1).If there are enlarged mesenteric nodes, and a clear malaise and local symptoms, there is probably pus
yellowish serous exudate, suspect mesenteric adenitis, and somewhere.
close. If the nodes are very large or numerous, (1) There may be a wound abscess.
take a biopsy from one for tuberculosis. (2).There may be a subphrenic abscess (10.2), localized
(2).If you find a purulent exudate, suspect PID in a woman intra-abdominal collection, pelvic abscess (10.3) or a
and other causes of peritonitis: make a midline incision. metastatic abscess in the liver (15.10). If there is a mucous
(3).If you can feel a tensely distended gall bladder when rectal discharge or diarrhoea, suspect that there is pus in
you pass your finger up through the incision, this may be the rectovesical pouch. Feel for a boggy inflammatory
due to cholecystitis or an obstructed gallbladder. Do not be mass above the prostate, or in a woman's rectovaginal
tempted to perform a cholecystectomy via a small incision pouch. Feel also for an inflammatory mass in the
in the right iliac fossa! abdomen. Get an ultrasound scan (38.2K).
(4).If there is a tensely distended caecum, there is large
bowel obstruction. Make a midline the incision and feel If the wound continues to discharge, there may be a non-
for its cause (12.2). absorbable suture left behind. Explore the wound and
(5);If there is blood in the abdominal cavity, remove any foreign body. There may be a faecolith left
the possibilities include ectopic pregnancy, a leaking behind. Explore the track, irrigate it and flush it out. There
ovarian follicle, pancreatitis, trauma, or necrotic bowel: may be:(1) amoebiasis, (2) tuberculosis, (3) actinomycosis,
make a midline incision. or (4) HIV disease.
(6) If there is an inflamed Meckel’s diverticulum about 1m If the appendix has a tumour found on histology,
from the ileocaecal junction, do a bowel resection to ileocaecal resection is only necessary if it was not
remove it. This will probably mean a midline incision. completely removed or within 2cm of the resection
margin.
If you make a formal laparotomy incision, do not remove a
normal appendix, but tell the patient the appendix remains If the appendix shows tuberculosis macroscopically or
in situ! Do not excise an uninflamed Meckel’s on histology, start anti-TB therapy and check the HIV
diverticulum. status.
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Remember that schistosomiasis, paracoccidiomycosis 14.3 Typhoid & small bowel perforation
and radiation >30Gray can also cause inflammatory
bowel disease. Generally try to reserve these cases for an
expert. Schistosomiasis of all types can cause, in the acute Although typhoid is common in many low and middle-
phase, a florid ulcerative enterocolitis with perforation, income countries, perforation seems to occur more
and with chronic infestation, granulomata, fibrotic commonly in some regions than in others. Where
strictures and polyps anywhere in the gastro-intestinal perforation is common (Madagascar, West Africa,
tract, but especially in the colon. These may result in particularly Sierra Leone and Ghana), it may be one of the
chronic stricture, intussusception, fistulae and rectal commonest causes of peritonitis. Less often, typhoid can
prolapse from persistent straining. also cause serious intestinal bleeding, cholecystitis,
pancreatitis or osteomyelitis.
Infective causes are many; typhoid (14.3) is common in
endemic areas. Campylobacter jejuni affects the caecum Typhoid is more common in Schistosoma carriers, those
and causes lymphadenitis in the terminal ileal mesentery; with sickle cell disease, and achlorhydria. The disease is
Yersinia enterocoli affects the terminal ileum with similar seasonal, and is most prevalent in the wet season.
lymphadenitis. You may be able to diagnose and It is characterized by high fever (38·5-39·5ºC), headache,
differentiate these by ultrasound. confusion, bloody diarrhoea and abdominal tenderness.
People eating Western diets for long periods often develop Bradycardia is only present in ⅓; splenomegaly in ⅓ and
diverticular disease, where there are weak spots in the wall hepatomegaly in ¼ of all patients.
of the descending and sigmoid colon due to increased
intraluminal pressure, usually on account of chronic A typhoid perforation is seldom dramatic, because loops of
constipation. These ‘blow-outs’ or diverticula may become diseased bowel stick together, so that the bowel leak
inflamed, or stenosed, fistulate, perforate or bleed just like remains contained. It is usually difficult to tell exactly
other causes of inflammatory bowel disease. when it occurs, unlike the perforation of a peptic ulcer.
Ultrasound may help in the diagnosis: the bowel wall will Often, there may be no specific complaint. The signs will
be >4mm thick and if there is an abscess, you will see a depend on:
poorly defined hypo-echogenic area adjacent. (1) how long ago the bowel perforated, and
Diverticulitis usually settles with eating restriction, and (2) how localized the peritonitis is.
IV metronidazole and gentamicin or a broad-spectrum
cefalosporin. If you are confident that an abscess has Exactly the same scenario exists with spontaneous
formed, you may be able to drain it under ultrasound bowel perforation due to HIV or lymphoma (17.6),
guidance; but if pain gets worse with tenderness and fever, Crohn’s disease, Behçet’s disease or lupus (the latter
indicating localized peritonitis, perform a laparotomy. common in Southeast Asia): the symptoms and signs are
virtually identical, and the same advice holds true.
If the affected large bowel is inflamed but not
perforated, wash out the abdomen and leave a drain You will seldom miss a perforation if:
adjacent to the bowel. (1) you examine the abdomen of any patient with typhoid
If there is severe large bowel inflammation or fever and HIV-related abdominal pain twice a day:
perforation with often an adjacent abscess cavity; resect perforations which occur in hospital are easily missed.
the affected segment, make a proximal end-colostomy and (2) you think of it in any case of acute abdominal pain,
close the distal end (Hartmann’s operation: 12.9), with signs of peritonitis, during a febrile illness especially
or fashion a mucous fistula if the distal segment is long with signs of depressed immunity.
enough. This may be difficult and bloody surgery, so have
blood cross-matched, and proceed carefully. If you are If there has been toxaemia and fever, with chronic
unable to resect the affected bowel, make the proximal abdominal pain for 2-3wks, and then sudden worsening
defunctioning colostomy as before, and leave in a drain. of the pain, a typhoid ulcer in the ileum has probably
The inflammation will usually settle but may form an perforated. This usually happens in the 3rd wk, but can
abscess which needs local drainage. occur in the 1st wk, or during convalescence. The bowel is
oedematous and friable, so surgery may be difficult.
Diverticular disease occasionally affects the ascending
colon, and is then more prone to complications. If a perforation presents insidiously, and appears to be
This is found commonly in Southeast Asia. If localized localized, you might like to opt for a conservative
sepsis develops, washout the abdomen as above; if this is approach, but if the patient deteriorates, surgery will be
severe it is reasonable to perform a primary ileocolic that much more difficult. If you resuscitate aggressively
resection. and operate early, you can reduce the mortality to 3-10%.
N.B. Salmonella typhi is now resistant to both
There is no indication to perform elective surgery for chloramphenicol and ampicillin in many areas. So adjust
uncomplicated diverticular disease, nor probably for antibiotic treatment accordingly: quinolones are best.
patients who have had several episodes of diverticulitis Ceftriaxone is an alternative. When a typhoid ulcer
successfully treated conservatively. However, follow-up perforates, many different bacteria are released into the
with colonoscopy or barium enema to exclude malignancy abdominal cavity, including anaerobes. S. typhi is only one
is wise. of them, and not the most aggressive.
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SPECIAL TESTS.
Blood culture is useful but the result will arrive after you
have had to start treatment. The Widal test is only helpful
if there is a fourfold rise in titre. The Diazo test (visible
pinkish froth giving a +ve result) with urine is cheap and
most reliable.
DIAGNOSING PERFORATION.
Fever and headache at the onset of the illness, are followed
by vomiting, abdominal pain, and distension. Following
perforation, tenderness usually starts in the right lower
quadrant, spreads quickly, and eventually becomes
generalized. There is usually guarding present, but seldom
the board-like rigidity characteristic of a perforated peptic
ulcer.
Percuss the lower ribs anteriorly; if there is gas between
them and the liver, the percussion note will be resonant
(due to the absence of the normal liver dullness).
The bowel sounds may be absent. Hypotension, oliguria,
and bradycardia are terminal signs. If possible, culture the
stools, if necessary more than once.
CAUTION! The bradycardia and leucopenia of typhoid
may occasionally mask the tachycardia and leucocytosis of
peritonitis.
RADIOGRAPHS. Take an erect chest film, and look for Fig. 14-4 TYPHOID FEVER.
gas under the diaphragm (50% +ve). If the patient is too A, characteristic appearance ('typhoid facies') of a patient with
weak to sit up, take a lateral decubitus film, and look for typhoid fever. B, bacteriology of intestinal perforation in typhoid
gas under the abdominal wall. This is a very useful sign. fever. (1,2) Note the two phases of S. typhi bacteraemia, and
(3), the third phase of bacteraemia, with organisms from the bowel,
You may also see loops of the small bowel dilated with that follows perforation. After Bitar R, Tarpley J. Intestinal Perforation
gas, usually without fluid levels. in typhoid fever. Rev Inf Diseases 1985:7.257-271
DIFFERENTIAL DIAGNOSIS OF BOWEL PERFORATION Suggesting appendicitis: pain starting over the umbilicus
includes appendicitis (14.1), perforations from other and moving to the right iliac fossa; pain precedes fever.
causes, such as HIV disease (5.6), tuberculosis (16.6),
ascariasis (12.5), schistosomiasis, paracoccidiomycosis, Suggesting HIV disease: cachexia, lymphadenopathy,
and necrotizing amoebic colitis (14.5). Tumours of the absent leucocytosis, and other signs of HIV disease (5.5).
bowel may also perforate: in the small bowel these are
likely to be lymphoma or Kaposi sarcoma; in the large Suggesting tuberculosis: a cough, cachexia, chest
bowel, adenocarcinoma (12.11). Crohn’s disease, radiographic changes and lymphadenopathy.
ulcerative colitis, colonic diverticulitis, and radiation
bowel disease are uncommon causes of inflammation and Suggesting ascariasis: worms seen in the stool or on a
perforation outside the Western world. A perforated peptic radiograph.
ulcer (13.3) and other causes of a septic abdomen (10.1)
such as small bowel obstruction from adhesions also of Suggesting schistosomiasis: large numbers of ova in the
course give rise to peritonitis. stool in an endemic area.
N.B. Don’t forget that unreported trauma may be a
cause of bowel perforation, particularly in a child! Suggesting paracoccidiomycosis: lymphadenopathy,
mucocutaneous lesions and chest radiographic changes in
Central and South American agricultural workers.
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Suggesting necrotizing amoebic colitis: a history of LAPAROTOMY FOR PERFORATED SMALL BOWEL
diarrhoea (especially with the passage of blood and (GRADE 3.4)
mucus), followed by acute pain in the right lower
quadrant, with guarding and a silent abdomen. PREPARATION. Make sure there is vigorous
Look for trophozoites in the stools. resuscitation already in process, there is a good urine
output, there is a nasogastric tube inserted, and you have
Suggesting a perforated peptic ulcer: a sudden onset, administered antibiotics.
and a history of ulcer symptoms.
INCISION.
MANAGEMENT. Here are some guidelines: Make a midline incision, most of it below the umbilicus.
As you incise the peritoneum, there will probably be a puff
If there are signs of localized or generalized peritonitis of gas, confirming that some hollow viscus has perforated.
perform a laparotomy. Take care not to cause more perforations, especially if the
bowel is adherent. Aspirate the free fluid. Gently divide
If the patient is moribund 36-48hrs after a perforation, the adhesions.
with a distended or board-like abdomen, a thready pulse, Expect to find:
and a very low blood pressure (septic shock), pour in large (1) Greenish ileal contents in the abdominal cavity.
volumes of warmed Ringers lactate or saline IV by (2);In typhoid, the last 60cm of ileum inflamed and
2 wide-bore cannulae. When the condition improves, oedematous, and the adjacent structures somewhat less so.
perform a laparostomy (10.1) with copious lavage of the Also, often an inflamed gallbladder (15.3)
abdominal cavity in the first instance. (3);In late cases particularly, dilated loops of jejunum and
proximal ileum.
If large volumes of melaena stools are passed (4) Soft, soggy mesenteric lymph nodes.
(or occasionally frank blood), transfuse blood to replace Start at the ileocaecal junction, hold the bowel very gently
the loss. Bleeding will probably stop spontaneously. with moist laparotomy pads, and work your way
Only operate if there is persistent or alarming bleeding. proximally until you reach healthy bowel, or the duodeno-
Tranexamic acid 1g IV stat and then 10mg/kg/hr is jejunal junction. Look for one or more tiny perforations in
effective in arresting massive bleeding, and worth starting the ileum. The jejunum does not perforate in typhoid,
before rushing to a difficult laparotomy in an unstable but may with HIV. Typhoid perforations are usually on the
patient. Dexamethasone 3mg/kg/day IV may reduce ante-mesenteric border of the ileum, not far from the
bleeding from inflammatory ulcers, usually in the distal caecum.
ileum, but which may be difficult to find. If you do find Note each perforation you find, until you have found them
one, perform an ileocaecal resection (12.7), or clamp the all. There is usually only 1, and rarely >5. Divide any
segment of bowel that is bleeding, and perform a 2nd look adhesions very gently by sharp, or if they are soft and thin,
laparotomy after 24hrs. This is a critical situation. by blunt dissection.
CAUTION! Handle the bowel with the greatest possible
RESUSCITATION is critical. Be prepared to rehydrate care: it may come apart in your hands at any moment.
vigorously. You may need to infuse >4l IV fluid. If you drop the bowel, start the examination again at the
Don't forget to add potassium lost. If the haemoglobin is caecum.
<7g/dl, transfuse blood. Monitor the urine output, and
maintain the fluid balance. If possible monitor the CVP. If a perforation is small (<1cm), freshen its edges if it is
sloughy, by excising 1mm of mucosa all round its
ANTIBIOTICS: Treat with IV chloramphenicol (up to 4g circumference, and close it transversely with 'all coats'
qid in very ill patients) or ciprofloxacin 500mg bd or sutures of continuous or interrupted 3/0 absorbable.
gentamicin 3mg/kg od. Decrease the gentamicin dose if If you put them through only part of the bowel wall, they
there is renal insufficiency. Add metronidazole 1g as a will cut out. Invert these 'all coats' sutures with a
loading dose, followed by 500mg tid. continuous layer of non-absorbable Lembert seromuscular
sutures (11-5E), and wrap some omentum around the
CONFUSION: treat with phenobarbitone for a restless closure.
patient; avoid sedatives which depress respiration.
If there is a considerable amount of soiling, and the
NASOGASTRIC SUCTION will empty the gas from the edges of the perforation are sloughy, trying to close
stomach, and, hopefully, diminish the distension of the perforated inflamed bowel will lead to disaster: it will
small bowel. Respiratory complications, particularly the leak! You should resect the affected segment of bowel,
aspiration of stomach contents, before, during, or after and either make an end-to-end anastomosis (11-7),
anaesthesia are an important cause of death. or bring both ends of bowel out as cutaneous stomas.
(If you open the bowel, and it is very distended, make sure
you empty it through the cut you have made, outside the
abdominal cavity, into a kidney dish, after protecting the
abdomen from contamination). Wait till the inflammatory
process has settled before attempting to re-anastomose the
bowel.
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If there is a perforated Meckel’s diverticulum, resect POSTOPERATIVELY. Chronic pre-existing illness and
the affected segment of bowel: because the inflammation preoperative metabolic abnormalities will still be
is usually localized (in the area of ectopic gastric mucosa imperfectly corrected. Manage as for other kinds of
which is present in 50%), you can usually perform an peritonitis. Monitor daily for the early detection of
anastomosis. collections of intra-abdominal pus. Continue
N.B. Do not be tempted to remove a normal appendix. chloramphenicol (or better, quinolones) at ordinary, rather
than high, doses for 2wks. This will help to combat
If the perforation is jejunal, pass a nasojejunal tube past typhoid, but not necessarily peritonitis.
the perforation for post-operative enteral feeding: Add metronidazole. Fever usually subsides in 4-5days.
if you use a fine tube, this is much more comfortable for
the patient, and you can insert a nasogastric tube as well DIFFICULTIES WITH SMALL BOWEL PERFORATION
adjacent to it to empty the stomach in the immediate Be prepared for:
postoperative period. (This can only be done for proximal (1) wound sepsis (11.13),
small bowel perforations). (2) a burst abdomen (11.14),
(3) intestinal obstruction (12.2),
If there is matted bowel with one or more perforations, (4) intra-abdominal sepsis (10.1),
which you may not be able to see, and you fear that (5) fistulae (very serious, 11.15),
manipulating the friable bowel will cause worse problems, (6) anaemia and difficult nutrition and hospitalization,
you can simply drain the area in the hope that a controlled (7) respiratory complications (11.12) especially, and
fistula will result. (8) an incisional hernia (18.13).
If there are multiple perforations, or a large If you don't find a perforation, there may not be one, and
perforation, or a severely diseased discrete segment of the peritonitis may be primary (haematogenous), or from
bowel, or if there is alarming bleeding, resect the some other cause. It is doubtful if typhoid ever causes
diseased segment, and perform an end-to-end anastomosis peritonitis without perforation, but primary peritonitis is
(11-7). Exteriorize this, because it may well fall apart. common especially with HIV.
An alternative is a mandatory second-look laparotomy
(10.1). If there is severe diarrhoea about the 4th day,
it will be very difficult to treat, and may be fatal. Replace
If there is reasonable length of normal bowel proximal to the fluid loss energetically, and don't forget to add
the perforation, insert an ileostomy tube (or a Foley potassium.
catheter) through it. Fix it in place with a purse-string
suture, correct fluid losses post-operatively, and then when If there is renewed pain, with postoperative deterioration,
the fistula track has matured (2-3wks), remove the tube suspect that there is another perforation. Perform a
and allow the fistula to close. (You can only do this for re-laparotomy, leaving the abdomen open (11.10).
distal small bowel perforations). Alternatively make a
formal proximal defunctioning ileostomy (11.6) to divert If there is a sudden spike of fever after about 5days,
the intestinal contents. Do this where presentation is late, when there should have been recovery from the typhoid,
with a localized collection of pus. suspect wound infection (11.13), a subphrenic abscess
(10.2), pelvic abscess (10.3), pneumonia, or an intestinal
If there are nodes or peritoneal nodules present, take a leak (11.15).
biopsy of a node or piece of mesentery for TB
examination.
Remember there will be much fluid loss, and excoriation of
the skin will be difficult to prevent. 14.4 Necrotizing enterocolitis
(Pigbel, Darmbrand)
DEALING WITH THE PERITONITIS depends on what
you find: Like typhoid fever, necrotizing enterocolitis (pigbel or
If peritonitis is localized, perform a local toilet only, darmbrand) is much more common in the tropics,
and avoid spreading infection to the rest of the abdominal but is occasionally seen elsewhere. It is probably due to
cavity. the ß-toxins of Clostridium perfringens type C which
If peritonitis is generalized, wash out the entire multiply in the bowel following a large meal, classically a
abdominal cavity several times with several litres of warm feast of pork, (hence its New Guinea name ‘pigbel’)
fluid. especially where there is trypsin and chymotrypsin
deficiency. This occurs with ingestion of sweet potato
CLOSE THE ABDOMEN completely without drains. especially and threadworm infestation which inhibit
Leave the skin open, for secondary closure later (11.8). trypsin secretion, and protein malnutrition where
If sepsis is severe, leave the abdomen open as a chymotrypsin levels may be undetectable. The result is a
laparostomy (11.10). patchy necrosis of the small and/or large bowel.
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This was at one time, before vaccination against ß-toxin, INDICATIONS FOR LAPAROTOMY.
the commonest condition requiring laparotomy in New
Guinea. It also occurred in Germany in chronically starved (1);Failure to improve, or deterioration on non-operative
people who were given a large meal, hence the term treatment.
darmbrand, meaning burning bowel. A virtually identical (2);Signs of peritonitis, and persistently large volumes of
condition is seen in HIV-patients, and occasionally after gastric aspirate.
feeding through a jejunostomy (11.7). There may be
associated mesenteric venous thrombosis (12.14). LAPAROTOMY FOR NECROTIZING ENTEROCOLITIS
(GRADE 3.4).
If bowel needs resecting, the chances of death are c. 50%.
This condition in premature neonates is discussed in 33.2. You may see the disease at any stage in its development.
It usually only involves the small bowel, but it may
Presentation is usually in a child, or young adult, with: involve the distal stomach, or the large bowel.
(1) Acute toxaemia. Classically, several loops of the small bowel, from near the
(2) Severe colicky abdominal pain and vomiting. duodenal flexure onwards, are acutely inflamed,
(3).Constipation with foul flatus, followed by bloody oedematous, and congested, often with localized necrotic
diarrhoea. areas mostly on the antimesenteric border, with a sharp
(4).Continued vomiting often with blood, and abdominal line of demarcation between normal and diseased areas.
distension. There may be perforations, localized abscesses, and
(5).An obscure abdominal illness, ending in a pelvic multiple adhesions causing partial obstruction.
abscess that is the result of a perforation. The necrotic areas are usually separate, but may
(6) Rectal bleeding (26.4). occasionally extend from the distal stomach to the sigmoid
Typically, the abdomen distends with generalized colon. The mesenteric artery is patent, and you can feel
tenderness, sometimes with a soft mass above the pulsation down to the terminal arterioles at the margin of
umbilicus. The patient is ill and may have a high fever. the affected bowel. The regional nodes are enlarged,
There may be erythema of the abdominal wall. and may be necrotic.
Only if any bowel is non-viable (11.3), resect it with an
RADIOGRAPHS: An early sign is intramural gas seen in adequate margin of healthy bowel, so that the blood supply
the bowel; later, a single dilated loop of bowel is highly to the area of the anastomosis is adequate.
suspicious; multiple fluid levels on an erect film, with gas If there is no sharp demarcation of healthy and
in the large bowel down to the rectum, indicate peritonitis. affected bowel, make a double-barrelled enterostomy
Free gas under the diaphragm indicates a perforation of the (11.5). Wash out any infection liberally. If you have
bowel. removed a considerable length of the small bowel, follow
up carefully, and treat any small-bowel deficiency that
SPECIAL TESTS. Leucocytosis (unlike the leucopenia of may develop with multivitamins, codeine phosphate,
typhoid) is usual, unless there is HIV disease. and cimetidine.
An abdominal tap may reveal bloody peritoneal fluid.
If you decide to leave inflamed but not obviously
DIFFERENTIAL DIAGNOSIS. necrotic bowel, plan a routine second-look laparotomy in
Intussusception (12.7): the presence of a tender 48hrs, and resect any gangrenous bowel.
abdominal mass and bloody mucoid stools.
PREVENTION. In endemic areas, war zones and famine
Suggesting ischaemic colitis: tests confirming sickle cell regions, prevent necrotizing enterocolitis by vaccination
disease, or an elderly patient with aortic vascular disease. with attenuated β-toxoid; this gives good immunity.
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They cause diarrhoea, with or without blood, pus, and (3) A similar perforation in the presence of acute dysentery
mucus. (this is rare in patients on metronidazole). Presentation is
The lesions in the bowel are usually quite superficial, usually with an 'acute abdomen', but diagnosing that
but if immunity is low, amoebae may invade more deeply, invasive amoebiasis is causing it is difficult
especially in the HIV+ve, the pregnant, the diabetic, pre-operatively.
the alcoholic or recently severely injured patient. Invasive
intestinal amoebiasis may cause massive mucosal necrosis Typically, there is abdominal pain, fever, diarrhoea, and
of the colon, so that large pieces of it separate as casts, and pain in the right iliac fossa. Often, there is a history
are passed rectally. Alternatively, sloughing, gangrene and of diabetes, alcoholism, pregnancy, or trauma.
perforation result in an acute necrotizing amoebic colitis. On examination, you find a mass in the right iliac fossa,
Bacterial infection may then spread as generalized or rigidity masking its presence, and often a distended
peritonitis, or it may remain localized as a abdomen.
pericolic abscess which you can feel as a tender mass.
Peritonitis may develop without actual perforation, or the If amoebiasis is endemic where your patients come
bowel can perforate extraperitoneally. As the result of this from, think of this as a likely diagnosis. It is better to start
suppuration, bowel may obstruct, or develop an ileus. treatment on suspicion, than to miss a treatable disease. If
Occasionally, the colon bleeds severely, or distends possible, treat non-operatively. Avoid surgery if you can,
massively as a toxic megacolon. because the colon will be friable and difficult to suture.
Fortunately, surgery is usually unnecessary, because the
If amoebiasis is more chronic, there may be: perforation will probably have been localized by the
(1).An amoeboma; this is a diffuse, oedematous, diseased colon sticking to the surrounding small bowel and
hyperplastic granulomatous swelling anywhere in the omentum.
colon or rectum, which is often multiple, and may be
palpable, and may obstruct the bowel (usually If there is generalized peritonitis because the perforation
temporarily). Although an amoeboma may form anywhere, has not sealed off, operation is mandatory even though the
a mass in the caecum is more easily palpable. If you do risks will be great.
feel a mass in a patient with amoebiasis, it is more likely to
be a paracolic abscess than an amoeboma. At laparotomy you may find:
(2).A fibrous post-amoebic stricture, which is one of the (1);A large inflammatory mass in the region of the
end results of an amoeboma. An amoeboma and a stricture caecum. This is more likely to be a paracolic abscess than
are two stages in the same process, and there may be a an amoeboma.
lesion with some of the features of both. Both are common (2) Greyish patches in the caecum.
in some areas (e.g. Durban, South Africa), and are the late, (3);Multiple and often adjacent perforations, mostly in the
chronic complications of amoebic colitis; they occur years caecum and sigmoid colon.
after the initial bloody diarrhoea, and are less serious than (4);Inflammatory lesions elsewhere in the large bowel.
acute invasive amoebiasis. (5) A hugely dilated megacolon.
The stricture usually involves the rectum (where you can (6);A single stricture usually in the anorectum or
feel it), the sigmoid, and the descending colon, rectosigmoid.
in that order. All can cause diarrhoea and other N.B. Avoid these mistakes:
abdominal symptoms, and obstruct the large bowel, (1).Do not attempt a right hemicolectomy and ileocolic
usually incompletely. anastomosis, which is more difficult, and more dangerous.
(2).Do not try to oversew a perforation: a necrotic colon
TREATMENT. will not hold sutures.
Treat with metronidazole 800mg tid for 5days and (3) Do not attempt a primary anastomosis.
diloxanide furoate 500mg tid for 10days.
In severe disease, add doxycycline 100mg bd for 5days. SAROJ (45yrs) was admitted with a history of fever, bloody diarrhoea,
abdominal pain, and a tender right suprapubic mass. Scrapings from
INVASIVE INTESTINAL AMOEBIASIS typical amoebic ulcers in her rectum showed trophozoites. After only
2days’ treatment with metronidazole, she felt better, her diarrhoea
If amoebae are invading the wall of the bowel, the danger improved, and her abdominal mass started to resolve.
is that it may perforate. If you can make the diagnosis MIRANDA (46yrs) had fever, diarrhoea, and vague abdominal pain for
before it has done so, metronidazole will probably be several weeks, worse during the last few days. She had a tender indurated
mass in her right lower quadrant. At laparotomy, she had acute
effective. Necrosis of the bowel wall in fulminant amoebic necrotizing colitis of her caecum, with multiple perforations, and much
colitis is commoner in pregnancy, HIV disease, diabetes sloughing tissue. After a rigorous washout of the abdomen, an ileostomy,
mellitus and the severely injured. and tying off the distant colon, she recovered slowly.
LESSONS (1) Patients often respond to metronidazole rapidly.
(2) When surgery is indicated, it is difficult.
When the bowel has perforated, treatment is much more
difficult. There are three forms of perforation:
(1) An extraperitoneal ('sealed') perforation.
(2) The perforation of an amoeboma, or an amoebic ulcer,
into the abdominal cavity, in the absence of acute
dysentery.
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LAPAROTOMY FOR INVASIVE AMOEBIASIS (GRADE 3.5) CAUTION! Remember to lavage the abdomen with
plenty of warm water.
INDICATIONS. Restore bowel continuity after recovery from the acute
(1) Frank peritonitis. disease.
(2) Failure of non-operative treatment.
DIFFICULTIES WITH INTESTINAL AMOEBIASIS
PREPARATION. If there is a mass in the large bowel, don't forget the
Resuscitate thoroughly, and follow all the steps described possibility of an AMOEBOMA. This usually responds
above for non-operative treatment: this is critical. rapidly to metronidazole, sometimes in only a few days.
Under GA when the muscles are relaxed, examine the
abdomen again, and perform a careful sigmoidoscopy. If there is a stricture, remember the possibility of post-
This may confirm the diagnosis, and determine if the amoebic fibrosis. You may need to dilate it with your
sigmoid colon is disease free. Take great care yourself not finger, or through a sigmoidoscope. If you cannot do this,
to cause a perforation! you may have to perform a proximal colostomy, or resect
the stricture. Because amoebomas and postamoebic
EXPLORATION. strictures are so rare in some areas, the danger is that you
Make a midline incision. Open the abdominal cavity, may think that this is a carcinoma. If you are in any doubt,
and examine it as for peritonitis (10.1). Gently feel for a try metronidazole, and take a biopsy.
mass. If there are greenish-grey, gangrenous patches on
the soggy, soft caecum, your diagnosis of invasive If you find a regular, firm, sausage-shaped mass in the
amoebiasis was correct. large bowel, remember the possibility of intussusception
It may fall apart and leak as you touch it. If the whole (12.7). You may find that it has ulcerated, but the ulcers
colon looks oedematous and inflamed, this may also be are unlikely to be amoebic.
invasive amoebiasis, but in an earlier stage.
If there is severe bleeding from the colon,
If there is extensive caecal amoebiasis, perform an this may be fatal, because it may look normal externally,
ileostomy (11.6). This is easier and less dangerous than so that you will not know where the blood is coming from
trying to manipulate the caecum to exteriorize it. (26.4). Arrange a colonoscopy if you can. If the bleeding
Insert a drain to the right iliac fossa. If the caecum has does not stop with installation of cold water, and perform a
perforated, aspirate the spilt faecal contents, pack off the colectomy of the affected segment.
rest of the abdominal contents, and insert a large Foley
catheter through the perforation into the distal bowel.
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spleen The patient wants to bend herself double, she rolls around,
and rarely keeps still. Intense pain comes in waves against
a background of a dull ache, typically in attacks lasting
about ½hr, 1-3hrs after a fatty meal. Pain makes breathing
15.1 Introduction difficult and may be accompanied by nausea and vomiting.
Attacks occasionally last as long as 6hrs. If unrelieved
The gallbladder may be diseased due to stones, ascaris >24hrs, cholecystitis develops. There may be tenderness in
(15.6), infection per se, tumour or volvulus. The frequency the hypochondrium or the right epigastrium, and be a
of these diseases varies from region to region, but stones +ve Murphy's sign (15.3).
are more common in women than in men, and especially in
obese, parous women >40yrs (fat, fertile, female over ULTRASOUND is a simple, cheap and accurate way of
forty). Gallstones are found in c.80% of adults with sickle finding stones in the gallbladder, whether or not there is
cell disease. Many patients are found at postmortem to jaundice: they cast an ‘acoustic shadow’ behind them
have gallstones which have caused no symptoms. (38-5). Occasionally you might find ascaris in a bile duct
Just because someone has gallstones, they may not be the (15.6).
cause of dyspepsia! Stones or thick biliary sludge may N.B. RADIOGRAPHS. Most gallstones do not show up,
however pass into the common bile duct and cause biliary so a plain film is unlikely to help.
colic, or obstructive (cholestatic) jaundice. Stones can
promote infection of the gallbladder and cause acute or DIFFERENTIAL DIAGNOSIS OF BILIARY COLIC
chronic cholecystitis, although this can arise de novo Suggesting ureteric colic: pain radiating towards the
especially with HIV disease. Stones, especially in the form groin and genitalia. Blood in the urine on microscopy.
of gravel (sludge), can also promote infection in the biliary Radio-opaque calcifications on abdominal radiographs
tree, especially in association with obstruction along the line of the ureter.
(cholangitis, 15.7) though this may also arise de novo;
they can also obstruct drainage of the pancreas and cause Suggesting right basal pneumonia: cough, fever,
pancreatitis. Rarely stones may fistulate into the small and lung signs at the right base.
bowel and cause obstruction therein.
You can usually treat acute cholecystitis non-operatively Suggesting upper small bowel obstruction: central
(15.3), but if this fails, you can drain the gallbladder by colicky pain with profuse unrelieved vomiting.
doing a cholecystostomy. If you are experienced enough,
you can treat chronic cholecystitis by removing the NON-OPERATIVE TREATMENT OF BILIARY COLIC.
gallbladder (15.8). If obstructive jaundice is due to Treat with pethidine 50-100mg 3-hrly IV or IM,
carcinoma of the head of the pancreas, you may be able to for 24-48hrs. Hyoscine 20mg may help.
relieve the symptoms by bypassing the obstruction and Restrict to clear fluids only by mouth. If vomiting ensues,
performing a cholecysto-jejunostomy (15-5), but the replace fluids IV.
situation is more complicated if the obstruction is due to Normally, pain will stop in 24-48hrs, and you can start
gallstones, ascaris, clonorchis sinensis (Chinese liver feeding cautiously, avoiding oily or fatty foods.
fluke) or tumour obstructing the bile duct. If symptoms persist >24hrs with tenderness in the right
You can usually treat acute pancreatitis non-operatively hypochondrium, acute cholecystitis has developed.
(15.13), but a pancreatic abscess (15.15), and a large
pancreatic pseudocyst (15.14) need drainage.
You will not be able to remove a pancreatic carcinoma,
which may be very difficult to differentiate from chronic
15.3 Acute cholecystitis
pancreatitis. Likewise you will not be able to remove
tumours of the liver whether primary (hepatoma) or Symptoms are often initially those of biliary colic (15.2),
secondary except with sophisticated equipment, and only but they last >24hrs and pain becomes constant.
when presenting early. However you will be able to treat There is a very good chance of recovery in 10days, even
hepatic tuberculosis. You may have to drain liver cysts, without treatment. There is a 5% chance that
and may need to remove large hydatid cysts carefully (1) the infection will build up in the gallbladder to produce
(15.12). You may need to drain liver abscesses especially an empyema,
if they are large (15.10), and likewise splenic abscesses (2) peritonitis will develop,
(15.18), which you can usually best deal with by (3) a fistula into bowel will occur from a perforation of the
splenectomy. This is also indicated for a number of gallbladder. Recurrent episodes of cholecystitis are likely
diseases, other than for trauma (15.17). in >50%.
Splenic tuberculosis is usually only diagnosed after you
have removed the spleen!
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In HIV disease, the gallbladder can be markedly inflamed ULTRASOUND. Gallstones readily show up with an
without the presence of stones (acalculous cholecystitis). ‘acoustic shadow’. With experience you will be able to
This is due to cryptosporidia or cytomegalovirus in 20%, see if the common bile duct is dilated and if more stones
and produces an ischaemia of the gallbladder wall. are found inside the duct. The presence of stones may
Infection may also be present with salmonella; in typhoid, imply cholecystitis, but does not prove it. To confirm the
organisms infect the gallbladder but cholecystitis is often diagnosis, you need to see a thickened gallbladder wall
masked by generalised peritonitis. Cholecystitis without and/or fluid around the gallbladder (38.2B).
stones may also be caused by brucellosis, dengue,
leptospirosis & campylobacter.
Stones may be in the gallbladder but also in the bile duct
and cause partial or complete obstruction with jaundice or
cholangitis. Biliary débris at the sphincter of Oddi may
result in pancreatitis.
Operate if:
(1) there is cholangitis which is life-threatening,
(2);the gallbladder forms a gradually enlarging acute
inflammatory mass,
(3);there are repeated attacks leading to chronic
cholecystitis.
SIGNS.
The patient is febrile, looks sick, and lies still. There is
well localized tenderness in the right upper quadrant.
There may be exquisite tenderness (unlike biliary colic),
with guarding and rigidity. Murphy's sign is usually +ve:
MURPHY'S SIGN.
Put your hand under the ribs on the right side, and ask the patient to take
a deep breath. If she feels pain as the gallbladder moves down on to your Fig 15-1 CHOLECYSTOSTOMY.
hand, the sign is +ve and indicates cholecystitis. A, right subcostal (Kocher’s) incision. B, insert a purse string suture.
C, aspirate the gallbladder. D, remove the stones. E, insert a Foley
A well-localized mass sometimes forms a few days after catheter. Kindly contributed by Gerald Hankins.
the start of the attack, just below the right costal margin.
Mild jaundice does not always mean that the common bile DIFFERENTIAL DIAGNOSIS OF ACUTE CHOLECYSTITIS
duct is obstructed by a stone. If there is jaundice, swinging Suggesting liver abscess (15.10): tender hepatomegaly
fever, chills and rigors, however, suspect cholangitis. with fever and previous diarrhoea and dry cough.
SPECIAL TESTS. There is a leucocytosis, unless there is Suggesting perforated peptic ulcer (13.3): sudden onset
untreated HIV disease. The serum bilirubin and alkaline of extreme constant pain, with previous dyspepsia.
phosphatase will only be raised if there is obstruction of
the biliary tree. The amylase & lipase are raised in Suggesting acute pancreatitis (15.13): pain radiating to
pancreatitis. the back, with alcohol abuse.
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Suggesting acute pyelonephritis: pain in the flank SPECIAL TESTS. Leucocytosis progresses from earlier in
associated with urinary frequency, haematuria and the disease. Amylase is usually normal.
previous ureteric colic or schistosomiasis. ULTRASOUND. The gallbladder is filled with turgid
fluid, and often gallstones; its wall is thickened (38.2B).
Suggesting volvulus of the small bowel with Aspiration may relieve some symptoms in a very sick
strangulation (12.8): initial colicky pain which then patient, but is not a lasting solution.
became constant, associated with abdominal distension,
tenderness and guarding. CHOLECYSTOSTOMY (GRADE 3.3)
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Using Desjardin's stone forceps, gently remove any stones Insert a T-tube (15-2E), and close the opening in the duct
that you can easily see (15-2D). The curve on the forceps snugly round the drainage tube with a transverse
may help you: the stones are probably well down the absorbable 4/0 suture (15-2F).
common duct at its lower end, where it enters the Bring the tube out through a stab incision, leaving some
duodenum. Do not prolong this stage of the operation if it slack inside, in case it is pulled on. Anchor it securely to
is difficult: you can do much harm. If there is much the skin with a non-absorbable suture.
'sludge', wash out the common duct by irrigating it with (You can make your own T-tube by slitting the end of a piece of ordinary
suction tubing, and cutting away ⅓ the circumference of the tubing.)
plenty of saline using a plain rubber catheter and a 20mL
syringe. Close the abdominal wall carefully: the wound is likely to
break down or become infected, so consider leaving the
skin open (11.10, 11-20).
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15.6 Cholangitis caused by ascaris (2).Around the Mediterranean, in East Asia, Latin
America, sheep liver flukes, fasciola hepatica, are found.
Ascaris worms sometimes crawl up into the common bile These flukes are large and tend to remain in extrahepatic
duct and gallbladder, where they can cause biliary colic, bile ducts. The flukes may actually eat into the wall of the
acute cholecystitis, obstructive jaundice, cholangitis, ducts, which leads to haemobilia, presenting as
and pancreatitis. This most often happens when a child has haematemesis and melaena, or more rarely perforate the
been given an antihelminthic. So, if a child has cholangitis, duct causing peritonitis. Inflammation leads to similar
or if an adult does not fit the usual clinical picture for complications as with opisthorchis, but because the extra-
biliary disease, suspect ascariasis. Finding ascaris ova hepatic ducts are preferentially involved, gallbladder
should arouse your suspicion, but does not confirm the distension and empyema are more common
diagnosis. Get an ultrasound scan. Do not operate, except
on the indications below. (3).Primary sclerosing cholangitis is an inflammatory
condition affecting both intra- and extra-hepatic bile ducts,
Nasogastric suction will empty the upper intestinal tract. in men and women equally of 25-40yrs. Fatigue, weight
Systemic antibiotics will help to control the cholangitis. loss, right upper abdominal pain, intermittent jaundice and
Later, treat with levamisole 120mg stat, or piperazine 4g itching are usual; an acute attack of cholangitis is rare.
stat, or if there is multiple parasitic infestation, A similar picture can arise in HIV disease (5.6), with or
mebendazole 100mg od for 3 days, repeated after 15 days. without papillary stenosis. No medication has been found
N.B. Dead ascaris worms may still block the bile duct! helpful.
SPECIAL TESTS. There is a microcytic hypochromic (4).Rupture of a hepatic hydatid cyst into the bile ducts
anaemia, a leucocytosis with >50% eosinophilia; bilirubin (15.12).
is raised in cholestatic obstruction and amylase in
pancreatitis. Ascaris lumbricoides eggs can be found in the SPECIAL TESTS.
stool. There is a leucocytosis (and eosinophilia with fluke
ULTRASOUND is best to determine if the ascaris worm infestation); the serum bilirubin and alkaline phosphatase
is no longer in the bile duct (38.2B). are raised. If infection is severe and liver cells are
involved, the transaminases are raised. Measure the serum
INDICATIONS FOR SURGERY. Deepening jaundice, amylase, because there is a 10% chance that there is also
spiking fever, chills and rigors which do not respond to pancreatitis. You may find ova and dead flukes in the
antibiotics; nausea and vomiting, toxaemia, dehydration, faeces and in duodenal aspirates.
tachycardia, and perhaps hypotension; together with a
leucocytosis. If there are these symptoms, explore and RADIOGRAPHS.
drain the bile ducts (choledochostomy, 15.5) after A plain radiograph may show air in the biliary tract due to
appropriate preparation. Remove any worms you find. an incompetent sphincter of Oddi.
Avoid a sphincterotomy as ascaris may then more easily ULTRASOUND often shows dilation of intra-hepatic
crawl into the pancreatic duct subsequently. before extra-hepatic ducts, and may actually detect mobile
flukes (38.2B).
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15.8 Cholecystectomy (GRADE 3.3) INCISION. Make a right subcostal (Kocher’s) or midline
incision (11-1) extending up to the costal margin.
The Kocher’s incision gives better access to the
Removing the gallbladder is the standard method of gallbladder itself, but the midline incision better access to
treating chronic gallbladder disease, but it is not an the bile duct, and any other pathology that may be present.
operation for the occasional surgeon, so unless you
are experienced, it is better to treat cholecystitis
non-operatively (15.2,3). However, if symptoms and signs
get worse, and you cannot refer the patient, and have
sufficient experience, it is best to operate early on an
acutely inflamed gallbladder than later when it becomes
hopelessly stuck down.
ELECTIVE CHOLECYSTECTOMY
INDICATIONS.
(1) Gallstones causing several attacks of cholecystitis.
(2) A carrier of salmonella typhi.
CONTRAINDICATIONS
N.B. These are relative, but important:
(1) Inexperience.
(2) Uncertain diagnosis and failure to exclude other causes
of dyspepsia.
(3);Insufficient symptoms and signs which justify the
Fig. 15-3 ANATOMY OF THE BILIARY SYSTEM.
operation. A, normal relationships of structures in this region. B-F, relations of
(4);Complicating factors, e.g. HIV disease or excessive the right hepatic artery. In B, (and A) it runs posterior to the
obesity. common hepatic duct (64%). In C, it runs anterior (24%), and in D,
(5);The need to bail out, or perform a cholecystostomy, it arises from the superior mesenteric artery (9%). In E, it runs
anterior to the portal vein (91%) and in F, posterior (9%).
if it is too dangerous to proceed. G-L, variations in the bile passages (>50%). Note the accessory
hepatic ducts in positions of surgical danger. M, a small pouch
ANTIBIOTICS. The main cause of death in gallbladder (Hartmann's pouch) may project from the right wall of the neck of a
surgery is postoperative sepsis. Use a perioperative diseased gallbladder downwards and backwards towards the
duodenum. When it is well marked the cystic duct arises from its
antibiotic (2.9) unless the case is a completely elective upper left wall and not from what appears to be the apex of the
one. gallbladder.
(1) fundus of the gallbladder. (2) neck of the gallbladder. (3) cystic
PREPARATION. duct. (4) common bile duct. (5) common hepatic duct. (6) right
hepatic duct. (7) left hepatic duct. (8) portal vein. (9) right branch of
A self-retaining and a Deaver's retractor are almost the portal vein. (10) left branch of the portal vein. (11)porta hepatis.
essential. You will need two assistants as well as the scrub (12) aorta. (13) some fibres of the diaphragm. (14) coeliac artery.
nurse. If you have facilities for radiography in theatre, (15) left gastric artery. (16) splenic artery. (17) right gastric artery.
make sure the patient lies on a suitable table so that (18) gastroduodenal artery. (19) hepatic artery. (20) right hepatic
artery. (21) left hepatic artery. (22) Hartmann's pouch. (23) cystic
radiographs can be taken of the upper abdomen. artery. (24) epiploic foramen (entrance to the lesser sac).
Check for sickle cell disease if this is common in your After Basmajian JV, Grant's Method of Anatomy, Williams & Wilkins 9th
area. ed 1975 with kind permission.
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Feel for the gallbladder. Feel for stones in the gallbladder Take a Lahey swab (15-4C,E), and gently push apart the
and in the bile ducts. Feel both lobes of the liver to be sure peritoneum, so that you see the junction of the common
they are smooth and normal. Examine the stomach and bile duct, hepatic and cystic arteries. This is most
duodenum. Feel the pancreas. important. Do not proceed unless you are certain of the
anatomy!
If the gallbladder seems far up under the rib cage, CAUTION! There are some important anatomical
run your hand over the right lobe of the liver, divide the variations:
falciform ligament across the dome of the liver, and draw (1) The common bile duct and the cystic duct may join
it down. Put some large packs between the diaphragm and high or low (15-3G-L). The cystic duct may be very short
the liver - do not forget to remove them afterwards! and the common bile duct is then dangerously tented by
traction on the gallbladder.
Insert a self-retaining retractor, and try to see the (2) The right hepatic artery may pass behind the common
gallbladder. Get the anaesthetist to empty the stomach with hepatic duct (15-3A, B, more common) or in front of it
a nasogastric tube. Use long tissue forceps to place large (15-3C, less common).
moist abdominal packs over the hepatic flexure of the (3) The cystic artery may be closely bound to the common
colon, the duodenum, and the stomach. Ask your first hepatic duct.
assistant to draw these downwards and medially. (4) The cystic artery usually (64%) arises from the right
You should now be able to see under the liver clearly. hepatic artery. It may cross behind (usually) or in front of
Protect the liver with a pack, and ask your second assistant (unusually) the common hepatic and cystic ducts to reach
to retract it upwards and laterally with a large Deaver's the gallbladder. Sometimes, it arises from the common
retractor (15-4B). Look at the gallbladder. Divide any hepatic (27%) or the left hepatic artery (5%), or from other
omental adhesions to the gallbladder, if present. arteries in the region (rare).
Be sure of your landmarks before you start to divide
If the gallbladder is acutely inflamed, perform a anything. Use a Lahey swab and dissect by the 'push and
cholecystostomy (15-1). spread' method and thereby find the junction of the
patient's cystic and common bile ducts, as described
If it is very small, shrunken, thick-walled, contains above. Be sure to identify 2cm of the common duct, both
stones, and is firmly stuck to nearby structures, leave it proximal and distal to the junction. This will give you an
alone, or take out the stones and perform a idea of its course and direction. The common bile duct lies
cholecystostomy. Removing such a gallbladder will be to the right of the structures going to the porta hepatis, and
very difficult. is a greenish colour: identifying it is one of the keys to safe
gallbladder surgery.
If it looks and feels reasonably normal, apart from a few If the cystic artery runs posterior to the common
stones, and is attached by fine adhesions only, it should be hepatic and cystic ducts (usual), take extra care. Using
safe to proceed. traction with your left hand on the gallbladder, follow the
cystic artery onto the gallbladder. Do not expect to feel any
A. THE RETROGRADE (‘DUCT FIRST’) APPROACH. pulsation in such a small vessel. If a strand of tissue runs
Use this if you can readily find the cystic duct, the to the gallbladder, assume it is the cystic artery, pass
common bile duct, and the hepatic artery, in the free edge 2 mounted ties around it, and divide between them. Expect
of the lesser omentum. The epiploic foramen (of Winslow) to find other branches and deal with them in the same way.
lies behind it; you should be able to pass one or two If the cystic artery runs anterior to the common
fingers through it into the lesser sac. hepatic and cystic ducts (unusual), define it by blunt
Place a gallbladder clamp, or sponge-holding forceps on dissection, and make sure that it is indeed going to the
Hartmann's pouch (15-4C). This is a widened area in the gallbladder.
lower part of the patient's gallbladder, just before it tapers CAUTION! Do not tie the right hepatic artery by
off into the cystic duct. Pull gently upwards on these mistake.
forceps, so as to stretch the tissues and make dissection If you are sure you have found the cystic artery,
easier. tie it doubly proximally and then close to the gallbladder
Incise Calot’s triangle of peritoneum between Hartmann's with 2/0 silk (15-4D), and divide it leaving a short cuff of
pouch and the common hepatic duct. This will appear tissue, distal to the tie.
when you apply traction to the sponge-holding forceps on If you have found the junction of the cystic and
Hartmann's pouch. It is a most important step. Start by common bile ducts, and you are sure that what you
making a small nick in the peritoneum with a long pair of presume is the cystic duct is going to the gallbladder,
Metzenbaum scissors. Carefully insert the tips of the and nowhere else, define it further, using blunt dissection
scissors, then, using 'the push and spread technique' (4-9), (15-4E). This is the time to perform an operative
or a Lahey dissecting swab, open up enough of the cholangiogram if you can and you are still not sure.
patient's peritoneum to expose the deeper structures. Using a long pair of Lahey forceps, gently open up the
CAUTION! Be careful not to cut any small blood cleft between the cystic and common hepatic ducts.
vessels. Bleeding will make the operation difficult. Pass a mounted tie of '0' absorbable suture through this
By spreading the blades of the scissors (but not too far!) cleft, and around the cystic duct, but not too close to the
before you cut, or using a Lahey dissecting swab, you junction to cause a kink there. Tie it and for safety’s sake,
should be able to separate peritoneum only. tie a 2nd suture around the cystic duct (15-4F).
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DIFFICULTIES REMOVING THE GALLBLADDER If you cannot find the distal end of the bile duct,
If you find an adherent inflammatory mass around the however, insert the distal limb of the T-tube directly into
gallbladder, withdraw and close the wound. the duodenum and secure it with a purse-string absorbable
Consider operating later, when the inflammation has suture. (To make a permanent by-pass, the definitive
subsided. Rarely this is a malignant mass, which is forever operation of choledochojejunostomy-en-Y using a Roux
inoperable. loop, is a very demanding procedure.)
N.B. Learn from your mistakes, seek to be able to
If you palpate stones in the common bile duct, or find forgive yourself, and carry on.
them on an operative cholangiogram, perform a
choledochostomy (15-2) and try to extract them with DIFFICULTIES AFTER CHOLECYSTECTOMY
Desjardin’s forceps, or perform a transduodenal Oddi if fresh blood discharges from the drain, the pulse rises,
sphincterotomy (15.5). Perform a post-extraction operative the blood pressure falls, and there are signs of a
cholangiogram, if you can. haemoperitoneum, the cystic artery is probably bleeding.
Reopen the abdomen, extend the incision, suck out all the
If the cystic artery bleeds from the depths of the blood and insert packs to control the haemorrhage.
wound, this can be alarming. Do not clamp blindly. Then try to visualize the bleeding vessel, clamp it and tie it
(1);Insert warm moist packs, apply pressure and wait off.
5mins by the clock. The spurting vessel will then be easier
to find and control. Or, If bile comes from the drain, with fever, severe pain
(2);Put your index finger into the epiploic foramen and a leucocytosis, suspect that infected bile and exudate
and squeeze the structures (portal vein, bile ducts, and are pooling under the liver. Treat with gentamicin or a
hepatic artery) in the free edge of the lesser omentum cephalosporin. Perform an ultrasound if you can to locate
between your index finger and your thumb (the Pringle and quantify the amount of liquid. If there is no
manoeuvre). This will control bleeding from the stump of improvement, reopen the abdomen, extend the incision,
the cystic artery. When you have suction and instruments suck out all the bile and inspect the cystic duct stump.
ready, remove the packs and try to visualize the vessel, If this is obviously leaking and you can hold it in a clamp,
and clamp it. Transfix it carefully with 3/0 silk. Do not use transfix it. Usually the whole area is grossly inflamed
diathermy in the depths of the wound especially if you and you will not be able to identify structures easily;
can’t see properly! If exposure is poor, enlarge your make sure the area is adequately drained.
incision.
If the patient becomes jaundiced, suspect the bile duct
If you suspect you have injured the cystic duct early on, has been damaged or a stone has lodged in the distal bile
make sure your suction is working properly and aspirate duct. Try to confirm this by finding a dilated proximal
bile so you have a good view. If necessary, enlarge your biliary tree on ultrasound (38.2B). Unless you have access
incision. Get a cholangiogram if you cannot interpret the to sophisticated endoscopy, arrange a re-exploration which
anatomy. If the cystic duct is incompletely divided, hold is difficult, and may mean a choledocho-jejunostomy-en-
the part near the gallbladder in a Lahey clamp, and pass a Y. If you cannot manage this, you can try to drain the
mounted tie around it at the common bile duct end and proximal biliary system percutaneously through the liver
complete the division of the cystic duct. If you injure it under ultrasound guidance, or insert a T-tube (15.5) in the
very near its union with the common bile duct, transfix it dilated part of the duct. Distal stones may pass on their
and carefully tie it, dividing it distally. Make sure you own; a specialized endoscopist may be able to remove
haven’t kinked or narrowed the common bile duct. them from below.
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If an older patient has a steadily deepening and usually A laparotomy for a stone may be life saving, but GA
painless obstructive jaundice, and the gallbladder is (especially with halothane) and the trauma of surgery may
palpably enlarged, some tumour is probably obstructing cause hepatocellular jaundice to deteriorate, perhaps
the common bile duct. fatally.
It is unlikely that there are gallstones (Courvoisier’s rule).
This is probably incurable, but a cholecystojejunostomy to ULTRASOUND (38.2B) is very useful. You need to show
decompress the gallbladder, by diverting the bile into the extrahepatic bile duct dilation >7mm to make an operable
jejunum, may make the patient’s last days more bearable. diagnosis.
There are several causes, however, of obstructive jaundice:
(1) A secondary tumour in the porta hepatis, usually from Suggesting malignancy:
a primary in the stomach or gallbladder itself. (1).Relentlessly progressive steadily deepening obstructive
(2) Carcinoma of the head of the pancreas. jaundice, weight loss.
(3) Cholangiocarcinoma or other cholangiopathies (15.7). (2).A palpable gallbladder which you can feel as an
(4) Metastatic liver carcinoma. elongated, smooth, non-tender mass, normal in contour,
(5) Hepatoma (although this is a common disease, and slightly mobile, which may extend to the umbilicus or
presentation as obstructive jaundice is unusual). even below it. If you can feel a distended gallbladder,
(6) Drugs, e.g. antibiotics, contraceptives, chlorpromazine, it strongly suggests a malignant obstruction at the lower
cimetidine, oestradiol, imipramine and many others. end of the common bile duct, but its absence does not
In endemic areas other causes are liver flukes (15.7) exclude this. Aspiration of green bile implies free drainage
or hydatid disease (15.12). from the common hepatic duct, but aspiration of ‘white
In neonates, look for a congenital abnormality (33.9) bile’ (i.e. mucus) suggests occlusion of the cystic duct.
DIFFERENTIAL DIAGNOSIS. First try to decide what Suggesting metastases in the liver or a hepatoma:
kind of jaundice the patient has. a large, hard, knobbly liver. A bruit is often present with a
Haemolytic jaundice. The stools are dark. There is no hepatoma, ascites is common, and is often bloodstained.
bilirubin in the urine, but the urinary urobilinogen is
increased. The blood shows increased levels of Suggesting a carcinoma of the stomach with metastases
unconjugated prehepatic bilirubin (leading to high in the porta hepatis: pain, anorexia, vomiting, an upper
readings on the indirect van den Bergh test). The serum abdominal mass, and the visible peristalsis of pyloric
transaminases (GPT & GOT) are normal, and so is the stenosis. Anaemia is common.
alkaline phosphatase. There is a reticulocytosis. Look for
evidence of a haemoglobinopathy, especially sickle cell Suggesting carcinoma of the head of the pancreas:
disease, and malaria. vague epigastric pain, a palpable gallbladder and weight
Check for consumption of medicines, especially dapsone loss.
or sulphonamides. Check for a splenomegaly and insect or
snake bites. Suggesting gallstones: a long history of intermittent
N.B. Haemolysis may result in pigmented gallstones! varying jaundice, severe intermittent colicky pain, fever,
Obstructive jaundice. The stools are pale (clay-coloured chills, and rigors (suggesting cholangitis), little or no
if obstruction is complete), and show no improvement in weight loss, flatulent dyspepsia. A leucocytosis suggests
colour in 10days. There is bilirubin in the urine, but little cholecystitis.
or no urobilinogen. There is a high conjugated
(posthepatic) bilirubin level (giving high readings on the Suggesting tuberculosis: caseating nodes in the porta
direct van den Bergh test). The alkaline phosphatase is hepatis, with signs of glandular tuberculosis elsewhere.
very high. The transaminases are usually normal.
Hepatocellular jaundice. This is commonly viral hepatitis Suggesting stenosis of the bile ducts, either malignant
with an obstructive phase lasting 7-10days, but sometimes or benign: a tender, enlarged liver. A chronic history of
much longer. At this stage the stools are pale. repeated attacks of cholangitis. The gallbladder may or
The urine contains bilirubin but little urobilinogen. may not be palpable. Common where liver flukes are
The serum bilirubin is moderately increased (mostly endemic.
conjugated). The alkaline phosphatase is usually only
moderately increased, but if cholestasis is a prominent Suggesting carcinoma of the gallbladder: an enlarged
feature it can rise to levels seen in obstructive jaundice. liver and a hard, irregular mass in the right
The transaminases are increased. As the oedema of the hypochondrium, usually in a female.
cells settles, the stools become normal or even dark,
the serum bilirubin falls, the urinary urobilinogen rises or MANAGEMENT. If there are gallstones, the patient needs
reappears, and the transaminases fall gradually. The return a choledochostomy (15-2) unless you can remove the
of stool colour is the most important sign. This form of gallstones endoscopically. If there is malignant disease
jaundice is not common >35yrs. with obstruction at the lower end of the common bile duct,
CAUTION! You may have difficulty distinguishing the a cholecysto-jejunostomy may help unless you can refer
obstructive phase of hepatocellular jaundice from surgical the patient for endoscopic stenting.
obstructive jaundice. Do all you can to make the
distinction.
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METHOD.
Pack off the distended gallbladder. Decompress it as at
cholecystostomy (15-1). Remove the purse string suture,
and extend the opening with scissors to a length of 1·5cm.
Apply Babcock clamps to the fundus of the gallbladder
about 1cm from each end of the incision. Lift the
transverse colon upwards and look for the ligament of
Treitz. This is the point where the retroperitoneal 4 th part
of the duodenum emerges to become the jejunum, slightly
to the left of the vertebral column, and distal to the
Fig. 15-5 CHOLECYSTO-JEJUNOSTOMY. attachment of the mesentery of the transverse colon.
A, the incision. B, the first layer of the anastomosis. Choose a loop of jejunum 30cm distal to the ligament of
Treitz, and draw it up towards the open gallbladder.
INCISION. Open the abdomen through an upper midline Apply one or two non-crushing bowel clamps across the
incision. Expose the liver and subhepatic area (15.8). jejunal loop. Apply two Babcock clamps 3cm apart on the
Good exposure is essential. Inspect and feel the upper antimesenteric border of the jejunum, to match those on
abdominal viscera carefully. Is the gallbladder normal in the fundus of the gall- bladder. Bring these clamps
size and appearance? If it is a hard, irregular mass which is alongside one another, making sure that there is no tension
fixed to the surrounding organs, it is probably malignant. on the jejunal loop. Aim to make a 1·5cm diameter stoma.
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CAUTION! Make the anastomosis neatly and carefully: Metronidazole usually treats an uncomplicated liver
biliary peritonitis is a serious complication of a leak. 'abscess' very effectively, but it occasionally (if >5cm
The end-to-side anastomosis is similar to that for a diameter) needs aspiration, and rarely (if >10cm) drainage.
gastroenterostomy (13.7). Make the seromuscular outer The major risk is that it will suddenly rupture into the
layer of sutures of 3/0 on an atraumatic needle. abdominal cavity, or through the diaphragm into the
Insert 5 sutures, which should ideally pick up only the pleural or pericardial space, or even into the lung.
seromuscular layer of the jejunum, but which will Rupture into the abdominal cavity is a dramatic
probably be of full thickness, in the wall of the catastrophe, with collapse and peritonitis, like the
gallbladder. perforation of a peptic ulcer.
Place them about 2mm away from the cut edge of the Although the contents of an abscess are sterile, they cause
incision, and on the bowel side about 2mm back from the an acute inflammatory reaction in the peritoneum,
antimesenteric border of the jejunum. Incise the jejunum whether this is acute or chronic.
3mm back from the suture line. Trim away redundant N.B. Common mistakes are:
mucosa with fine scissors. Apply Babcock forceps (1) Not to perform a sigmoidoscopy.
temporarily over any bleeding points. Insert a continuous (2) Not to recognize amoebic ulcers when you do see them.
'all coats' posterior layer of 3/0 atraumatic absorbable (3) Not to remember the existence of acute necrotizing
sutures, starting at one end; then continue to close the amoebic colitis with perforation.
anterior layer with the same suture. Finally, continue with (4) Not to use all the evidence you can to diagnose a liver
the previous 3/0 to insert an anterior layer of seromuscular abscess.
Lembert sutures. Cover the anastomosis with a layer of
omentum, and suture this in place. CLINICAL FEATURES.
Be careful to close the abdominal wall soundly (11.8.) The patient is usually male (8:1 chance), <30yrs, and may
be a child. In endemic areas (e.g. Kwazulu in South
DIFFICULTIES WITH CHOLECYSTO-JEJUNOSTOMY Africa; Pakistan; Mexico) amoebic 'abscesses' are not
If you do find gallstones, make sure that the jaundice is uncommon in babies, and also occur in the elderly.
not caused by stones distally in the bile duct. The pain in the right upper quadrant, or the lower right
If it is, perform a choledochostomy (15-2), extract the chest, is constant or intermittent, not colicky, and does not
stones, and if you are experienced, remove the gallbladder radiate. It slowly gets worse, but is seldom severe.
also. If the gallstones seem an incidental finding, the Deep breathing and coughing often make the pain worse.
gallbladder is not inflamed and there is tumour distally, Fever, anorexia, weakness, and loss of weight steadily
proceed with cholecystojejunostomy as above, but try to progress. There is only a 30% chance of having had
remove the gallstones from the gallbladder itself. diarrhoea with blood and mucus during the previous year.
Often, there is some associated disease, such as
If there is gastric outlet obstruction (<10% of patients), tuberculosis, HIV, malnutrition, or alcoholism.
shown by an enlarged stomach, and tumour obstructing the The liver is tender, smooth, diffusely enlarged,
duodenum, perform a gastrojejunostomy (13.7) as well. and without an obvious lump. Palpation of the liver may
To avoid bile refluxing into the stomach, you can make a cause much distress. Pressure over the lower 5 ribs in the
third anastomosis, a jejuno-jejunostomy (part of the right anterior axillary line is painful. Examine also for
traditional ‘triple by-pass’) but this adds to the morbidity. evidence of a pleural effusion.
Remember you are doing palliative surgery only.
A Roux-en-Y (15.14) cholecysto-jejunostomy is probably SPECIAL TESTS. Leucocytosis & anaemia. Raised ESR.
a better combination with a gastro-jejunostomy. Check for hypoglycaemia & hyponatraemia.
Look for amoebic ulcers with a sigmoidoscope.
You are unlikely to find amoebae in the stools.
Use new PCR tests which are very sensitive if you can.
15.10 Liver abscess
A. Amoebic liver abscess: CHEST RADIOGRAPHY. Look for a pleural effusion,
and elevation of the right dome of the diaphragm.
extra-intestinal amoebiasis
ULTRASOUND is by far the most reliable diagnostic tool.
When Entamoeba histolytica spreads outside the bowel, Look for a fluid-filled cavity in the liver (38.2A). Measure
it usually involves the liver. Here it can cause an 'abscess' how near the abscess is to rupture: <1cm liver tissue is
filled with liquid necrotic liver. To start with this is yellow dangerous! You cannot differentiate an amoebic from a
or yellow-green, later it becomes a syrupy dark reddish- pyogenic liver abscess except by aspiration.
yellow. The central area of necrosis is surrounded by
zones of progressively less damaged tissue and amoebae. DIFFERENTIAL DIAGNOSIS includes:
The term amoebic 'abscess' is a bad one, because there is (1) hepatoma,
no pus. (2) cholecystitis,
There is an 80% chance that the abscess is in the right lobe (3) hydatid cyst,
of the liver, where you will be able to detect it clinically, (4) pyogenic liver abscess,
unless it is very deep. Collections in the liver are (5) perinephric abscess.
sometimes multiple.
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Suggesting a hepatoma (15.11): a hard nodular mass, OPEN DRAINAGE FOR LIVER ABSCESSES
liver less painful and less tender, no fever or low fever (GRADE 2.4)
(fever only occurs with very rapidly growing tumours), INDICATIONS. (This is rarely necessary if you have used
a bruit, bloody ascites. metronidazole, and aspirated the abscess adequately.)
(1) A deep-seated amoebic liver abscess which you have
Suggesting cholecystitis (15.3), perhaps with spreading not been able to aspirate, and the patient is deteriorating on
suppuration: pain and tenderness is localized to the medical treatment.
gallbladder region, there may be a history of intolerance to (2) Fluid too thick to aspirate.
greasy foods, and presence of jaundice, more commonly in (3).Very large abscesses >10cm diameter, which recur
a female. after repeated aspiration.
Suggesting a hydatid cyst (15.12): the mass arises from (4).A large abscess in the left lobe which may perforate
one or other lobe, rather than enlarging it diffusely; into the pericardium.
it grows slowly and is largely asymptomatic; it is smooth, (5).Abscesses causing marked elevation of the diaphragm.
tense, and cystic; tenderness is minimal, there is no fever, (6) Secondary infection of the abscess.
and the general condition is good. All this may change (7);A suspicion of a pyogenic liver abscess or an infected
rapidly, if the cyst becomes infected. hydatid cyst.
Suggesting a pyogenic liver abscess: a short history; DRAINAGE. Make a subcostal incision, pack away the
severely ill with a spiking fever. rest of the abdominal contents and insert an aspirating
needle directly into the abscess cavity, to identify it.
Suggesting a perinephric abscess (6.15): the swelling is Push an artery forceps into it, open it and suck out the pus.
low down over the liver on the right; the distinction may Take some scrapings from the wall of the abscess,
be very difficult. Aspiration may establish the site. and examine a warm wet specimen for trophozoites.
If there is much discharge, insert a tube drain, and bring
MEDICAL TREATMENT FOR HEPATIC AMOEBIASIS: this out through a separate incision on the abdominal wall.
metronidazole 800mg tid for 5days, and then The liver may recede from the abdominal wall as you
diloxanide furoate 500mg (children: 20mg/kg) tid for drain it, and end up as a shrunken blob, in the right upper
10days or chloroquine 600mg od for 5days. abdomen. Remove the drain in 6-7days, to minimize the
risk of secondary infection.
ASPIRATION FOR LIVER ABSCESS (GRADE 1.4)
INDICATIONS. DIFFICULTIES WITH EXTRAINTESTINAL AMOEBIASIS
(1);To confirm the diagnosis. If there is a sudden pain like a perforated peptic ulcer,
(2);As a method of treatment if the abscess is >5cm the abscess has probably ruptured into the abdominal
diameter, or if the patient fails to improve with medication cavity. Resuscitate with IV fluids and start IV
in 48hrs, or if the abscess is in the left lobe of the liver, metronidazole. As soon as the general state is satisfactory,
as this may perforate into the pericardium. perform a laparotomy.
(3);If there is on ultrasound scan <1cm liver tissue Make a midline incision. Explore the liver, as best you
between the abscess and the liver surface (38.2A). can, and look for the site of the rupture: a ragged area with
(4);If there is jaundice, suggesting involvement of the chocolate-coloured fluid pouring from it. Suck out as
biliary system. much of this you can. Mop up what you cannot aspirate.
Irrigate all the crevices of the peritoneum with several
METHOD. Treat with metronidazole for 48hrs before litres of warm saline or water. Ensure a thorough lavage,
aspirating. Check the prothrombin index if there is and close the abdomen. Treat postoperatively as peritonitis
jaundice; and correct a clotting defect with vitamin K (10.1)
10mg IM. Using LA and full aseptic precautions,
preferably under ultrasound guidance, pass a wide-bore If there are tender ill-defined masses in the abdomen,
(>1mm) long needle on a 50ml syringe, or better, a wide suspect that the abscess has leaked into the abdominal
bore pigtail catheter through healthy skin, over the site of cavity. Start intensive medical treatment, and monitor the
greatest swelling, or maximum tenderness. abdomen closely. Mark the outline of any mass, and check
If you obtain >250ml, introduce a multi-holed plastic its size regularly. Perform a laparotomy if it gets bigger.
catheter on a trocar in the same direction, attach a 3-way
tap, and aspirate until the cavity is apparently empty. If an abscess presents on the chest wall, it will ultimately
Irrigate through the tube daily. Continue until the cavity is rupture through the skin, which may become infected
empty and then remove the tube. with amoebae, and form a chronic ulcer (14-5A).
You have only c.10% chance of finding amoebae in the Treat with metronidazole.
fluid. They are more often found in the wall of the cavity.
If a severe cough and dyspnoea develops, this may, or
may not, mean that there is a pleural effusion.
If the effusion is small, it will resolve as the liver abscess
improves. If it is large insert an underwater seal chest
drain.
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If there is an ulcerating skin lesion round a sinus from 15.11 Hepatoma (Hepatocellular carcinoma)
the liver, caecum, or anus, remember the possibility of
CUTANEOUS AMOEBIASIS. Metronidazole cures Hepatoma is the one of world's common malignant
cutaneous amoebiasis so fast, that you can use it as a tumours, mostly because it is so common in China,
diagnostic test. In the perianal area ulcerating skin lesions Southeast Asia, the Amazon region and Peru, Sub-Saharan
are usually non-specific. Untreated the lesions spread fast; Africa, where it is even more common than secondary
biopsies show up the trophozoites. tumours of the liver. In Africa, there is a 90% chance that
N.B. Tuberculosis, malignancy, and fungi are often a liver with a hepatoma is also cirrhotic, due to the strong
commoner. association of hepatoma with hepatitis B, C & D infection,
and with the aflatoxin produced by the aspergillus fungus
If the patient coughs up dark reddish-yellow fluid, growing in damp stored food. Prevalence of hepatitis B is
the liver abscess has ruptured into a bronchus. also high in Greenland, Alaska and Northern Canada, and
Although this may drain the abscess, it may also fatally hepatitis C is a global problem.
flood the bronchial tree. Get a chest radiograph and treat A hepatoma often arises simultaneously as multiple
with IV metronidazole, aspirate the liver abscess, nodules in many parts of the liver. Sometimes, a huge
and use postural drainage for the lung (11-24). mass deforms one lobe. The other primary liver tumour,
cholangiocarcinoma, is a problem in Southeast Asia.
If the liver abscess discharges into the pericardium,
it usually does so from an abscess in the left lobe. The patient is usually male (8:1), and 30-50yrs.
Pericardial rupture is not uncommon in endemic areas, is He complains of pain, anorexia, weight loss, or a mass;
often not recognized, and is usually fatal. Watch therefore jaundice is a late sign. The pain is usually constant, and
for abscesses in the left liver lobe, and aspirate them. sharp or burning, and is in the upper abdomen, usually on
Try to aspirate the pericardium (9.2). the right.
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It is commonly made worse by food, which causes an NEEDLE BIOPSY OF THE LIVER (GRADE 1.4)
inappropriate feeling of fullness after only a small meal. INDICATIONS.
Typically, the pain is made much worse by alcohol; An enlarged liver when the diagnosis is unknown.
so much so that it may have caused abstinence.
SPECIAL TESTS. Serum α-fetoprotein >500μg/l is Fig. 15-7 LIVER BIOPSY NEEDLES.
present in 70-80% of cases. Though this test is unlikely to A, Menghini needle. This has a sharp stout end (a), with an
adjustable guard (b), and a Luer lock (c). B, viewed in cross section,
be available locally, it may be easier to get a laboratory to the assembly has an obturator outside the needle, and a blocking pin,
do it rather than get histology on a potentially dangerous which slips loosely inside the needle and prevents the biopsy
liver biopsy. The bilirubin rises late, and is often not raised fragment from falling back, and breaking up in the syringe.
on presentation. If it is >40μmol/l, life expectancy is To take a biopsy using a Menghini needle: (1) insert it through the
skin, (2) expel skin fragments, (3) aspirate, (4) advance the needle
weeks only. The bilirubin and alkaline phosphatase levels into the liver, with the patient holding his breath, and gently suck up
rise parallel with one another. The transaminases are tissue by holding the syringe steady, (5) extract the needle whilst
normal, unless there is also chronic active hepatitis. gently maintaining suction.
If there is ascites, aspirate a sample of the fluid and After King M. Medical Care in Developing Countries, OUP 1967.
examine it. Blood-stained fluid supports the diagnosis of (A) MENGHINI NEEDLE
malignancy, not necessarily of the liver. Anaemia is Fit the Menghini needle to a well-fitting 10ml syringe, set the guard at
seldom a marked feature. about 4cm, and draw up 3ml of sterile saline. Pass the needle point
Do not forget to test the bleeding and clotting times. through the anaesthetized track through the intercostal space. Inject 2ml
of saline to clear the needle point of any skin fragments.
CAUTION! Now, ask the patient to hold his breath in expiration.
RADIOGRAPHS. Chest radiography usually shows that Start to aspirate, and while continuing to aspirate, rapidly push the needle
the right lobe of the diaphragm is raised. Metastases rarely into the liver perpendicular to the skin, then, immediately pull it out
show up but are present in 50% of patients post mortem. again. Apply pressure to the site of the biopsy. Continue aspirating until
you have placed the needle point under some saline in a glass dish.
Discharge the saline remaining in the syringe. The biopsy specimen will
ULTRASOUND is extremely useful and will show appear. Rescue it and transfer it to formol saline. Clear the needle with
solitary or multiple lesions, or fluid cavities (38.2A). the obturator.
Use it to help guide a needle biopsy.
(B) VIM-SILVERMAN NEEDLE.
Fit the inner obturator into the sheath. With firm, but well-controlled
NEEDLE, liver biopsy, Menghini, 1∙6mm, normal Menghini point, with pressure, push the needle through the abdominal wall while the patient
adjustable stop. holds his breath. You will feel the peritoneum 'give' as you go through it.
NEEDLE, liver biopsy, Vim-Silverman, adult size, 23mm x 88.5mm, with Do not push the needle in too far at this stage. Ask the patient to take a
Franklin modification. deep breath. If the needle moves with respiration, its tip is already in the
liver; if not, ask him to hold his breath again, and gently push it 3cm
further in, or until it moves.
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This has hollowed-out biopsy jaws, a sleeve which fits over them, and an If you have not succeeded, try again in a different place.
obturator to discharge the specimen. The inner jaws grasp a core of
If you fail after several attempts, there is probably no solid
tissue, after which you slide the sleeve over them to trap it. Surgeons vary
in the needle they prefer. A Menghini needle is in a patient's liver for a tissue that can be biopsied. If the needle goes in without
shorter time, so it is safer. Its disadvantage is that it is less likely to any resistance, attach a 20ml syringe to it and aspirate:
withdraw a satisfactory specimen in a cirrhotic. This is important because you may withdraw pus of a liver abscess (15.10), or blood
cirrhosis is common in areas where hepatoma is common.
from a haemangioma, or clear fluid of a hydatid (15.12).
CAUTION! Do not manipulate the needle during regular breathing,
or you may tear the liver. POSTOPERATIVELY, (both methods), keep the patient
Ask him to hold his breath, then remove the inner obturator and replace it supine for 12hrs. Monitor the pulse and blood pressure
with the biopsy jaws. Steady the needle with your left hand, and push the during this time, just in case there is bleeding into the
jaws with your right hand into the needle as far as they will go.
peritoneal cavity. A hepatoma is very vascular, and
Ask him to hold his breath again. Hold the biopsy jaws firmly with your
right hand, and slide the outer jaws 3cm further into the liver. occasionally bleeds when you biopsy it.
This will wedge the jaws and the tissue firmly in the outer sheath.
Rotate the needle once or twice, to break off any tissue which is attached DIFFERENTIAL DIAGNOSIS. Try to exclude treatable
at the tip, and then quickly withdraw it. Ask him to breathe again.
diseases. Some of these are inflammatory, and so produce
You can do everything in a few seconds. Long breathholding is
unnecessary. Slide the sheath over the biopsy jaws and open them. Use a fever, but this also occurs in primary hepatoma (8%), so it
fine needle to remove the core of tissue from the jaws into formol saline. is not a reliable guide.
CONTRA-INDICATIONS.
(1);Do not do this if your histology service is dubious in
quality, or if the results are unlikely to arrive for weeks!
(2);Deep jaundice, severe anaemia, or any bleeding
tendency, as shown by petechiae, ecchymoses,
or haemorrhages.
(3);Hydatid disease, where needle biopsy may lead to fatal
anaphylaxis or dissemination.
(4);Do not attempt this if you cannot transfuse blood in an
emergency. Correct coagulation problems first!
CAUTION! Measure the bleeding time (normal
<3mins) and clotting time (normal <8mins) before taking a
biopsy and treat with vitamin K 10mg IM till the bleeding
& clotting times are normal.
Lay the patient supine near to the right side of the bed, Suggesting cholangiocarcinoma: deep jaundice, no bruit,
and place a firm pillow against the left side in the hollow and a liver which is less big and irregular than with
of the bed. Place his right arm behind the head, and turn hepatoma.
his face to the left.
Choose a point in the mid or anterior axillary line in the Suggesting carcinoma of the head of the pancreas:
8th, 9th, or 10th intercostal spaces, or over the palpable mass deepening jaundice, little or no pain, the absence of bile
that you want to biopsy. Clean the skin with iodine, and pigment in the stools, a gallbladder which is usually
anaesthetize the chosen site with LA solution, down to the palpable, no bruit.
parietal peritoneum.
Pierce the anaesthetized area with a scalpel (or with the Suggesting amoebic abscess: fever, a smooth, diffusely
special trocar). enlarged, tender liver with no obvious lumps, no jaundice;
tenderness, especially intercostal tenderness.
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Suggesting gallstones: severe colicky pain, biliary The presentation is typically of a tense, almost painless,
dyspepsia, little or no weight loss. long-standing (years), smooth, rubbery, mobile cyst in the
upper right quadrant, with little fever or malaise,
Suggesting hydatid disease, with cholangitis: contact it is probably a hydatid cyst: it may be enormous,
with dogs, a tense, almost painless, long-standing (years), and there may be more than one.
smooth, rubbery mass, commonly in the right upper A hydatid cyst usually contains several litres of clear
quadrant; little weight loss, general condition good. highly antigenic fluid under pressure. Around it there is a
thin, tough, fibrous ectocyst. Inside this, and separated
Suggesting a subphrenic abscess with downward from it often by an easy plane of cleavage, is a thick,
displacement of the liver: fever and an acute or subacute yellowish, slimy, gelatinous endocyst, which the parasite
illness, cough and chest signs on the right side, shoulder forms, and which tends to split and curl up on itself when
tip pain on the right side. you cut it. Scolices, which are tiny, barely visible, white
granules, and daughter cysts, like grapes or soap bubbles,
Suggesting tuberculosis of the liver: a hard irregular float free in the fluid of the cyst.
liver, often with no fever, no jaundice, pain is not marked, Echinococcus vogeli, a parasite found in Central & South
especially in an immunocompromised patient. When there America, produces multiple cysts in the liver. Likewise,
is no jaundice, you cannot distinguish hepatoma and Echinococcus multilocularis, found in Central Asia,
secondary carcinoma from tuberculosis, except by needle produces multiple cysts, but also inflammatory infiltrations
biopsy, which is one reason why it is so useful. that mimic tumour, and can spread to the lungs in 30%.
Suggesting intrahepatic stones: fever, right upper
quadrant pain, rarely jaundice in a patient in East Asia.
If hydatid disease is endemic in your area, you may find A cyst in the liver may rupture into:
hydatid cysts in the liver (80%), spleen (7%) or the other (1) the bile ducts and cause cholangitis,
parts of the abdomen (14%), or occasionally in the lungs, (2) a serous cavity, where it may cause a hypersensitivity
brain, bones, or indeed almost anywhere. If there is a reaction, varying from urticaria to anaphylactic shock.
peripheral cyst, expect that there is at least one in the liver
too. The diagnosis is difficult without ultrasound, and the
disease may be so rare that you forget it as a possibility.
There is hardly ever any hurry to operate, so investigate it
as fully as you can.
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Surgery is likely to be difficult, so treat it medically before Aspiration is part of treatment. Do not try to tap a hydatid
you operate or aspirate. The method of puncture, cyst merely to make it smaller.
aspiration, injection (of scolicide) and re-aspiration (PAIR) If you are aspirating what you think is an abscess, and
is safer than surgery in most cases. You may be able to do you aspirate clear fluid, it is highly likely to be a hydatid
this under ultrasound control if you have had some cyst. Continue aspirating to dryness, before you remove
experience. the needle. Then inject a scolicide, wait, re-aspirate and
then quickly withdraw the needle.
If you intend to remove a hydatid cyst surgically, do so
in the plane between the tissues of host and parasite: leave DIFFERENTIAL DIAGNOSIS.
the ectocyst, and do not try to remove the entire cyst intact, Suggesting simple liver cyst: smooth hepatomegaly,
unless you can do this easily, as in the ovary or spleen. with single cyst wall on ultrasound.
Instead: Suggesting liver abscess: fever, tender smooth
(1);Gain access to the cyst, and pack it off, so that if any hepatomegaly, with short history of illness.
infective hydatid fluid does escape, it will not contaminate Suggesting hepatoma: irregular huge liver with ascites
the peritoneal cavity; 1mL can contain thousands of and weight loss; audible bruit.
scolices. Suggesting secondary carcinoma of the liver:
(2) Aspirate some of the fluid, and inject a scolicide. hard knobbly enlarged liver with weight loss.
(3);After 10mins, aspirate as much remaining fluid as you
can.
(4) Scoop out the endocyst and the daughter cysts.
(5);Close the cavity, so that it does not leave a sinus or a
fistula.
In a child, the cyst will probably be monolocular, so that
aspirating it will not be too difficult. But in an adult,
it is likely to be multilocular, so that:
(1);the fluid will be difficult to aspirate, because the
daughter cysts block the needle, and
(2);the scolices will be difficult to sterilize, because the
scolicide cannot penetrate in to them.
The great dangers are that you will spill the fluid which
may:
(1);allow daughter cysts to establish themselves in the
peritoneal cavity, &
(2);cause anaphylactic shock. The recurrence rate is
usually at least 25%.
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TREATMENT INCISION.
Treat with praziquantel 15-25mg/kg bd for 7-14days, Make a midline incision unless the cyst is very peripheral.
pre-operatively. This kills the proto-scolices. Small cysts If necessary, extend this laterally in a J-shape, so that you
may disappear without surgical intervention. Albendazole have adequate exposure. Another way of getting better
in high doses (10mg/kg od for 28days) damages the access is to stuff packs, soaked with scolicide, into the
germinal membrane and so is complementary to right subphrenic space, so as to push the liver down.
praziquantel. You should therefore use both! Repeat the If you know exactly where the cyst is, a subcostal incision
dose 4 times after a rest interval of 15days. It is contra- may be even better.
indicated in pregnancy. Mebendazole 600mg tid for 3wks
is an alternative, but only effective in c.40%. The cysts present as smooth white swellings. Look and
Use cimetidine 400mg bd in addition. feel carefully to find how many there are. The rest of the
liver is usually large, smooth, and distended.
PERCUTANEOUS ASPIRATION, INJECTION & Select a place where the cyst is close to the surface,
RE-ASPIRATION (PAIR) and isolate it with carefully placed scolicide-soaked packs.
Treat medically first for a minimum of 3wks. Suture a tubular polythene sheath 6x15cm with 3/0 silk to
the pericyst without puncturing the cyst. Aspirate through
If there is a single cyst <5cm diameter, withdraw as the polythene sheath at least half the fluid with a 1∙5mm
much fluid as you can under ultrasound guidance through needle (15-10C).
a wide bore needle, and inject, preferably through a
T-connection piece, an equivalent volume (or slightly If the needle blocks, clear it by injecting a little scolicide.
more) of a scolicide (preferably chlorhexidine 0·04%, If needle aspiration does not work, use a trocar and
which is safer and more effective than other scolicides cannula. If necessary, try introducing a multi-holed
such as cetrimide, 70% alcohol, 1% povidone iodine, 0·5% catheter through the cannula. This will however increase
silver nitrate, hydrogen peroxide or hypochlorite.) the risk of spillage. If many daughter cysts block the
Start slowly by injecting a small volume; if there is any sucker, it is probably multilocular.
pain, abandon the procedure. If not, continue, and
re-aspirate after 1hr. Collect the fluid in a bag containing an excess of scolicide.
CAUTION! Do not use formalin or hypertonic saline as Do not use an open dish as fluid may spill! Keep a record
scolicides. of the volume you withdraw, as a guide to how much
Do not use PAIR if the cyst communicates with the biliary scolicide you will need to inject. Leave the needle in place
tree. Remember that the liver moves with respiration and and inject 50-100ml scolicide back into the cyst until it
so even then a needle will not stay immobile. becomes tense. Then tie a purse string suture snugly round
the puncture site, and remove the needle. Wait for 10mins
LAPAROTOMY FOR HYDATID CYSTS OF THE LIVER for the contents of the cyst to become sterile.
(GRADE 3.4)
Re-aspirate the cyst till it becomes flaccid and open it
INDICATIONS. through the part which presents most easily. Insert the tip
Large, symptomatic, subcapsular cysts in young patients; of the sucker, and suck out the remaining fluid. Record-
large especially peripheral viable cysts, prone to traumatic sized cysts have had over 40L! Using a kitchen spoon,
rupture. remove all the daughter cysts, sediment and debris
Do not attempt operation if the cyst is high on the right, (15-10E). Then, using finger dissection, find the natural
under the diaphragm, or there are multiple, deep-seated plane of cleavage between the ecto- and the endo-cyst.
cysts, or if there is a communication with the bile ducts
because extensive mobilization of the liver will be To get adequate exposure, you may have to incise the cyst
necessary. across the full width of its bulge, and deroof it.
Remove the yellow laminated membrane of the endocyst
PREPARATION. Kill the hydatids and make completely, piece by piece, with sponge forceps (15-10F).
dissemination less likely by using praziquantel or There will be little bleeding.
albendazole as above. CAUTION!
Treat with hydrocortisone 100mg IM 12hrs before the (1);Try not to rupture the daughter cysts as you remove
operation, so as to minimize the danger of anaphylaxis them, because their contents are probably still infective.
when you open the cyst and reduce the risk of laryngeal (2) Do not try to remove the ectocyst; it is tightly stuck to
spasm. the liver, and will bleed.
Have ready: An aspirator, or a large-bore syringe with a Swab the inside of the cyst with packs soaked in scolicide,
needle and 3-way tap; a long pair of sponge forceps, and explore it for secondary cavities. If you find any,
and a sterile kitchen spoon to scoop out the cyst; coloured repeat the process of aspiration and injection.
packs which will let you to see the brood capsules and
scolices more easily (soak the packs in scolicide); If the cavity is small, you may be able to bring its edges
2 suckers, one for the trocar (if you use one), and another together with mattress sutures.
ready for any spills; a sterilized 6x15cm tubular polythene
sheath; & a scolicide.
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If the cavity is large, you can: If there is obstructive jaundice, perhaps with
(1).Suture any obvious small bile duct openings, and leave cholangitis, aim to drain the common bile duct (15.7).
it alone, which is probably the wisest method. Remove all hydatid sludge, debris, and daughter
(2).Fill it with ordinary 0·9% saline, and suture it. cysts from the duct, and irrigate it thoroughly.
(3).Saucerize it by excising the protruding portion. Drain the common bile duct with a T-tube.
The difficulty with this is that the cut surfaces of the liver
will bleed. If a cyst is leaking into the peripheral bile ducts,
(4).Fill it with a graft of omentum. Dissect a strip of sterilize, evacuate, and drain the cyst. An external biliary
omentum on a vascular pedicle and stitch this into the fistula may develop, which may improve cholangitis
cavity. The omentum will swell to fill the space and absorb which is likely to be present.
the fluid from the cavity.
(5).Bring the walls of the cyst together with multiple If a fever develops postoperatively, the cyst cavity is
absorbable sutures, so that the cavity is obliterated. probably infected. Treat with gentamicin or
Drain large cavities for about 10days, especially if you chloramphenicol.
have not been able to remove all the endocyst.
CAUTION! If there are features of a liver abscess: a swinging fever,
(1);Do not let the untreated cyst fluid spill, or daughter anorexia, and increasing pain, suspect that a hydatid cyst
cysts will form in the peritoneal cavity. has become infected. Open it, saucerize it, and drain it
(2) If the needle hole leaks, insert a purse string suture. (15.10). Infection will have destroyed the hydatids.
If the cyst is a simple non-hydatid cyst, you can simply If there are recurrent cysts, they will probably take
de-roof it and obliterate the cavity with omentum. about 3yrs to develop, be multiple, and be in the
Make sure you control bleeding from the cut cyst edge abdominal cavity. Distinguish recurrent cysts from the
with a running suture or diathermy. manifestation of an unsuspected second cyst. Start medical
treatment.
DIFFICULTIES WITH HYDATID CYSTS
If there are cerebral cysts also, use praziquantel in
If there are signs of peritonism with an anaphylactic higher doses (60-90mg/kg bd for 30days), together with
response, shock, and dyspnoea, the cyst has ruptured into dexamethasone 4mg qid)
the peritoneal cavity. Use hydrocortisone 0·5-1g IV, and
adrenaline 1:1000 1ml SC. If a cyst is calcified and asymptomatic, leave it alone.
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The underlying cause is usually: (The Balthazar score gives the severity of the pancreatitis in terms of the
degree of inflammation and necrosis seen, but this needs contrast-
(1) alcohol abuse (especially spirits), or
enhanced CT scanning.)
(2) gallstones (or ‘sludge’), and occasionally,
(3) ascaris worms, RADIOGRAPHS are not very helpful but may show
(4) liver flukes, pancreatic calcification, if there have been previous
(5) leptospirosis, attacks; and a left pleural effusion, or distended loops of
(6) HIV disease (including treatment with ARV therapy), bowel from ileus.
(7) rarely typhoid.
(8) mumps or coxsackie virus, ULTRASOUND demonstrates oedema, and fluid
(9) hypercalcaemia, hyperlipidaemia, collections (or even necrosis) of the pancreas (38.2C).
(10) systemic lupus or cystic fibrosis You may see gallstones, and especially ‘sludge’ in the
(11) trauma (including endoscopic instrumentation) common bile duct, or a completely different diagnosis!
(12) drugs such as sulphonamides, thiazides, œestrogens
(13) poisons such as organophosphates TREATMENT.
(14) tityus scorpion envenomation (in Trinidad, Brazil & If pancreatitis is mild, it will settle by a régime of
Venezuela). restricting oral intake, with nasogastric drainage, analgesia
and IV fluid replacement.
You may diagnose pancreatitis clinically, or from
laboratory tests, or only when (in error) you perform a If pancreatitis is severe, replace fluid loss energetically
laparotomy for an acute abdomen. Estimating the serum with large volumes of 0∙9% saline, Ringer's lactate, or a
amylase is not difficult, and your laboratory should be able plasma expander. Correct electrolyte losses. Monitor the
to do it, because you should avoid a laparotomy for urinary output, the haematocrit, and if possible, the central
pancreatitis at all costs! venous pressure. Monitor glucose; start an insulin sliding
scale. The pain may be overwhelming: treat with large
Chronic relapsing or recurrent pancreatitis is one of the doses of opioids, supplemented by diazepam or
causes of a severe chronic upper abdominal pain. It is quite promethazine. Administer oxygen by mask; consider
common in alcoholics anywhere, and there is a calcific mechanical ventilation. Prophylactic antibiotics, especially
type found much in Kerala and Orissa in India, but also in against staph aureus are advisable. You may need blood
Japan and sub-Saharan Africa; the pancreas calcifies and transfusion later.
its endocrine function deteriorates. A longitudinal
pancreaticojejunostomy is helpful if the pain is If you are sure of the diagnosis, do not operate; but it is
debilitating, but this is formidable surgery indeed. better to operate unnecessarily, than not to operate on a
Chronic pancreatitis may also be due to tuberculosis (16.5) case of strangulated bowel, for example. The amylase
level may rise with necrotic bowel. Severe cases may
ACUTE PANCREATITIS benefit from lavage with saline, via tubes which can be
inserted in the flanks under LA (13.3), but attacks tend to
DIFFERENTIAL DIAGNOSIS includes: recur. Formal open lavage is then better.
(1) gastritis,
(2) perforated peptic ulcer (13.3), If you do open the peritoneum, you will know that there
(3) acute cholecystitis (15.3), is pancreatitis when you see areas of whitish-red fat
(4) rupture of a liver abscess (15.10), necrosis on the transverse mesocolon, or omentum, and the
(5) strangulating upper small bowel obstruction (12.2). exudate described above. The pancreas feels swollen and
oedematous, and may contain greenish-grey necrotic areas.
SPECIAL TESTS. Serum amylase rises within hours of The fat necrosis may be confused with TB, so take a
the start of the pain, and remains high for about 2days. biopsy. Drains by themselves do not help, but you may use
A level of >1,000 Somogyi units is almost diagnostic. them for continuous peritoneal lavage.
A peritoneal tap in the right lower quadrant will confirm
the diagnosis: the aspirate may be straw-coloured, or If the abdomen is difficult to close, leave it open as a
reddish-brown, but its amylase is always high. laparostomy putting on a vacuum dressing (11.10, 11-20)
or make fasciotomies in the rectus sheath.
In severe acute disease (Ranson’s criteria),
(1) the white count is >16000/mm³ DIFFICULTIES WITH ACUTE PANCREATITIS
(2) the glucose is >10mM; after 48hrs, If you find that there are also gallstones, consider doing
(3) the haematocrit drops >10%, a cholecystectomy (15-4) later. Do not be tempted to
(4) the urea rises >10mM, remove the gallbladder in the acute phase.
(5) the serum calcium drops <2mM,
(6) the pO2 drops <60 mm Hg with a metabolic acidosis. If, during the course of 2-3wks, septicaemia develops,
suspect that a pancreatic abscess (15.15) is developing,
Hyperglycaemia is common with chronic calcific especially if there is haematemesis.
pancreatitis.
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If deterioration continues, your only chance will be to DRAINAGE FOR A PANCREATIC PSEUDOCYST
refer to a centre where CT scanning is available: (GRADE 2.4)
a pancreatic necrosectomy may be life-saving. TIMING.
Do not operate until >6wks after an attack of pancreatitis,
If respiratory or renal failure develop, usually in the by which time the cyst wall will be mature enough to take
first 48hrs (5-10% chance), death is likely. There is little sutures. Once a pancreatic pseudocyst is palpable it rarely
you can do except treating with oxygen, plenty of IV disappears spontaneously. Operate as soon as possible
fluids, and plasma expanders. Monitor the CVP, ventilate after 6wks; if you leave it too long it may bleed, rupture,
mechanically, add broad spectrum antibiotics and become infected, or destroy much of the pancreas.
nutritional support.
DIFFERENTIAL DIAGNOSIS includes:
(1) liver abscess (15.15),
(2) hepatoma (15.11),
15.14 Pancreatic pseudocyst (3) hydatid cyst (15.12),
(4) renal cyst or hydronephrosis (27.14),
A large watery pancreatic exudate sometimes collects in (5) gastric outlet obstruction (13.7),
the lesser sac. This has no epithelial lining, hence the term (6) Burkitt's lymphoma (17.6),
‘pseudocyst’. It usually presents >3-4wks after an (7) abdominal tuberculosis (16.1),
abdominal injury, or an attack of acute pancreatitis, with a (8) aortic aneurysm (35.8).
mass in the abdomen and epigastric discomfort or pain.
There may be toxaemia with fever and tachycardia, but the Rarely a pancreatic carcinoma can form a cyst.
degree of sickness is much less than in acute pancreatitis,
or a pancreatic abscess. The mass usually distends the
abdomen: it may extend right across the epigastrium, and
reach down to the umbilicus or beyond it. It is not usually
tender, but may be quite tense and not fluctuant if very
large. Sometimes, there are symptoms of pancreatic
insufficiency, with steatorrhoea.
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PREPARATION
In dehydration, anorexia, or toxaemia, administer IV fluids
and high calorie high protein enteral feeding for a few
days pre-operatively. Insert a nasogastric tube the evening
before operation, and wash out the stomach thoroughly.
INCISION.
Make a midline incision.
Choose an area on the anterior wall of the stomach that is
overlying the cyst. Use a knife or diathermy to start a 4cm
incision in the long axis of the stomach between
2 Babcock forceps. Enlarge it with scissors. Clamp any
briskly bleeding vessels, and retract the edges of the
incision, so that you can inspect the posterior wall of the
stomach. Suck it empty.
After opening the stomach, aspirate through its posterior
wall into the cyst. Expect to find a mildly opaque
straw-coloured, or murky brownish fluid. If so, insert a
small haemostat through the hole in the stomach into the
cyst, and open it so as to enlarge the opening to 3cm.
Suck out the fluid: expect to aspirate up to 4l.
CAUTION! Do not incise the cyst widely; it may bleed
severely.
N.B. If you aspirate fresh blood, the ‘cyst’ may be an
aortic aneurysm: stop! Get an ultrasound scan (38.2D).
If you have waited the 6wks for adhesions to form and the Fig. 15-12 THE ORIGINAL ROUX LOOP.
A, the distal afferent (Roux) loop, which you can use to drain the
cyst wall to mature, there will be no need to suture the gallbladder, bile duct, pancreatic cyst, or stomach. B, the proximal
stomach wall to the cyst, as they will already be tightly efferent loop. The small bowel has been divided at c, and the
stuck together. But control brisk bleeding from the proximal part anastomosed end-to-side at c'. Here the plan is to
stomach edge; so quickly oversew the opening all round anastomose the Roux loop to the gallbladder.
with a continuous interlocking haemostatic suture of 2/0
non-absorbable. Do not use absorbable suture, because SIMPLE CYSTOJEJUNOSTOMY FOR PANCREATIC
pancreatic juice digests it. When you are sure the posterior PSEUDOCYST (GRADE 3.4)
opening in the stomach is no longer bleeding, close the
anterior opening in two layers, the first a full-thickness INCISION. This is a simpler, but less satisfactory,
haemostatic continuous layer of 3/0 absorbable sutures, procedure. Make a midline incision. Open the lesser sac to
and the second a seromuscular Lembert layer of get access to the pancreatic pseudocyst; check that its wall
continuous non-absorbable suture. Close the abdominal is thick enough to hold sutures. Then pack off the
wall in the usual way. abdominal contents with large swabs, open the cyst by
2cm only and drain its contents. Bring a loop of proximal
CYSTOJEJUNOSTOMY-EN-Y FOR PANCREATIC jejunum up to the cyst and make a side-to-side
PSEUDOCYST (GRADE 3.5) anastomosis (as for a gastrojejunostomy (13-16).
INCISION. This is the definitive operation. Proceed as POSTOPERATIVELY, restrict oral intake with
above; after opening the cyst, lift up the proximal jejunum nasogastric suction for 3-4days, until flatus is passed;
and look at its blood supply; select a point 30cm from the then start oral fluids, followed by a soft diet.
ligament of Treitz where to divide the bowel so that the
distal loop easily reaches the pseudocyst. Divide the bowel
15.15 Pancreatic abscess
between non-crushing clamps. You will need to divide
some of the vascular arcades in the mesentery to mobilize
the distal bowel (the Roux loop) adequately. When you are This is a dangerous complication of acute pancreatitis
satisfied there is no tension, make an end-to-side (15.13) or perforated duodenal ulcer. Occasionally it
anastomosis of the loop to the opening in the pseudocyst. results from severe pancreatic injury. A collection of pus,
Then anastomose the proximal cut end of jejunum to the necrotic tissue, and clot fills the lesser sac; it enlarges
right side of the Roux loop some 20cm along its length behind the peritoneum, it expands anteriorly to obliterate
with an end-to-side anastomosis, making sure the bowel the lesser sac, and it pushes the stomach and transverse
lies comfortably. Close any mesenteric defects carefully colon forwards. It may present with a catastrophic
avoiding damage to the fine mesenteric vessels. haematemesis.
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LAPAROTOMY FOR PANCREATIC ABSCESS (GRADE 3.4) DIFFICULTIES WITH PANCREATIC ABSCESS
If pancreatic juice is still discharging after 2wks, leave
PREPARATION. Resuscitate with adequate IV saline or the catheters in situ for a month and then withdraw them
Ringers lactate. Correct hyperglycaemia with insulin. slowly 5cm per day.
Administer oxygen, bicarbonate and calcium in seriously
ill patients. Catheterize the bladder. Treat with gentamicin, If a pancreatic fistula develops, collect the juice in a stoma
ampicillin and metronidazole. Cross-match blood. bag with the orifice carefully cut to size to prevent skin
Decompress the stomach with a nasogastric tube. excoriation. This can be mixed with jejunostomy feeds if
malabsorption is a problem.
EXPLORATION. Make an upper midline incision from
the xiphisternum to beyond the umbilicus. Open the If bleeding becomes severe, try pinching the vessels in
abdominal cavity with care, because the mass, or the the free edge of the lesser omentum between your fingers
stomach or colon, may have stuck to the abdominal wall. and pack the pancreatic area. Leave the packs for 48hrs
You may find it difficult to know what you are seeing. and remove them at a second laparotomy, when bleeding
Dissection is difficult and dangerous, because the tissues should be much less.
are so vascular and oedematous. Lift and free the
abdominal wall from the organs under it, and insert a
self-retaining retractor. Feel for the upper border of the
abdominal mass. Try to find a place where you can incise 15.16 Pancreatic carcinoma
it without injuring anything. This will usually be through
the lesser omentum, or better, the transverse mesocolon to If the carcinoma is in the head of the pancreas (70%),
the left of the ligament of Treitz. When you have decided it may obstruct the common bile duct, so that presentation
where to drain, seal the area from the rest of the is with painless progressive obstructive jaundice (15.9).
peritoneum with large moist packs. Using a syringe and a If it is in the body of the pancreas (30%), presentation is
large needle, aspirate the place where there seems to be the with upper abdominal and back pain and general
thinnest layer of tissue between the abscess and your symptoms of malignancy. Spread to the lymphatics and
finger. Take pus for culture. If you find pus under surrounding structures is early, and 10% of patients
pressure, decompress the abscess with suction. Enlarge the develop ascites.
abscess so that you can insert two fingers, but don't try to Thrombophlebitis migrans (thrombophlebitis in any
dissect further. Wash out any floating solid matter. superficial vein appearing, resolving, and then appearing
again elsewhere) may occur with any malignant tumour,
CAUTION! Don't disturb the necrotic pancreatic tissue but is particularly common with this one.
at the bottom of the abscess - it will bleed!
Place 2 catheters in the abscess cavity, and bring them out Radiotherapy, chemotherapy, and surgery are of little
through stab wounds. Bring one out anteriorly, and the value, but differentiation with tuberculosis is important.
other as far back as possible, in the most 'dependent' Taking a biopsy of the pancreas itself may cause
position. Use these to irrigate the abscess cavity pancreatitis and worsen the condition, so try to get a piece
continuously (about 2l in 24hrs). Make a feeding of tissue from an adjacent node or piece of omentum.
jejunostomy (11.7), because oral feeding will not be Sometimes carcinoma of the pancreas cannot be easily
possible for 3wks, and you will probably be unable to feed distinguished from chronic pancreatitis (15.13)
parenterally. Feeding through a jejunostomy results in less or tuberculosis.
secretion of gastric juice than feeding through a
gastrostomy.
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15.17 Surgery of the spleen It occurs more often in females than males (4:1);
there is usually quite a good response to prednisolone,
but eventually this option becomes undesirable in the
If you operate on the spleen, you often end up removing it. chronic case.
The indications for doing so (apart from trauma) must be However splenectomy may not benefit 20% of cases.
good, because the spleen of a tropical patient is commonly Do not do it if systemic lupus erythematosus or rheumatoid
large, and may be so firmly stuck to the diaphragm that: arthritis is the cause of the chronic thrombocytopenia.
(1) exposing it is difficult. Never do it for the acute thrombocytopenia, and especially
(2) bleeding is likely from the vascular adhesions that join not where thrombocytopenia is due to drug sensitivity
it to the diaphragm. (especially quinine). If you have access to radiotherapy
If there is portal hypertension, the vena cava carries high this may be the safer option.
pressure venous blood which escapes into the systemic
circulation. Remember the spleen protects against (4) Haemolytic anaemias.
subsequent infection, especially pneumococcal There are several haemoglobinopathies, including sickle
pneumonia, malaria and dog & cat bites with cell trait (never sickle cell disease) thalassaemia, and
Capnocytophaga canimorsus (a common commensal) spherocytosis for which splenectomy may be beneficial,
which may rapidly be fatal. Infection is even more but their selection needs the advice of an expert.
common if HIV is present.
(5) Splenic torsion or wandering spleen.
INDICATIONS (OTHER THAN FOR TRAUMA) FOR These are both very rare and arise when the spleen has an
SPLENECTOMY abnormally long pedicle and no adhesive attachments.
You are unlikely to make the diagnosis before you operate.
(1) Spontaneous rupture.
Torsion of the spleen tends to occur during pregnancy
This is rare, but may occur typically in massive malarial
(not bilharzial) splenomegaly; though it may be truly when it is confused with an ovarian tumour!
spontaneous, e.g. in mononucleosis, the patient may not
(6) Hydatid cyst (15.12).
remember any trauma because it was slight. It may occur
after colonoscopy. Signs are of shock, left upper
abdominal pain and abdominal distension, although (7) Malignancy.
HIV-ve lymphoma, Schistosomiasis related giant follicular
initially there may be felt a reduction in abdominal girth as
a large spleen bleeds. lymphoma, chronic myeloid or lymphatic leukaemia,
or fibrosarcoma affecting only the spleen, but you should
get advice from an expert.
(2) Hypersplenism.
A big spleen may be responsible for removing all the KASHY (20yrs) complained of a swelling in the right iliac fossa.
blood cell lines, resulting in anaemia, leucopenia and Ordinarily, it was painless but during attacks of 'fever' it became painful
thrombocytopenia of varying severity, though the and tender. At laparotomy, the whole spleen was found to be in the right
thrombocytopenia is commonest. The problem is that the iliac fossa, but the splenic vessels crossed the abdomen to their normal
position. The 'wandering spleen' was removed easily.
same picture can be shown by HIV disease, which itself LESSON Some rare conditions have easy solutions.
can give rise to splenomegaly. Thrombocytopenia is a
serious hazard in surgery and so you need to have some CONTRA-INDICATIONS TO SPLENECTOMY
experience before attempting a splenectomy without
platelets available for transfusion. However, your hand (1) Splenic abscess (15.18) occurs occasionally. It starts
may be forced if a patient continues to bleed elsewhere acutely, it may become chronic, and it shows up
because of the thrombocytopenia, particularly if there is radiologically as a fluid level in an irregular space.
portal hypertension. Ultrasound shows the spleen to be filled with dense fluid.
If the underlying cause is HIV disease, blood counts will The pus is sterile usually, but may be secondary to
improve with ARV therapy (5.8) without splenectomy. amoebiasis, brucellosis, salmonellosis, leptospirosis or
You should anyway be wary of removing a spleen when candidiasis. There may be sickle cell disease, acute
there is HIV disease because of the risks of infection; myeloid leukaemia or pancreatitis. Carefully pack away
you may be able to make the distinction between other abdominal viscera, and drain the abscess: do not try
hypersplenism and HIV-pancytopenia by looking at a bone to remove the spleen.
marrow film: this is normal or hyperplastic in
hypersplenism, but hypoplastic in HIV disease. (2) Tropical splenomegaly syndrome
This is an immune response to recurrent attacks of malaria,
(3) Chronic idiopathic thrombocytopenia. and is responsible for nearly all large spleens in malarious
Here the low platelet count is not associated with an areas. It responds to long courses of antimalarials.
enlarged spleen but through destruction of platelets by Do not remove such spleens unless hypersplenism is a
antibodies. There are often ‘megathrombocytes’ in the complication.
peripheral blood film and raised numbers of
megakaryocytes in the bone marrow.
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(3) Splenic tuberculosis (16.5). Carefully expose the splenic vein by dissecting away the
Anti-TB therapy should make splenectomy superfluous; fatty tissue in the pedicle and tie it off. You can then tie off
fibrosis during healing will shrink the spleen. HIV disease the splenic artery and divide the splenic pedicle.
is particularly likely. For extra security apply a second set of ligatures at the
same point before the vessels divide.
(4) Leishmaniasis (34.7). Medication should likewise CAUTION! Make sure you pass the ligatures and tie
make splenectomy unnecessary. them before dividing the vessels. If you use haemostats
and the cut vessel drops off and is lost in a pool of blood,
(5) Acute diseases, viz. leptospirosis, acute thrombo- you may never find it again.
cytopenia.
If you haven’t been able to draw the spleen forwards,
(6) HIV disease (5.6). do so now, if necessary by dividing adhesions to the
Whilst not an absolute rule, the risk of infection increases, parietal peritoneum. Then divide the peritoneum lateral to
and so the indication must be really good. Institute ARV the spleen (the lienorenal ligament); put your finger into
treatment first. the opening and gently free the spleen. You can now bring
CAUTION! it well outside the abdomen. Free the splenic flexure of the
(1);Do not operate lightly; your only absolute indications colon from the spleen and separate the tail of the pancreas
for doing so are the first three. from the splenic vessels. Free the spleen from its
(2);If the spleen is huge, think seriously about operating attachments to the greater curvature of the stomach by
because it may need a thoraco-abdominal approach. dividing the short gastric vessels individually in the
gastrosplenic ligament.
SPLENECTOMY (GRADE 3.4) CAUTION! Do not include an area of stomach wall
with your ligatures, especially at the upper margin of the
PREPARATION. spleen.
Make sure you have a wide bore cannula in place for fluid Remove the spleen, keeping it in saline for possible
replacement; have blood cross-matched (but do not be in a autotransplantation (see below), and put a big dry pack in
hurry to raise the haemoglobin if this has been chronically the splenic bed. Leave it there for 5mins; then remove it
low), and a nasogastric tube to decompress the stomach. and look for any bleeding vessels and tie them off.
Provided there is no allergy, always give prophylactic If the operative site is not absolutely dry and you are
penicillin perioperatively. Place a sandbag or pillow uncertain about an injury to the tail of the pancreas, place a
behind the left thorax to rotate it to the right. large drain in the splenic bed.
INCISION. Make a midline or left subcostal incision: SPLENIC IMPLANTATION. This is controversial and
this will give better direct access to the spleen, and you may not work. Keep some slices of spleen, say 5x3x0·5cm,
can extend this as a chevron with a right subcostal and implant them under the peritoneum in the side wall of
incision. Alternatively for a very big malarial spleen, the abdomen, or in the anterior abdominal wall. Or, place
you can make a left thoraco-abdominal incision, because some 1cm cubes of spleen within a sandwich of omentum.
this allows you to see vascular diaphragmatic adhesions They will usually take, and may reduce the severity of
directly. (11.1) attacks of malaria and perhaps the danger of septicaemia,
Doing an elective splenectomy is different from an but will not fully protect against pneumococci.
emergency splenectomy in that you can approach the The risk of adhesions is much less than the risk of
spleen in a relaxed manner. Explore the abdomen, life-threatening infections. You can check if the splenic
noting the condition of the liver and presence of any slices are functional after 4wks if there are no Howell-Jolly
lymph nodes, as well as the mobility of the spleen. bodies and no target cells in the peripheral blood film,
If it is adherent, and large, it is wisest to tie the splenic and the platelet count is normal.
vessels first. Do not do this with splenectomy indications 4,5,6 or if
You can improve access by placing a pack behind the there is already an accessory spleen.
spleen if there are insignificant adhesions. Otherwise
divide the peritoneal attachments. If bleeding is a problem SEGMENTAL SPLENECTOMY (GRADE 3.5)
at this stage, deliver the spleen, rotate it forwards to the Preserving a functional remnant of c. 20-30% of the spleen
right and tie a thick ligature right round the entire splenic avoids septic and immunological problems also; it can also
pedicle. This is safer than trying to grasp it with a large be used in hypersplenism. You need to devascularize
clamp. As you do so, try not to damage the stomach, anatomical segments (especially middle and lower
and try to cause the least possible damage to the pancreas. portions) of the spleen, by ligating branches of the splenic
When you have controlled bleeding, proceed to tie the artery at the hilum.
vessels individually. Wait for 5mins to observe a line of demarcation, and cut it
Enter the lesser sac by opening a window in the greater along this line in a V-shape whilst squeezing the proximal
omentum, and lift up the stomach off the pancreas by portion manually. A vascular clamp across the pedicle will
dividing the adhesions between them a short distance. reduce bleeding. Then sew over the remnant an omental
Then feel for the splenic artery along the upper border of patch, bringing the edges of the ‘V’ together. This is not
the pancreas. Incise the peritoneum over it, pass an angled easy surgery.
haemostat underneath it and pass ligatures round it.
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DIFFICULTIES WITH SPLENECTOMY There is left upper abdominal pain, a dragging sensation in
If you have damaged the stomach or the colon, close the the abdomen, discomfort after meals, anorexia, and a
perforation in two layers with long-acting absorbable palpable tender mass extending down from the left upper
suture, make sure nasogastric suction is in place. quadrant towards the right lower quadrant. This might be
Start gentamicin and metronidazole. huge. There is usually anaemia and a low-grade fever.
The mass may be tympanic because it usually is filled with
If you have damaged the pancreas, suture a piece of gas, arising from oxygen liberated by red cells in the
omentum over the damaged segment of pancreas and leave spleen, and carbon dioxide from tissue metabolism rather
a drain. Try to monitor the amylase levels of fluid draining than gas-forming organisms.
If bleeding from the diaphragm persists, insert one or SPECIAL TESTS. Leucocytosis and anaemia are usual,
two dry packs for 10mins by the clock; then come back but the white count may not be raised with HIV disease.
and remove them to see if you can identify the bleeding
vessels to tie them. If you still fail to control bleeding, CHEST RADIOGRAPH. An erect film will show a gas
leave packs tightly in situ, close the abdomen, and return bubble and fluid level below the left hemidiaphragm,
after 48hrs to remove them by which time the bleeding pushing it upwards.
will almost certainly have stopped.
ULTRASOUND. Look for a fluid-filled cavity in the area
If shock suddenly develops postoperatively, a ligature of the spleen (38.2F). Much of the splenic tissue may be
has probably come off. Reopen the abdomen immediately, destroyed. Aspiration will confirm the diagnosis, but
with good suction available to try to find the bleeding beware of causing severe haemorrhage or rupturing the
vessel, and tie it off. colon. You may be able to aspirate a splenic abscess
completely, and avoid surgery. Treat with antibiotics 48hrs
If the wound sloughs and there is a fluid discharge, beforehand and then follow a procedure as for a liver
the tail of the pancreas or stomach may have been injured. abscess (15.10).
Reopen the wound, and suture a piece of omentum over
the damaged viscus; do not try to ligate the pancreas or LAPAROTOMY FOR SPLENIC ABSCESS (GRADE 3.1)
suture the gastric perforation as sutures will probably cut
out and cause more damage. INDICATIONS. Essentially all splenic abscesses need
surgery.
If there is fever with no obvious cause, and you have
given penicillin, check for a subphrenic abscess (10.2). PREPARATION. Cross-match blood and start
pre-operative penicillin and metronidazole.
If there is rapidly developing haemolytic anaemia and
fever, suspect malaria or babesiosis, a tick-borne illness EXPLORATION. Make a left subcostal incision or
usually affecting domestic or wild animals, and get both Chevron (inverted-V double subcostal) for very big
thick and thin blood films. Use quinine 650mg orally tid abscesses. Pack away the rest of the abdominal contents.
and clindamycin 600mg orally tid for 5-10days. Drain the abscess and leave a large tube or catheter in the
space, passed through a separate stab incision in the lateral
If there is respiratory distress postoperatively, think of abdominal wall. Lavage the abdomen with warm saline or
a pneumothorax. water.
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Abdominal TB is common and becoming more so, especially All this pathology can present in so many ways, and with so
with HIV disease. Extra-pulmonary TB will suggest HIV few distinguishing signs, that diagnosis is difficult. With all
disease in 90% of cases where TB was previously not so forms of TB a patient loses his appetite, loses weight, and
common. It is responsible for about 10% of bowel feels ill, just as with TB elsewhere. There is vague abdominal
obstruction in some parts of the world, viz. India and Nepal. pain and tenderness, and maybe vomiting. Depending on the
You may see it when you are expecting something else. type of TB there may be symptoms of abdominal swelling
(the ascitic type), obstruction (the plastic type or tuberculous
strictures), abdominal masses (the glandular type), bleeding
or perforation (tuberculous ulcers). There may also be
symptoms of chronic PID (gynaecological TB, 23.1).
Not infrequently abdominal TB presents after a laparotomy
for another condition, e.g. a Caesarean Section.
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16.2.The ascitic type SPECIAL TESTS. Check the Hb, ESR and HIV. Get a chest
radiograph and examine sputum for AAFB’s.
Do an abdominal ultrasound scan to look for
Tuberculosis may be responsible for 80% of all your cases of lymphadenopathy, and the condition of the liver and kidneys.
ascites. Presentation is with a swollen abdomen containing
many litres of straw-coloured fluid. A child with advanced Examine the ascitic fluid: if the white cell count is over 25/μl,
abdominal TB typically has 'a ballooned abdomen and with at least 70% lymphocytes, tuberculous peritonitis is
matchstick legs', but in many children the diagnosis is far fairly likely.
from obvious. The fluid accumulates as a result of large If the fluid has fewer lymphocytes than this, the ascites is
numbers of exudative miliary tubercles on the peritoneum. more likely to be caused by cirrhosis, periportal fibrosis or
The only certain way to make the diagnosis is to perform a bacterial sepsis. Your lab will be unlikely to find any AAFB
mini-laparotomy, or laparoscopy, which will also enable you in it, because they are very sparse. Use GeneXpert
to diagnose cirrhosis, periportal fibrosis (due to Schistosoma polymerase chain reaction (PCR) testing if possible (5.7)
mansoni), carcinomatosis of the peritoneum or hepatoma.
You can usually diagnose miliary TB with your naked eyes; Measure the protein in the peritoneal fluid. In tuberculous
but you can be wrong, so take a biopsy of the parietal peritonitis it is usually 4-10g/l, but it may be up to 20g/l,
peritoneum and/or the liver. (The small seedlings may be or higher. Most patients with ≥20g/l have carcinomatosis.
cryptococcal in HIV+ve patients). Occasionally the ascites If it contains >4g/l of protein, it is likely to be an exudate.
may be encysted and be confused for a giant ovarian cyst. If it contains <4g/l, it is likely to be a transudate as found in
cirrhosis or periportal fibrosis.
In the Concato syndrome, there is a pleural and pericardial
effusion as well; this may be due to polyserositis, but in such A more accurate test is the albumin gradient
cases, you should start anti-TB therapy (and prednisolone (i.e .the difference between serum and ascitic albumin):
120mg od, tapering off over 4wks) immediately and not this is >1·1g/l in cases of portal hypertension,
intervene surgically: the patients are just too ill for that! and significantly less than 1g/l in tuberculosis.
Only stop TB treatment if you can really prove its absence!
If you can do it, measuring adenosine deaminase is highly
specific: levels >33 units/l indicate TB in >95%. Note that in
the presence of cirrhosis, the value may be lower.
You may be able to get special dipsticks for ascites which,
though expensive, are very useful.
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Open the peritoneal cavity through a midline incision, mostly If a tuberculous ulcer of the colon has fistulated into the
below the umbilicus, and look for the signs of TB. bladder or vagina, make a defunctioning colostomy (11.6);
Biopsy a lymph node. If the site of the biopsy bleeds, control do not attempt resection until treatment has made the patient
it with packs or with a 3/0 figure of 8 suture which runs better.
under the bleeding point on both sides.
If loops of the bowel are severely stuck down by plastic
If you cannot find peritoneal tubercles or rubbery lymph peritonitis, do not do too much dissection: the risks of
nodes easily, take a biopsy from the parietal peritoneum. creating fistulae are too high. Instead, if obstruction is
definite, perform a simple side to side ileo-transverse
If you find a firm mass at the ileocaecal junction, perhaps colostomy or entero-enterostomy (11-10) without resecting
with adhesions to adjacent structures and a normal any bowel. This will bypass the diseased segment, and avoid
peritoneum, the diagnosis is more difficult. Cut across an much stressful surgery but creates a ‘blind loop’.
enlarged node. If you see caseous areas, you have confirmed However, a repeat laparotomy later will probably be needed
the diagnosis. Even so, take a specimen for histology. after anti-TB treatment is completed in order to correct
Avoid taking a biopsy from the wall of the bowel: this may malabsorption problems of the blind loop.
lead to a fistula. If the nature of the ileocaecal mass is
uncertain, but is probably tuberculous, leave it if it is not
causing obstruction. In this case, perform an
ileocaecal resection (12.7), or if this is too difficult, 16.4 The glandular type
an ileo-transversostomy side-to-side. If it might be
neoplastic, and mobile, try to perform a right hemicolectomy This presents as irregular lumps in a child's or young adult’s
(or ileocaecal resection if there are metastases); if immobile, abdomen, sometimes with ascites, and with little tendency to
biopsy an enlarged node nearby and await the histological obstruct. The mesenteric nodes are large, and not very
report. mobile. They may be so large that you can feel them through
the abdominal wall. They are matted together, and firm to
hard, with characteristic pale yellow areas of caseation on
their cut surfaces. There is often hepatosplenomegaly,
moderate anaemia, dry depigmented skin, hypoproteinaemic
oedema and low-grade fever.
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Presentation occurs with: CYSTOSCOPY (27.3) will confirm the diagnosis, show the
(1).Symptoms of chronic cystitis: frequency and dysuria. degree of involvement of the bladder, and exclude
This later progresses to the burning nocturia and strangury schistosomiasis. You may see a ‘golf-hole’ ureteric orifice.
(slow and painful discharge of urine, drop by drop) of a small
shrunken bladder, which may become secondarily infected.
These symptoms make the bladder appear to be the cause of
the disease, rather than the kidney.
(2);Painless intermittent microscopic haematuria or rarely
obvious bleeding. (By contrast, a renal carcinoma usually
presents with macroscopic haematuria).
(3).Dull discomfort in the loin, which gets steadily worse,
especially when TB is complicated by a pyogenic infection
(20% of cases). The kidneys are not enlarged or tender,
until late.
(4).Malaise and the usual general symptoms of TB.
SPECIAL TESTS. Urine with pus cells and red cells, but no
bacteria on standard culture (unless there is secondary
infection), is strongly suggestive. However recurrent E Coli
urinary infection occurs in 20%.
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If there is a relapse, and you think that drugs have not been
taken faithfully, consider changing to a regime using second-
line drugs. Check the HIV status if this has not already been
done, or was previously -ve.
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Remember that the neck and axilla are very vascular areas METHOD FOR GROIN NODE BIOPSY (GRADE 1.5)
with much ‘clockwork’, so you must be able to see what Make sure the patient is bathed and clean. Position him
you are doing! Therefore, make sure you have a good supine; if the hair is likely to be in the way, shave it but
operating light, and preferably diathermy available. take care not to cut the skin. Make a 5cm incision in the
If not, be certain to have sufficient haemostats, gauze and groin crease or over the node, away from anywhere where
a suction that is working available. the underlying pathology is infiltrating the skin because
If you cannot remove the whole lymph node, cut it clean the wound may then not heal. Deepen the wound through
and take a representative sample: do not try to be heroic the fascia. Keep the wound edges apart with self-retaining
and excise a huge node without seeing what is underneath! retractors. There are many superficial veins; tie these or
Try to handle the node as gently as possible because you diathermy them to keep a dry field. There are superficial
distort the architecture if you are rough, and this makes nodes just below the inguinal ligament and around the long
histological interpretation difficult. saphenous vein. If the enlarged node is one of these,
gently separate it from surrounding tissues and remove it
INDICATIONS FOR LYMPH NODE BIOPSY as above. If the long saphenous vein is involved or
(1).Tuberculous lymphadenitis (if fine needle aspiration is damaged, clamp it and ligate it. There are deeper nodes in
uncertain & to confirm the diagnosis). the femoral canal; palpate the femoral artery and so locate
(2).Matted, firm or hard lymphadenopathy >2cm in the femoral vein just medial to it. The nodes are more
diameter. medial still. Do not attempt to remove one of these unless
(3).Suspicion of metastatic disease with the primary you are prepared for a block dissection (17.8);
tumour unknown. satisfy yourself with a biopsy of a part only. Close the
wound with a drain if you have dissected deeply.
METHOD FOR NECK NODE BIOPSY (GRADE 1.5)
Position the patient with the head tilted up and turned to EXAMINATION OF THE NODE
the opposite side. Make an incision over the node in the A normal node has a pale colour and is uniform;
direction of Langer’s skin lines, and extend it 1cm to either you may be able to distinguish the cortex and medulla with
side of the node. (Do not try to remove a node through a the naked eye. It may show abnormalities nonetheless on
key-hole incision). Deepen the incision and make sure histology and so you should not assume it to be normal;
of haemostasis. Keep the wound edges apart with a however direct examination of nodes can give valuable
self-retaining retractor. If there is now too little room to instant information.
operate, your incision is too small: go back and increase its
size. Under a good light, look for caseation or tuberculomas
which are present in 75% of tuberculous nodes. Caseation
If there is only fascia covering the node, incise this and may occur with lymphoma, histoplasmosis, blastomycosis
carefully extract the node with scissors using the ‘push and and tularaemia, but these are relatively uncommon, and
spread’ technique (4-9B). If the node lies deep to other where tuberculosis is endemic, you should start treatment
structures (muscle, artery, vein or nerve), retract these out whilst waiting for the histology result.
of the way. You may need an assistant to do this.
Dissect gently down to the node, dividing only what you Pus within the node or showing purulent necrosis suggests
can see. There is usually a fairly large artery feeding the TB in over 90%, especially when surrounding cellulitis is
node behind it, so you should push the node to one side to absent. You should examine the pus and a smear of the cut
see this to tie it off, or diathermy it. Carefully free the lymph node on a glass slide by microscopy and ZN
node, or cut off a part clean if it is too big to remove in staining for AAFB’s.
toto. Ensure there is no bleeding; if there is some oozing,
close the wound with interrupted non-absorbable 3/0 If you see hypervascular nodes, especially with a
sutures around a small Penrose drain (4.9). purplish colour, this is likely to be Kaposi sarcoma.
METHOD FOR AXILLARY NODE BIOPSY (GRADE 1.5) DIFFICULTIES WITH LYMPH NODE BIOPSIES
Position the patient with the arm flexed under the head,
which is turned to the opposite side. Make a transverse If you cannot control the bleeding, do not plunge
incision at least 5cm long and deepen it through the haemostats blind deep into a cavity. Pack the cavity and
axillary fascia. Keep the wound edges apart with one or get the suction ready. Then carefully remove the pack
two self-retaining retractors. This exposes the fat of the under a good light so you can see properly, and apply a
axilla and the tail of the breast; here are the pectoral group haemostat to the bleeding vessel. If the bleeding is coming
of nodes. There are more nodes adjacent and behind the from a major vein or artery, and you cannot control it,
axillary vein which is at the upper border of the axillary pack the wound again and press on it. Get more assistance,
fat; these nodes may be lateral, central or apical and are put up an IV infusion of saline or Ringer’s lactate and
also close to branches of the brachial plexus. So you need anaesthetize the patient.
to operate carefully here making sure you can see Open a major dissection instrument pack, preferably with
properly; gently separate the node from surrounding vascular clamps. For an axillary biopsy, position the
structures and control bleeding as you go. patient with the head tilted up and turned away from you.
Once you have sampled the node, ensure there is no When everything is ready, extend the incision to get good
bleeding and close the wound as above. exposure and slowly remove the pack using suction.
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Put vascular clamps (or haemostats) on either side of the 17.5 Salivary gland enlargement
bleeding vessel, and tie them off. Do not be tempted to use
diathermy in this situation. If all this fails, tightly pack the A very noticeable facial feature is bilateral parotid gland
wound, wait 24hrs and re-explore the next day. enlargement; this may be endemic especially in
malnourished patients with vitamin deficiency, suffering
If the node is too big to remove safely, cut part of the from multiple parasitic disease, but is also a common
node off clean and leave the remainder. feature of HIV disease and almost diagnostic where this is
common. These patients often, but not always, have other
If the node is actually an abscess, clean the cavity out signs of HIV disease. However, as parotid enlargement
and pack the wound, or if it is rather large insert a Penrose occurs even when CD4 levels are normal, there may be no
drain, and close the wound with interrupted sutures. other overt signs of HIV infection. Initially the parotid
Do not forget to take some tissue for biopsy, and a swab enlargement may be unilateral, but it almost always
for culture & AAFB’s. becomes bilateral with time. The parotids may feel lumpy
or cystic or both; aspiration produces a yellowish fluid,
If the node is actually not a node but a tumour occasionally opaque. Repeat aspiration is often necessary,
(benign or malignant), proceed as above to try to excise it and superadded infection not uncommon. The parotids
if you can. If it is stuck, just take part of it for biopsy, may become quite grossly enlarged, particularly with
and close the wound. tuberculosis or lymphoma; fine needle aspiration is then
helpful to get a diagnosis, but operative intervention is
If the node is cystic, try to excise the cyst complete with neither useful nor safe. The enlargement will recur and
its lining. If it bursts, try to remove as much of the lining facial nerve palsy is a real hazard.
as you can to prevent its recurring.
Bilateral parotid enlargement may be caused by:
If you find malignant melanoma (34.6) in the node, (1) chronic recurrent sialadenitis,
take a biopsy and prepare for a block dissection within a (2) Sjøgren’s syndrome,
week. Look for the primary, and make sure that is widely (3) sarcoidosis,
excised then, if necessary with skin grafting of the defect. (4) sialectasis in Chagas disease,
(5).swelling from excessive pipe, glass or trumpet
If the ‘node’ is actually an incarcerated femoral hernia, blowing.
proceed to hernia repair (18.7) with bowel resection if (6) leukaemia.
necessary (18.8): do not abandon the procedure! None of these causes warrant surgical intervention.
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(2).Tumour debulking. If presentation is late, try, if DIAGNOSIS. The fact that you are in an endemic area,
possible, to remove the large bulk of the tumour surgically the child's age, and the site of a rapidly growing tumour
first. If you can remove more than 90% of it, you will should alert you to the diagnosis. Get radiographs.
double the survival time. Unfortunately, you are unlikely Carry out a fine-needle aspiration for cytology (17.2).
to be able to do this, except perhaps by removing a girl's Take a standard biopsy, or a smear biopsy. If possible,
ovary, or her breasts, or a mass in the mesentery. If you send a bone marrow smear for histology, and examine the
try, spilling the tumour is unimportant, because there will CSF for malignant cells. Check the HIV status.
be a malignant ascites anyway. So, if a child is to be
treated early, and perhaps to be treated at all, you will DIFFERENTIAL DIAGNOSIS: this varies with the site.
probably have to treat him yourself. There is no time for a A swelling of the jaws: an infected tooth socket (6.9),
leisurely workup: try to start treatment in 24-48hrs. perhaps with osteomyelitis, injury, maxillary sinusitis
(29.8), a dentigerous cyst or an adamantinoma (31.6),
There are two important complications: or a nasopharyngeal carcinoma (29.16).
(1).The acute tumour lysis syndrome is a combination of Burkitt's lymphoma usually displaces the teeth.
lactic acidosis, hyperkalaemia, and hyperuricaemia, and is Proptosis: retinoblastoma (28.16) affects the eye itself
the result of the rapid destruction of a large mass of whereas Burkitt’s lymphoma usually displaces the orbit.
tumour. Resection of most of the tumour before An abdominal swelling: tuberculous lymph nodes (17.4),
chemotherapy reduces this risk. This syndrome, and the other lymphomas, a nephroblastoma (27.35).
post-surgical complications of far advanced disease,
are the common causes of an early death. STAGING. Prognosis is directly related to stage:
Stage A Single site (often the jaw).
(2).The excretion of cyclophosphamide in the urine can Stage B Two sites excluding abdomen, thorax,
cause a haemorrhagic cystitis. You can reduce both these CNS or bone marrow.
dangers by maintaining a high urine output and by Stage C Abdomen or thorax tumour, excluding
alkalizing the urine with bicarbonate. CNS or bone marrow.
Stage D Involving CNS and/or bone marrow.
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Late complications include: obstruction to the trachea and Arranging RADIOTHERAPY will probably be
bronchi, pleural effusion, biliary obstruction causing impossible, so you will have to rely on chemotherapy.
jaundice, cord compression, lytic and/or sclerotic bone If you can provide radiotherapy, here are the relative
deposits, anaemia, and infections, especially in debilitated indications for it:
patients.
Stages I-II. Comparable results to chemotherapy,
Untreated cases deteriorate, many only slowly, and die in a but radiotherapy has fewer side-effects.
few months to a few years. Radiotherapy and Stage III. Radiotherapy difficult because a wide area
chemotherapy cure some of them, and cause many has to be irradiated; chemotherapy better.
long-term remissions. Chemotherapy is so successful in Stage IV. Radiotherapy impractical, chemotherapy
early cases that only Burkitt's lymphoma should have necessary.
greater priority.
PREPARATION.
DIAGNOSIS. Prepare for chemotherapy (37.4). Sadly this is too costly in
Examine all accessible lymph nodes. Note the nature and most instances; the régime mostly used is a variation of the
size of all enlarged ones. Feel for enlargement of the ‘MOPP’ combination:
patient's liver and spleen; assess the weight loss.
'MOPP' VARIATION: AN ESTABLISHED COMBINED
SPECIAL TESTS. DRUG REGIME FOR HODGKIN’S LYMPHOMA
Do a total and differential white count, and count the
platelets. Get a chest radiograph: look for widening of the Chlorambucil 6 mg/m², max dose 10mg, PO days 1-14.
mediastinum and enlargement of the hilar lymph nodes. (cyclophosphamide 1g/m² may replace chlorambucil)
You must establish the diagnosis by biopsy Vincristine 1·4mg/m², max dose 2mg, IV days 1&8.
(cytology alone cannot give you a definitive answer). Procarbazine 100mg/m², max dose 200mg, PO days 1-14.
Measure the blood urea. Check the HIV status. Prednisolone 40mg/m², PO days 1-14.
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Leucopenia from chlorambucil and procarbazine; Diagnosis, special tests and differential diagnosis are as for
the latter may also cause anaemia and thrombocytopenia, Hodgkin’s disease
which may present late. Delay the drugs till the counts
recover. STAGING is the same as for Hodgkin's lymphoma, but is
less important because 90% of patients present in Stages
Local irritation, ulceration and peripheral neuritis III or IV. The prognosis depends more on the histological
occur if the drug leaks from a vein. They will not be type, than on the clinical stage.
helped by delaying the drugs; they take far too long to
recover. Thrombophlebitis is also common. PROGNOSIS. 'Small cell', high, or intermediate grade
Change the veins used, and use a wide bore vessel. lymphomas are more likely to respond favourably.
'Large cell' tumours are likely to be unfavourable.
Peripheral neuritis, from vincristine and procarbazine, Nodular involvement promises a better prognosis than
presents as pain, weakness, loss of sensation, and hot diffuse involvement, which is, unfortunately most
palms and soles of the feet. These effects are usually commonly found in children.
reversible if the drug is stopped, but take time. In the next
course, use only ½ the dose. Or, if pain is a problem, Untreated, low grade cases survive 7-8yrs and
stop them at least temporarily. Stop them if there is any intermediate or high grade cases 2-3yrs, but of course this
objective muscle weakness on dorsiflexion of the foot. is much less if there is HIV disease also. All patients
Unfortunately, the response rate will then be much lower. with HIV will relapse after chemotherapy unless
anti-retroviral treatment is also used (5.8). This may then
Ileus from Vincristine. Delay the next dose until the become complicated because of drug interactions and
condition improves, and use ½ the dose on restarting. blood count toxicity.
Stomatitis and diarrhoea from procarbazine (unusual). INDICATIONS. Chemotherapy is the mainstay of
Use ½ the dose. treatment, and radiotherapy is no better.
Lethargy, hyperexcitability, and fits (uncommon) from Combination treatment: low grade follicular lymphoma,
procarbazine. Stop the drug. or lymphoma of intermediate or high grade type, large cell
or small cell.
N.B. The steroidal side-effects of prednisolone:
raised blood pressure, moon face, increased weight, Single-agent treatment: low grade lymphocytic
peptic ulceration, the unmasking of diabetes, etc. are lymphoma with masses of tumour tissue, anaemia, and
seldom sufficient to stop the drug, or to reduce the dose. leucopenia.
If there is a replapse, the possibilities are: No treatment: Asymptomatic low grade lymphocytic
(1) Radiotherapy. lymphoma, in stages 3 or 4.
(2) A second course of 'MOPP' with a response rate of
about 50%. PREPARATION. Establish a baseline (37.4).
(3) An alternative regime: adriamycin 25mg/m² IV day If necessary, transfuse blood before starting.
1&15, bleomycin 10 U/m² IV day 1&15, Vinblastine
6mg/m² IV day 1&15, dacarbazine 375mg/m² IV day ‘CHOP’: A WELL ESTABLISHED REGIME FOR
1&15 monthly for 6 courses. NON-HODGKIN’S LYMPHOMA
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17.7 Salivary gland tumours If there is any sign of a facial palsy, the facial nerve is
involved, and the tumour is malignant. Unfortunately,
the absence of a facial palsy does not mean that the tumour
About 85% of salivary gland tumours occur in the parotid is benign. Even then many salivary tumours extend outside
gland (17-3A,B), 10% in the submandibular gland, their ‘capsule’ and need excision with a wide margin.
and 5% in the mucous secreting glands inside the mouth,
especially on the palate (31-16C). Similar tumours DIFFERENTIAL DIAGNOSIS includes:
occasionally arise from the lacrimal gland (28.10, 11). (1) Lymphadenopathy (17.1), especially tuberculosis and
actinomycosis
Malignant tumours need radical excision, but this is only (2) Non-salivary tumours (neuroma, lipoma,
really justified for advanced, but mobile tumours of the lymphangioma) and mandibular or dental tumours.
parotid. Even after this, some recur locally. (3) Chronic sialadenitis or sialectasia.
(4) Masseteric hypertrophy or tumour.
Malignant submandibular tumours may need a block (5) Mastoiditis.
dissection of the neck for any hope of cure. However, CAUTION! Do not biopsy the growth. This may spread a
spread to the lymphatics and bloodstream is usually late. benign pleomorphic adenoma locally, and you may
damage the facial nerve.
There are several histological varieties.
The relatively benign ones are: MANAGEMENT.
(1) pleomorphic adenomas, In a parotid tumour, facial palsy is the critical sign because
(2) monomorphic adenomas, it means the prognosis is poor, even after radical surgery
(3) adenolymphomas (usually cystic). and radiotherapy.
The more malignant ones are:
(4) adenocarcinoma (including cylindroma), If there is no facial palsy, excise the tumour completely,
(5) muco-epidermoid carcinoma, and do not merely shell it out. This makes sure that the
(6) pleomorphic adenocarcinoma, and commonest lesion (a pleomorphic adenoma) is completely
(7) squamous cell carcinoma. removed, and will not recur. The patient needs a
(8) lymphoma (17.6) can occur within the salivary gland. conservative parotidectomy, in which the 5 branches of the
facial nerve are dissected out, and the part of the gland
containing the growth is removed; either its superficial
part, its deep part, or both. This operation is difficult but
important, because correct surgery will cure a pleomorphic
adenoma, if it is early.
For a submandibular tumour, complete excision of the
gland is not so difficult.
SUBMANDIBULAR SIALADENECTOMY
(GRADE 2.5)
POSITION
Position the patient with the head tilted up and turned
away from you, stabilized on a head ring.
INCISION
Cut 5cm below the border of the mandible, parallel to it so
Fig. 17-3 SALIVARY GLAND TUMOURS. that it extends 2cm either side of the gland, through
A, inoperable adenoid cystic carcinoma of the left parotid, with platysma down to the gland (17-4A). If the tumour is here,
extensive ulceration and metastases in the patient’s cervical nodes. do not dissect right onto it, but at a little distance from its
B, large pleomorphic adenoma, which has grown slowly over 20 yrs.
After Adekeye EO, Robertson JM. Salivary gland tumours in Northern edge. Free the superficial part of the gland by dividing the
Nigeria. Tropical Doctor 1979;9(4):168-74 with kind permission.. facial artery and vein above and below it.
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Fig 17-4 SUBMANDIBULAR SIALADENECTOMY. You can sacrifice parts of adjacent structures but take care
A, skin crease incision. B, divide the platysma and retract the not to injure the lingual nerve which is in contact with and
submandibular ramus upwards. C, lift up the gland to reveal the
lingual nerve underneath. D, the view with the submandibular gland behind the deep part of the gland, (17-4C). It runs along
excised. After Greenfield LJ et al, Surgery, Scientific Principles & hyoglossus, and crosses the much thicker submandibular
Practice, Lippincott-Rowen, 2nd ed. 1997 p.648. duct posteriorly. You may have to cut some branches of
the lingual nerve, but try to preserve the main part of the
Make sure your haemostasis is perfect. Get your assistant nerve, especially when you find a stone in the duct here.
to retract the superficial tissues (and with it the mandibular Then lift out the whole gland en bloc and make sure there
branch of the facial nerve unless this is involved by is good haemostasis once you return the patient’s head to
tumour) and so completely free the superficial part of the the level.
gland.
Close the wound with interrupted non-absorbable sutures
Then, get your assistant to retract the border of the around a Penrose drain.
mylohyoid medially and pull on the gland laterally
(17-4B), so you can free the deep part of the gland. Do not
hold the gland with clamps: you may cause spillage of
cells which produce a recurrence.
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17.8 Block dissection of the inguinal lymph (2).Malignant melanoma; block dissection is often only
nodes (GRADE 3.2) palliative, but is not always so. The nodes may be large
and ulcerate.
Block dissection of the nodes of the neck or axilla (24.5) Do not wait for this to happen before you operate, because
is necessary in certain cases of contained malignancy, then the nodes may be impossible to remove.
but these are difficult operations. However, the situation in The prognosis is much worse than with squamous
the groin is different. carcinoma, because there may already be secondary
deposits elsewhere.
Squamous cell carcinomas of the skin of the leg, and the
penis, and melanoma metastasize to the nodes of the groin. If you need also to perform an amputation,
Removing these metastases in a block of tissue, containing e.g. below the knee for a squamous carcinoma,
the horizontal and vertical inguinal nodes, can be very perform both operations at the same time unless the
successful, because these carcinomas may be slow primary tumour is ulcerated and infected. If you are also
growing. going to amputate the penis, make the incisions in
continuity, and perform a bilateral dissection.
The femoral vein, artery, and nerves lie close to the nodes
that need to be removed, and may be displaced by them. METHOD.
Removing them without damaging these structures is a Cross-match 2 units of blood.
difficult, delicate, major operation. Afterwards, there is Position the patient supine with a sandbag under the
always a lymphatic discharge and so the wound can buttock of the affected side. Make a vertical or ‘lazy S’
readily become secondarily infected. Healing may be incision (17-5A, B): this allows you to remove skin,
delayed, the flaps may necrose, and lymphoedema may and produces the least skin necrosis, but finding your way
develop in the legs (5-10%). may be more difficult.
If you have to remove the inguinal nodes yourself, study If some skin is involved by tumour, keep away from the
the anatomy thoroughly before you start, and dissect diseased area, and cut an ellipse round it, so that you can
carefully. Blood loss is usually not great, provided you do excise it with the lesion.
not damage major vessels!
Make the central limb 8-10cm long, centred just distal to
The idea is to remove all the nodes en bloc, preferably the mid-inguinal point, where you can feel the femoral
without even seeing the nodes themselves; an adequate pulse. Reflect the superior flap with about 0·5cm of
tumour clearance is essential for successful oncological subcutaneous fat, and undermine it c.5cm above your
surgery. incision and expose a triangular block of tissue laterally,
medially, and distally. Make its apex at least 4cm distal to
Do not try to remove nodes prophylactically, in the hope any palpable node. Use a knife or scissors to dissect
of removing metastases which you cannot feel. It will not upwards under it, until it is about 5cm wide.
improve the prognosis, and may be complicated by
lymphoedema (34.12). Only perform a block dissection At the upper extremity of the flap divide the subcutaneous
therapeutically, when the lymph nodes are palpably tissues covering the abdominal muscles in the depth of the
enlarged by secondary growth. If infection is likely to be wound. Reflect a block of subcutaneous tissue
the cause of the enlargement, confirm it by fine needle downwards (17-5C), until you reach the inguinal ligament.
aspiration (17.2) and wait for it to improve after the Do not cut the cord. Clamp, divide, and tie the vessels as
amputation, and review regularly. Perform a block you go.
dissection if the nodes start enlarging. Make the decision
to operate clinically, and do not let a cytology (or biopsy) Divide the fascia lata over the lateral edge of sartorius and
report adversely influence you; a malignant deposit in a free its attachment. Try to save the lateral cutaneous nerve
node may have been missed, or it may only be in other of the thigh going through it.
nodes, which weren’t biopsied.
Cut through the subcutaneous tissues at the edges of the
INDICATIONS. triangular mass, down to the deep fascia or muscle
(1).Clinical involvement of the inguinal nodes, with (17-5D). As you do so, find and clamp the saphenous vein
secondary deposits from squamous cell carcinoma of the at the lower end of your dissection. Tie it with 0 silk.
penis, or leg. If a patient's nodes have not ulcerated, Its surface marking is a line from just medial to the mid-
removing them may provide a cure. If they have ulcerated, inguinal point to the medial aspect of the medial condyle
you may be unable to remove the mass of ulcerated tissue of the femur.
completely. The determining factor is whether or not they
have stuck to deeper structures, especially the femoral
vessels.
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CAUTION!
(1).Pulling on the block of tissue may pull up the femoral
vessels, so you may think that the femoral vein is the
saphenous vein. Do not clamp, divide, or damage the
femoral vein, which may become flat and empty as you
pull on the tissues.
(2).Try not to damage the profunda femoris or circumflex
vessels (medial and lateral), which pass deep to the
muscles of the thigh.
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There may be several consequences: Common sites of abdominal wall hernia are: inguinal
(1);Irreducibility. Coughing or straining may push (18.2), femoral (18.7), umbilical (18.10), para-umbilical
omentum, or a loop of bowel, through the neck of the sac, (18.11), and epigastric (18.12). Rarer sites are lumbar,
after which oedema may prevent spontaneous reduction. Spigelian (lateral ventral, through a defect in the
This is more likely the smaller the hernia defect. transversus aponeurosis and internal oblique muscles),
Sometimes, you may find the hernia reduces obturator, perineal or gluteal. Any abdominal wall incision
spontaneously with sedation. Occasionally you may be can result in an incisional hernia, but the commonest is the
able to effect reduction manually (taxis, 18.6). lower midline abdominal incision.
This is dangerous if you use force.
There are some rarer, but important, types of inguinal
(2) Obstruction. A hernia is one of the commonest causes hernia:
of intestinal obstruction (12.2, 12.3). Again this is more
likely the smaller the hernia orifice is. Bowel outside the If only part of the wall of the bowel is involved, this is a
hernia can rarely also twist and obstruct (12.8, 12.9) Richter's hernia (18-2B). This is particularly dangerous
because:
(3);Strangulation. Blood may be able to enter but not (1) the bowel may strangulate without being obstructed,
leave the organs in a hernia, so that they swell. so vomiting may be absent and bowel action normal.
This is more likely to happen in a hernia with a narrow Instead, there may be diarrhoea until finally peritonitis
neck, i.e. femoral, or inguinal. If the swelling persists for develops.
>6hrs, the arterial blood supply is cut off and the organs in (2) the local signs of strangulation may not be obvious.
a hernial sac become ischaemic (strangulated, 18-2A).
If the peritoneal lining of the hernial sac is incomplete,
If this happens to the omentum or Fallopian tube, the risk and an abdominal organ (laterally, the caecum on the right,
is small. But if the bowel becomes gangrenous, peritonitis and sigmoid colon on the left, or the bladder medially),
and septicaemia at worst, or a fistula and cellulitis at best, forms part of its wall, this is a sliding hernia (18-2C,D).
will follow. If more than a little of the bowel strangulates,
it cannot propel its contents onwards normally, If two loops of bowel herniate, the central segment
so it obstructs. Most strangulated bowel is therefore between the 2 loops within the abdomen may strangulate.
obstructed also (18.6). Important exceptions are Richter's, This is a Maydl (or W-shaped) hernia.
(18-2B), Littré’s (18.3), Amyand’s, and de Garengeot’s
(18.7) hernias. If the caecum and terminal ileum herniate, because the
caecum is more mobile than normal, a loop of ileum may
N.B. Incarceration. This is an imprecise term. When a prolapse through a hiatus below the lateral paracolic
hernia strangulates, it suddenly becomes painful, tense, peritoneum thereby created. This causes strangulation
and tender, and loses its cough impulse. Even so, you will of the proximal bowel inside the abdomen.
often find it difficult to know if a hernia is merely This is Philip’s hernia.
irreducible and obstructed, or whether it is strangulated,
because pain and constipation are present in both.
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Apply the principles of hernia repair: (1).The sac may have no obvious neck (unless it is a
(1) define the sac, separating it from adjacent tissues, Busoga hernia, where there is a narrow defect), so that you
(2) open the sac (herniotomy), do not excise it; instead, you tuck it in (18-10).
(3).examine the sac contents and deal with them as (2).The weak area in a direct hernia is ill-defined,
appropriate, and tends to involve all or most of the posterior wall of the
(4) excise the sac, or close it, inguinal canal. Here a mesh is most useful:
(5) reduce the hernia, you can sterilize mosquito netting to give a perfectly
(6).repair the defect (herniorrhaphy), restoring the acceptable alternative. You can strengthen this by suturing
anatomy as best as possible. the external oblique aponeurosis behind the cord;
N.B. This part is not necessary in children (18.5). something you should never do with an indirect hernia.
You can perform the herniorrhaphy in several ways but we (3).A patient with a direct hernia is likely to be older with
recommend making a darn closing the gap between the poor tissues, and perhaps prostatism, a urethral stricture,
conjoint tendon (which is formed by the fibres of the dyspnoea, a cough, or constipation, all of which will stress
internal oblique and transversus) and the inguinal the hernia repair.
ligament behind the cord. (4).The bladder may enter the hernia, and is easily injured.
This is a tension-free modification of the Bassini repair. (5).A direct hernia is twice as likely to recur as an indirect
Having done this, you then suture the external oblique one, especially if it is a sliding hernia.
aponeurosis in front of the cord. This is an alternative to
what is now the standard in the developed world, The common mistakes are:
the Lichtenstein repair, where a mesh is sewn in to (1).To forget to examine the hernial sites of anyone with
strengthen the defect. The other ‘definitive’ operation, an abdominal pain or vomiting, especially if the hernia lies
the Shouldice repair, is difficult to do correctly and is not under an apron of fat.
recommended .The Lichtenstein method introduces a (2).To forget the possibility of a Richter's hernia (18-2),
foreign material which is very hard to remove if it which may confuse the diagnosis by causing diarrhoea
becomes infected. Fixing the mesh may cause a chronic instead of constipation.
neuroma, which is very painful. So you should be wary of (3).To persist in using taxis (18.6) when a hernia should be
using a mesh: use it only in special circumstances (18-13). operated on.
(4).To delay surgery, especially in children.
(5).To repair a hernia, especially a direct one, before
dealing with the cough, asthma, constipation or poor
urinary flow that have provoked it.
N.B. If you are experienced, and no suprapubic catheter
has been used, you may be able to carry out a
prostatectomy and hernia repair at the same operation.
(6).Not to transfix the neck of the sac high enough, so as to
obliterate it completely; a simple ligature on its own may
slip off.
(7).To fail to make sure the groin is well cleaned pre-op.
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If there is a history of a inguinal swelling that comes Suggesting inguinal lymphadenopathy: the swelling is
and goes, make a determined effort to demonstrate the constant, and below the inguinal ligament.
hernia clinically. (Femoral lymphadenitis may appear like a strangulated
femoral hernia, but there will be no signs of obstruction).
If, however, it does not appear on standing, straining
(i.e. a Valsalva manoeuvre) or coughing, do not operate. Suggesting filariasis: a thickened oedematous spermatic
Review the situation later, and wait until you have actually cord, with no cough impulse (34.14).
seen or felt the hernia. It is worthwhile asking such
patients to come for review in 3-6 months. Suggesting torsion of the testis, epididymis, or both
(27.25): there is a tender scrotal swelling which you can
get above.
BILATERAL ADENOLYMPHOCOELES
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CAUTION!
Do not try blunt dissection near the ring where landmarks
are hard to distinguish, especially if there is much
extraperitoneal fat.
Fig. 18-7 SIMPLE HERNIOTOMY. If the sac descends into the scrotum, open the sac and
A, site of the incision. B, incise the skin and expose the external make sure your finger enters the peritoneal cavity easily
oblique aponeurosis. C, open the external oblique aponeurosis, from
the external ring laterally, to expose the internal oblique with the
through it. Then holding the proximal part of the sac,
ilio-hypogastric and ilio-inguinal nerves. D, open the spermatic cord divide it (but not the cord!) and drop the distal part of the
to search for the sac. E, free the sac. F, open the hernia sac. G, tie the sac back into the scrotum. (Leaving it open prevents
sac off and remove the excess. (If a repair is needed, it would be done formation of a hydrocele.) Finally continue to dissect out
at this point). H, close the external oblique aponeurosis. I, operation
complete.
the proximal part.
After Maingot R, Abdominal Operations, HK Lewis 4th ed 1961 p.874,
876, Figs 1,3 with kind permission.
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Dissect the sac free from connective tissue right down to If one side of the neck is thick, there may be bladder or
its neck. You may see the inferior epigastric vessels bowel in its wall. This is more likely in a sliding hernia,
running medial to its neck. Avoid them. If necessary, tie or either direct or indirect.
diathermy any small branches. You will know that you
have dissected as far as you should when you find: D. CLOSE THE SAC.
(1) the deep epigastric artery and veins on its medial side. Twist its neck until the turns reach the internal ring
(2) the constriction that forms its neck. (18-7G). If there is any bowel or omentum in the sac,
(3) a collar of extraperitoneal fat around it. this will force it back into the peritoneal cavity. Transfix
(4) its wider junction with the peritoneal cavity, visible the neck as far proximally as you can with absorbable
when you pull it up. suture and encircle the neck of the sac, tying it with a triple
throw. Leave the ends of the knot long, and hold them with
haemostats.
TWO DETAILS OF HERNIA REPAIR
Fig. 18-8 TWO DETAILS OF HERNIA REPAIR. If the neck of the sac is wide, place haemostats round it
A, narrowing the internal ring. In an adult a normal internal ring
from outside, divide it distally, and close it with a
just admits the tip of your little finger. If it is larger than this, narrow
it. Start medially and work laterally. B, bladder occasionally bulges continuous suture, as if you were closing the peritoneum
forwards extraperitoneally on the inner side of a direct hernia, and of an abdominal wound.
you can easily injure it. Divide the stump 1cm distal to the ligature. Examine it.
After Rob C, Smith R. Operative Surgery. Butterworth 2nd ed 1969 Vol 4
When you are sure that the ligature is not going to slip, or
Part 1 p.223 Fig 8, p.229 Fig 25 with kind permission.
ooze, cut its threads. If it is loose, apply another ligature or
C. OPEN THE SAC. a continuous suture. When you release the stump, it will
Open its fundus (if you have not already done so) between quickly disappear from view under the arched fibres of the
haemostats, as if you were opening the peritoneal cavity. internal oblique.
The sac has a moist shiny inside surface. Examine the neck
of the sac (18-7F) and look through it into the peritoneal CAUTION!
cavity to make sure the sac is empty, and no bowel or (1).Do not tie the sac distal to the internal ring as the
omentum remains inside. Make sure no adhesions remain hernia is more likely to recur.
of omentum onto the sac. (2) Do not include the vas in your ligature.
(3) Leave the distal end open, if you need to divide the sac,
If the hernia is irreducible, beware: you can very easily or else a hydrocoele may result.
open bowel as you open the sac! (4).Avoid damaging small vessels; good haemostasis is
essential to prevent a haematoma.
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E. NARROW THE INTERNAL RING. Use the long ends of the ligature to anchor the stump to the
Feel the size of the internal ring. In an adult, a normal aponeurosis of the external ring above and lateral to the
internal ring should not admit your index finger. If it is internal ring.
wider than this, it is dilated. If it is only a little dilated,
narrowing it will be enough, as it is in children. Obliterate the now empty inguinal canal with a few sutures
If the internal ring is only moderately dilated, suture it joining the conjoint tendon and the transversalis fascia to
with monofilament nylon, starting medially, and suturing the inguinal ligament. This is the so-called standard
laterally, until the ring fits snugly around the cord but does Bassini repair; it is satisfactory only if there is no tension
not strangle it (18-8). Tie the inner and outer ends of the on the suture line. Close the internal inguinal ring
suture together to prevent the inner end of the suture line completely.
pouching forwards. There is nothing to strangulate. If the muscles are weak,
draw the upper edge of the external oblique aponeurosis
CAUTION! toward the inguinal ligament with a darn: this is a
(1).Do not leave the internal ring too wide, modified Halsted repair.
or the hernia will be likely to recur.
(2).Do not constrict the internal ring too much, F. REPAIR. Our recommended technique for the male is
or the testis may atrophy. the Moloney nylon darn repair (18-9), which has been
shown to be equivalent in strength and durability to the
With experience you may narrow the internal ring as part Lichtenstein mesh repair.
of your repair, as described below.
After you have completed the herniotomy, release the
In a female, an inguinal hernia is probably caused by a straight haemostat that you originally inserted on the lower
congenital sac which is firmly stuck to the round ligament. flap of the external oblique, and replace it with the
This is narrower and less vascular than the spermatic cord. self-retaining retractor so that the cord lies behind the
The inguinal canal is smaller and you will hardly see aponeurosis while you repair the posterior wall of the
anything to represent the cremaster. The hernial sac can inguinal canal. This will keep the cord out of the way
extend only to the labia majora. Proceed as above, while you proceed with the repair. Alternatively, hold the
dissecting the sac from the round ligament. Use sharp cord with gentle traction using slings (18-9) or Babcock
dissection to free this, the sac and the vessels from the forceps, or within Lane’s forceps.
labium, or blunt dissection if the
tissues are very loose.
Clamp, tie, and divide the round
ligament close to its insertion.
Then clean it and the sac as far as
the internal ring. Open the sac,
inspect its inside, and then probe
it to make sure it is empty.
Grasp the sac, the round ligament
and their vessels.
Transfix, and tie them, leaving the
ends of the ligature long.
Then divide these tissues 1cm
beyond the ligature.
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Clean away all the areolar tissue from the upper surface of It may help to bring the layers of the external oblique
the inguinal ligament. Retract the fleshy arching internal aponeurosis together behind the cord (an anterior
oblique muscle upwards, and expose the aponeurotic part transposition of the cord), to strengthen the
of the transversus and internal oblique muscles which inguinal region. This is a modified Halsted repair.
form the conjoint tendon. Use this tendinous layer for If it is convenient, overlap the flaps, suture the upper one
reconstruction, not the overlying muscle layer, unless the to the inguinal ligament, and bring the lower one on top of
aponeurosis is poorly developed. it so as to overlap it about 2cm.
CAUTION! Make quite sure that the unusual double
Use 1/0 monofilament, or steel, on a round-bodied (Saddle or Pantaloon) hernia, a COMBINATION OF A
half-circle needle (avoid a cutting needle as this is one of DIRECT AND INDIRECT HERNIA (18-12), is not
the most hazardous operations in terms of pricking present. A few minutes looking for an indirect sac is time
yourself!), to apply a continuous figure-of-8 loop (herring- well spent!
bone) suture 8mm apart from the arching fibres of the
conjoint tendon above, to the inner shelving margin of the BUSOGA (GILL-OGILVIE) DIRECT HERNIA
inguinal ligament below (18-9). Do not pull these This is an unusual, but important, variety of direct hernia,
structures tight: think of the darn as a patch to repair the peculiarly found quite frequently in certain areas of
defect. Put a narrow retractor at the medial end of the Uganda (and elsewhere), predominantly in women.
wound, and take the first bite through the periosteum over Its importance is that it is a type of direct hernia where the
the pubic tubercle and leave this end long. Proceed from bowel may strangulate, like a Richter’s hernia (18-2B,
the medial side laterally taking substantial (6-8mm) bites 18-11).
of the aponeurosis.
CAUTION!
(1).Beware of the femoral artery and vein, which lie just
behind the inguinal ligament under the mid-inguinal point.
Injuring the femoral vessels is the most serious potential
complication of hernia surgery.
(2).Do not strangulate the cord with your most lateral
suture. Make sure you can still insert the tip of your
forceps through the internal ring, alongside the emerging
cord.
(3).Use non-absorbable sutures only. Do not use silk;
if it becomes infected, it will cause sinuses, and you will Fig. 18-10 BUSOGA (Gill-Ogilvie) HERNIA: Anatomical Features.
later have to pick out every piece. A, release a strangulated Busoga hernia. As soon as the sac is opened,
grasp a loop of trapped bowel gently with Babcock forceps.
As you do so, gently but firmly stretch the neck of the sac with the tip
ORDINARY DIRECT HERNIAS. of your little finger. B, sometimes you have to make a small cut in the
fibrous edge of the ring. You can release a femoral hernia in much
In a direct hernia, the posterior wall of the inguinal canal the same way. Kindly contributed by Brian Hancock.
is weak and flabby and provides little resistance to your
fingers as you press. There is usually an obvious bulge You will see a tight bulge of bowel coming through the
medial to the epigastric vessels. The cord almost always conjoint tendon medially (18-11) or transversalis fascia
lies anterior to it. (18-12B). Hold the bulging bowel lightly with Babcock
If its medial wall feels thick and fleshy, suspect that there forceps to prevent it slipping back (18-10A). Cut the edge
is bladder in it and there is a sliding hernia present. of the tight ring in the conjoint tendon with a half-open
There is almost never a danger of strangulation, in contrast scissors cautiously (18-10B).
to the Busoga hernia. Dilate it with your finger alongside the sac. Open the sac.
Withdraw the bowel and assess it by the criteria of
Do not try to open, tie, or excise the sac of a direct hernia, viability (11-6).
unless it is of the funicular type. Push it inwards with a
sponge dissector, and while you keep it pushed in,
make a darn as before.
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If the sac tears at its neck, so that there is no longer If the ovary & Fallopian tube appear in the sac (rare),
anything to twist and tie off, try to free the peritoneum untwist them. If they are viable, return them.
from the abdomen to close the defect that exists. If they are gangrenous, tie their pedicle and excise them.
If you don’t do this, a recurrent hernia is inevitable.
POSTOPERATIVE DIFFICULTIES WITH INGUINAL
If the sac is large and reaches the scrotum, HERNIAS
dissecting it out distally will be difficult. Dissect it out
proximally as usual, and clamp and transfix its proximal If a haematoma forms, you probably failed to tie the
end. Divide it and leave its distal end open. If you close its superficial vessels adequately, or used blunt dissection
distal end, a hydrocoele may form. You may occasionally forcefully. Next time, prevent this by delicate technique
have to divide the cord (18.4) in an elderly man to obtain a and carefully controlling bleeding at every stage.
secure repair. If the defect is very large, use a mesh to Release blood from the haematoma by removing skin
repair it as above. sutures, and ease the wound open with sinus forceps.
If you have mistakenly passed your needle through a If the scrotum swells (common), you can reassure the
major vessel, continue and tie it tight. If bleeding patient that the swelling will probably only be transient,
continues and you think you have gone through the provided you have not tied off the lower end of the sac of
FEMORAL VEIN, remove the needle and press the an inguinoscrotal hernia. Swelling often follows the repair
bleeding area for 5mins until the puncture seals itself. of such a hernia, and may be due to venous obstruction.
If it does not, you have a major problem.
Open the inguinal area about 2cm distal to the inguinal If the testicle swells (not uncommon after a difficult
ligament and try to clamp the vein on both sides of the hernia repair), this is usually due to thrombosis of the
hole. If bleeding is controlled, try to close the hole with spermatic veins. This usually settles and leaves a normal
fine 4/0 or 5/0 monofilament set 1mm apart; otherwise use testis. Alternatively, it arises from infection relayed
an aneurysm needle to encircle it with '0' silk, and tie it off. through the vas or blood stream. It is then worth using an
The leg will be oedematous postoperatively, but this is antibiotic.
usually only temporary. Do not tie the saphenous or
profunda femoris veins, because these will not control If the testis atrophies, you have probably interrupted the
bleeding from the femoral vein. circulation in the spermatic artery by handling it roughly,
or strangulated it with sutures at the internal ring.
If you think that you have injured the bladder, You will not be able to revive the testis, so remember the
repair its mucosa, and its muscle with absorbable suture. problem when operating the next time.
Tuck it back and continue with the repair. Drain the wound
and leave in an indwelling catheter for 2wks. If urinary retention develops, insert a urinary catheter;
remove the catheter when the patient is eating, walking,
If you find an inflamed appendix in the hernial sac and pain free.
(Amyand’s hernia), excise the appendix (14.1).
Close the wound by delayed primary closure (11.8), If deep infection in the inguinal canal persists,
because of the high risk of infection, and use prophylactic it may not resolve until the non-absorbable suture is
antibiotics as usual. removed: swallow your pride, reopen the wound and take
out the darn, trying not to disrupt the natural fibrosis
If the hernial sac contains pus or blood, around it, and leave the wound open to granulate.
which has drained from the peritoneal cavity, perform a
laparotomy (11.2). If you have used a mesh and infection persists,
you may have to remove this to allow the infection to
If a piece of bowel has a white ring on it, settle. This will prove to be a messy and difficult
a (Garré) stricture may develop later at the site of the ring operation, so have some blood ready and take your time.
if you return it to the abdomen. So, if you can, resect this The result will be a severe weakness in the inguinal area,
segment of bowel. which will need another mesh to repair it much later!
If a loop of bowel escapes into the peritoneal cavity, If a faecal fistula results, you have injured the bowel.
and you are not sure if it is viable or not, make a midline This is a serious problem but if there is no obstruction,
incision and examine it. This will be much safer than wait; it will probably close (11.15). Otherwise open the
leaving it. abdomen (11.2).
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At birth the inguinal canal is short, and if the hernia is MANIPULATION FOR CHILD INGUINAL HERNIAS
large, the external ring may lie directly over the internal
ring, which is convenient, because it allows you to dissect If a child's hernia is irreducible, sedate him, and put him
out the sac, without opening the external oblique into gallows (overhead skin) traction if he is <3yrs.
aponeurosis. In young children, simply open the sac There is a 50% chance that it will reduce spontaneously,
(herniotomy), and tie it off. Herniorrhaphy is not needed. or with a little gentle manipulation. Do not induce pain,
or use any force! If this succeeds,
operate as soon as it is convenient.
If it fails, operate without delay.
INCISION.
Make a 3cm incision in the skin crease
above the inguinal ligament, more
medially and superiorly than you would
for an adult. Cut through the
subcutaneous tissues, and pick up and tie
the small superficial epigastric and
external pudendal vessels with
haemostats. Separate fat and superficial
tissues by the ‘push and spread’
technique (4-8). Do not split the external
oblique aponeurosis: this is unnecessary.
Fig. 18-15 ABNORMALITIES OF THE PROCESSUS VAGINALIS.
A, when it remains completely open, a complete inguinal hernia To find the hernial sac, which should be anterior to the
forms. B, if it closes distally, and leaves the tunica vaginalis covering cord, push with your little finger in the scrotum through
the testis, an incomplete inguinal hernia forms. C, when the processus the external ring. Gently separate tissues off the cord
vaginalis becomes narrow, but does not disappear, fluid passes down which appears as a distinctly blue structure and thereby
it from the peritoneal cavity and forms a hydrocoele around the
testis. D, if there is a wider area in the course of the processus free it. You should then be able to get behind it with a
vaginalis, it may form a hydrocoele of the cord. Operate on a finger and so hold it between the thumb and index finger
congenital hernia and on a congenital hydrocele: tie and divide the of your left hand. Dissect the sac very carefully away with
processus vaginalis. After McNeill Love WJ. Bailey & Love’s Principles gauze or scissors from the spermatic vessels and vas,
& Practice of Surgery, HK Lewis 15th ed 1975.
which is a thin white strand. Beware: it is all too easily
Wait to operate until a baby is 6 or preferably 9 months damaged because it is so fine!
old, when anaesthesia and surgery will be easier.
Never apply a truss. Free the sac to the internal ring taking care not to tear it.
The operation involves dissecting out the sac carefully Unless it is obviously empty, or just has hydrocoele fluid
(making sure that you do not damage the spermatic vessels in it, open it between haemostats, as if you were opening
or the vas), transfixing its neck at the external ring, and the peritoneum for an abdominal operation, and reduce the
excising it. contents unless they need resection.
There is no need to open the inguinal canal of a young CAUTION!
child. You may occasionally need to narrow the internal (1).Free the sac completely before you open it. In this way
ring of an older child. you are less likely to split it.
(2).A girl's Fallopian tube and ovary may slide into the
You may find a sliding hernia of the bladder or colon, sac: do not remove them as part of it.
or of a girl's adnexae. Hernias are often bilateral in (3).If you find the appendix in the sac, do not remove it.
children: examine the other side carefully therefore to (4).A boy's vas is very small, do not mistake it for a piece
avoid the child having to return later for another operation. of fibrous tissue.
Always also look for maldescended or absent testes
(27.27). Otherwise, divide the sac and transfix its neck with 3/0
absorbable suture, and tie it off.
CAUTION! If you find bilateral inguinal hernias in
girls, look for signs of ambiguous genitalia or intersex
state.
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OPERATION FOR IRREDUCIBLE OR STRANGULATED If viable bowel or omentum is present, replace them into
INGUINAL HERNIAS the abdomen by gently manipulating the bowel through the
widened neck of the hernia. Be patient and manipulate
PREPARATION. small segments at a time. Make sure the patient is well
Use peri-operative gentamicin and metronidazole. relaxed.
Get consent for a laparotomy and possible bowel resection.
Prepare all the skin of the abdomen and genitalia. If bowel is non-viable, or dubiously viable, resect it.
Insert a nasogastric tube to drain the stomach well. Gently pull out adequate lengths of bowel on either side of
Use analgesic sedation and GA. the gangrenous portion. If this is difficult, widen the neck
of the sac further; if there is still not enough length,
BISTOURY, guarded. This is a curved probe with a cutting edge on its perform a laparotomy via a midline incision. When the
concave surface near the tip (18-18B). It is the safest instrument for
enlarging a constricting hernia ring. bowel anastomosis is complete, return it into the abdomen
with extreme care, so as not to disrupt the anastomosis.
INCISION. Proceed as before (18.2) to open the inguinal
canal. If omentum is strangulated, pass long haemostats across
A. OPEN THE SAC. the healthy part, cut off the gangrenous part distal to them,
You will see a tense mass emerging from the internal ring transfix the healthy omentum with a needle, and then tie it
and passing towards the scrotum. If oedema and off. You may need more than one haemostat and
congestion make identifying the overlying structures transfixion suture.
difficult, use blunt-tipped scissors and the 'push and spread CAUTION! Be sure to control all bleeding before you
technique' (4-9B) to incise the first 2 layers: the external return anything to the peritoneal cavity.
spermatic fascia and the cremaster muscle. If they dissect
off easily, good, if they do not, leave them, except for a C. CLOSE THE SAC as before (18.2).
small area near the fundus. Incise this between a pair of D. NARROW THE INTERNAL RING, because you have
fine haemostats, just as you would if you were opening the deliberately widened it!
peritoneum for a laparotomy. E..REPAIR the defect with a darn unless there has been
gross sepsis, in which case it might be best to advise a
CAUTION! Surround the operation site with large formal repair later.
swabs to prevent the soiling of the wound by the septic F..DO NOT CLOSE THE WOUND if there has been gross
contents of the hernial sac, which is likely to contain sepsis: leave it open and use delayed primary closure
virulent aerobic and anaerobic organisms. (11.8). If there was obvious perforation, drain the canal
Pick up layer by layer in forceps, and carefully incise each through the scrotum.
layer till you reach the peritoneum when fluid will run out,
and you will see bowel or omentum. Apply several DIFFICULTIES WITH IRREDUCIBLE OR
haemostats to the peritoneal margins to prevent them STRANGULATED INGUINAL HERNIAS
retracting into the abdomen. Attach a Babcock forceps to
the bowel or omentum to prevent them slipping inside the If presentation is very late with oedema, cellulitis or
abdomen. abscess formation on the abdominal wall or scrotum,
overlying the gangrenous contents of a strangulated
B. RELEASE THE CONSTRICTION RING. inguinal hernia, a faecal fistula is about to form. Expect
Feel for the constriction with your finger. If you can insert this beyond the 4th day of strangulation. It can form:
an instrument through it and nick its lateral margin, do so. (1);in the inguinal region, where the prognosis is better,
If not, retract its upper edge with a retractor, and cut down especially if the hernia is of the Richter type (18-2B) and
on it from outside. Alternatively, push your little finger the bowel obstruction is incomplete.
into the ring. While your assistant holds the contents of the (2);in the scrotum, where the prognosis is worse.
sac out of the way, push a large haemostat into the ring In this situation, start IV gentamicin and metronidazole,
lateral to the neck and spread it open. Divide the lateral and infuse 2l IV Ringer’s lactate. Start nasogastric suction.
side of the ring with scissors or a bistoury (18-18).
Open the groin, and identify the strangulated loop of
Gently deliver the contents of the sac. If it extends to the bowel; doubly ligate both ends tightly with 2 silk as close
scrotum, it may be easier to deliver the testis also. as you can to the hernia neck. Pack off the area of the
The bowel or omentum may be blue, purple, or black. internal inguinal ring, remove the gangrenous bowel
between the ligatures.
CAUTION!
(1) Do not damage the spermatic cord as you open the sac. Curette the fistula track, taking care not to damage any
(2);Do not incise the medial side of the internal ring, or local structures. Wash the groin wound thoroughly and
you may cut the inferior epigastric artery. Do not cut the leave it open applying betadine dressings bd. Exteriorize
bowel! the bowel ends as ileostomies. Do not attempt any hernia
Examine the contents of the hernia. If the bowel has been repair at this stage.
trapped, withdraw a few centimetres of the afferent and Continue resuscitation till you are sure the patient is
efferent loops. Assess its viability (11-6). passing good volumes of urine, and then plan bowel
anastomosis as below.
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352
If you find a gangrenous testis on opening the sac Fig. 18-16 REPAIRING A FEMORAL HERNIA.
(especially in children), perform an orchidectomy (27.26) A, expose the external inguinal ring. B, retract the lower flap and
and make sure the other testis is present in the scrotum. mobilize the sac. C, suture the inguinal ligament to the pectineal
If not, perform an orchidopexy (27.27) on that side. (Cooper's) ligament.
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DIFFERENTIAL DIAGNOSIS
Suggesting enlarged lymph nodes: look for a
septic focus on the leg, the lower abdomen, or the
buttock or evidence of tuberculosis elsewhere.
An enlarged deep inguinal lymph node may be
almost impossible to distinguish from a femoral
hernia, except for signs of intestinal obstruction.
Suggesting a varix of the long saphenous vein:
a soft, easily compressible swelling (unless it is
thrombosed), which fills up again when you release
the pressure.
Suggesting a psoas abscess: a much larger
fluctuant swelling associated with spinal TB or
HIV disease
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A strangulated femoral hernia is more often misdiagnosed RELEASE THE STRANGULATION by holding the
than a strangulated inguinal hernia: bowel in a swab between the finger and thumb of one
(1).It may be small, and lost in the thick fat of the groin. hand. Meanwhile, try to widen the femoral canal by
(2).Only the circumference of the bowel may be caught inserting the very tip of your finger into the hernia, just
(Richter's hernia), so that you can hardly feel anything in outside the sac itself. With your finger inside the femoral
the thigh. canal, move it around the neck of the sac and try to free it.
(3);When it is large, it may have a rounded fundus and a
narrow neck, which allows the fundal part to move CAUTION! Do not let go of the bowel at this point,
painlessly, so you may think there is no strangulation. because if you lose it, you have to perform a laparotomy to
retrieve it.
This makes it very important to explore any doubtful lump Now draw the bowel down out of the sac a bit more.
in the femoral region, when a patient has abdominal If it does not quite come, repeat the dilating manoeuvre,
symptoms and especially intestinal obstruction, especially but this time with your finger inside the sac, between it
if femoral hernias are not uncommon in your area. and the bowel.
IF THERE ARE ABDOMINAL SYMPTOMS, If you still cannot deliver the bowel into the wound,
EXPLORE ANY TENDER FEMORAL LUMP clear the neck of fatty tissue. Enlarge the ring on its medial
side by dividing the lacunar ligament, and the fibrous
There are 2 approaches to a strangulated femoral hernia, tissue in front of the ring.
with some debate as to which is best: Protect the contents of the sac while you divide the
(1).the standard approach, which requires two incisions, ligament by passing a grooved director up the medial side
one over the hernia and another in the lower abdomen, and of its neck. Then carefully cut down on the director with
(2).the Lotheissen approach through a single incision in the one or two nicks of a scalpel. Watch out for an abnormal
posterior wall of the inguinal canal: this is more difficult. obturator artery.
In the standard approach, cut down just above the patient's With the bowel drawn down into the sac, wrap it in a
inguinal ligament and aim to: warm wet swab, to see if it is viable (11-7).
(a) Expose and isolate the sac.
(b) Open and inspect its contents. If the bowel is viable, let it slip back into the abdominal
(c) If the bowel is not viable, open the abdomen through cavity, and repair the hernia from the groin (18.7).
a lower midline incision. Expose and if necessary enlarge
the femoral ring from above. If the bowel is not viable, perform a lower midline
(d) Amputate the bowel in between pairs of clamps. (or Pfannenstiel) incision, and resect and anastomose the
(e).Remove non-viable bowel from the hernia sac. bowel from inside by laparotomy (18.6).
(f) Excise the sac and leave the wound open.
If protruding omentum looks as if it might not be
OPERATION FOR STRANGULATED FEMORAL HERNIA viable, transfix it, tie it, and excise it.
(GRADE 3.3)
If an area of necrosis only involves part of the wall of
ANAESTHESIA. the bowel (Richter's hernia, 18-2B), bury it with
(1).Ketamine and LA: infiltrate the field widely. Inject invaginating seromuscular absorbable sutures. You need
more solution into the deeper tissues as you get to them. not resect it, provided it follows the criteria for safe
(2).Spinal or epidural anaesthesia if the patient is fairly fit. invagination (18.2).
(3).GA and tracheal intubation with relaxants.
If you are in any doubt about the viability of the bowel,
PREPARATION. (including a Richter's hernia), excise the damaged portion
Pass a catheter and empty the bladder. Make sure the and perform an end-to-end anastomosis (11-7).
patient is well-hydrated. Use perioperative IV gentamicin
and metronidazole. CAUTION!
(1).Always open the sac and inspect its contents before
INCISION (STANDARD APPROACH). you return them to the abdomen. They may be gangrenous.
Make a transverse incision in the skin crease over the If there is a Richter's hernia, be especially careful not to let
hernia itself. Divide the covering layers, including the it escape back into the abdomen.
deep fascia, and dissect them off the sac. Sweep your (2).Take great care not to contaminate the peritoneal
finger round the hernia to mobilize it, and define its neck. cavity.
Clean it by dissection with your finger, and a swab and
not-too-sharp-nosed scissors. REPAIR. If you have opened the abdomen, it may be
difficult and dangerous to reduce the hernia contents if
OPEN THE SAC by inserting retractors and packing off they are incarcerated (and especially if they are
the sac while you carefully cut down on it. Like an onion, strangulated). You might need to divide the bowel loops
it will have more layers than you expect. As soon as you inside, and then remove the remainder outside (18.6).
are inside it, there will be a warning spurt of turbid
blood-stained fluid. The bowel is often gangrenous.
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CAUTION! Take care to free the sac of surrounding 18.9.Hernia of the umbilicus &
tissues before you excise it, or you may pass sutures into a anterior abdominal wall
protrusion of the bladder or colon.
Close the femoral canal by passing three interrupted
monofilament sutures between the inguinal ligament and There are several hernias in this region, and you must not
the pectineal ligament (18-16C). Do not go too far confuse them:
laterally with these sutures, or you may constrict the (1).The common true umbilical hernias of children,
femoral vein. which rarely need surgery.
(2).The much rarer paraumbilical hernias of adults through
DIFFICULTIES WITH STRANGULATED FEMORAL HERNIAS or beside the umbilicus, which usually need surgery.
(see also 18.3,7) (3).Small and usually harmless epigastric hernias of the
linea alba between the xiphoid and the umbilicus,
If you cannot dilate up the femoral canal enough to which often do not need surgery, but which are easy to
mobilize the strangulated bowel, approach it from above repair.
via a laparotomy. Use blunt dissection to expose the neck (4).Hernias which follow incisions, particularly Caesarean
of the sac medial to the femoral vessels. sections, other laparotomies, appendicectomy or kidney
If this is not successful, cut the lacunar ligament, operations.
the medial boundary of the femoral ring under direct (5).Rare lumbar or Spigelian hernias, which are direct
vision. Be careful; you may meet an abnormal obturator hernias in the flank or 3-4cm above the inguinal ligament
artery (18-18A)! through the linea semilunaris (18-3).
If you still cannot dilate up the femoral canal enough,
divide the inguinal ligament: this is very rarely necessary. If there is a large midline bulge in the upper abdomen,
At the end of the operation, suture its free end against the which feels muscular, this is a wide separation
pectineal line, so as to obliterate the femoral canal. (divarication) of the recti muscles: you should not operate
The danger with this is that, if the wound becomes on this. Try to get the patient a corset for support.
infected, a hernia may form later which will be difficult to
repair. Whatever you do, remember that the femoral vein Remember that, both in adults as well as children,
lies on the lateral side of the femoral canal! an umbilical hernia will bulge with coughing or crying,
and other causes of abdominal distension. The hernia itself
If you find a strangulated femoral hernia expecting an is not the cause of the problem, and you should resist
inguinal hernia, proceed as in the Lotheissen approach: attempts of a patient or parent to get you to operate.
Strangulated bowel and omentum may be more easily dealt with 18.10 Umbilical hernia in children
by this method, than by the 'standard approach'.
Make an incision 1-2cm above the inguinal ligament, as for a
strangulated inguinal hernia (18.2, 18.6). Sweep away the In many areas of the world, a child commonly has a defect
superficial fatty tissue from the external oblique in the lower in the linea alba at the umbilicus through which a hernia
wound flap, until you come to the bulging femoral hernia below forms (18-12A). These hernias rarely obstruct or
the inguinal ligament. strangulate, usually heal themselves without treatment,
Deal with the hernia sac as above. and seldom need repair. In areas where they are common,
Open up the inguinal canal as for an inguinal hernia. Hold the and accepted as being merely a variant of the normal,
cord out of the way, and incise its posterior wall (the conjoint there will be little demand for surgery. Accept this and do
tendon and transversalis fascia medially and the transversalis not operate without good reason.
fascia only laterally). Make a 2½cm incision 5mm above and
parallel to the inguinal ligament. Tie and divide the inferior
epigastric artery and vein, that lie deep to the inguinal ligament in If you do have to operate, repair is usually straightforward.
the medial border of the internal inguinal ring; then extend the The child's umbilical scar is weak and the neck of the sac
incision laterally to 4cm. Apply haemostats to its upper and wide; it has one compartment, and is covered by skin,
lower edges to hold them apart. to which it may be closely adherent. It may contain small
Look for the neck of the hernia from above by gauze dissection. bowel, omentum, or large bowel, and rarely strangulates.
You will find a tongue of peritoneum disappearing into the Strapping such a hernia in a child is useless.
femoral canal. Working from above and below, and using the
methods described above, reduce the hernia and the sac. A large defect at birth (omphalocoele or exomphalos)
Be careful to clear the sac from the bladder medially.
requires a different approach (33.4).
Deal with strangulated bowel or omentum as above.
Transfix, tie, and excise the sac. Use interrupted monofilament to
close the femoral canal, by passing sutures between the inguinal
ligament and the pectineal ligament. Protect the femoral vein
laterally with your finger while you place these sutures.
Close the posterior wall of the external oblique aponeurosis as
for an inguinal hernia.
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MANAGEMENT.
If a child is born with a small hernia, reassure his mother
that it will become a little larger up to 3-5yrs; 90% will
close spontaneously by 3yrs and 95% by 5yrs unless the
defect is >2cm diameter.
If the parents blame a hernia for recurrent bouts of
periumbilical pain, make sure that this is not due to
hookworms or sickle-cell crises, or even a cough!
The hernia will always bulge when the child cries, but it is
usually not the cause!
An irreducible hernia will however often reduce under
sedation or ketamine with gentle taxis (18.6).
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18.11 Para-umbilical hernia in adults Control bleeding carefully with diathermy. Define the
margins of the neck of the hernia. This is seldom as neat as
in other hernias. You may not be able to grasp the fundus
Try to distinguish in adults whether a hernia in the
if it is firmly attached to the umbilicus, so define the neck
umbilical region occurs above or below the umbilicus,
on all sides, and ignore the fundus initially.
through a weak place in the linea alba, rather than directly
through the umbilicus itself. You may occasionally see a
true umbilical hernia so huge that it can accommodate a
pregnant uterus! This may arise from a healed exomphalos
(33.4) where the defect was never repaired in childhood.
DIFFERENTIAL DIAGNOSIS
A hard lump at the umbilicus may not be an irreducible
hernia.
If it bleeds at menstruation, it is endometriosis.
If it is stony hard, it is a Sister Joseph’s nodule indicating
widespread intra-abdominal malignancy.
If it is purplish with a tendency to ulcerate and bleed,
it is Kaposi’s sarcoma.
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Continue to open the sac with blunt-tipped scissors, DIFFICULTIES WITH PARAUMBILICAL HERNIAS
working from the neck towards the fundus. As soon as you
have made a sufficient opening, put your finger into it and If a paraumbilical hernia discharges faeculent fluid,
feel for adhesions. Cut round the circumference of the sac a loop of large bowel has strangulated and perforated, and
with scissors (18-20B). Carefully examine the contents of caused a faecal fistula. General peritonitis is usually
the sac. prevented by the tight fit of the neck of the sac,
If a loop of bowel has stuck to the sac, pass your finger which seals off the rest of the peritoneal cavity.
up beside it. Find a part of the sac wall which is free of The differential diagnosis includes other causes of a
adhesions, and open this up as best you can: it is better to discharging umbilicus, carcinoma of the transverse
leave a piece of sac adherent to the bowel than to injure it. colon or stomach, and a persistent vitelline duct.
A patent urachus will discharge urine.
If the omentum has stuck to the sac, clamp, transfix, tie,
and divide small sections of it at a time, and then return it You can deal with this electively: perform a laparotomy
to the abdomen. taking care not to soil your operative field. Resect the
colon with the hernia en masse and close the abdominal
Turn the sac inside out, so that you can see its contents and wall, but leave the skin open.
peel them away. Remove adherent omentum along with
the sac, and separate adhesions between loops of bowel.
Finally, cut the umbilical skin off the fundus of the hernia.
Suture the superficial fascia to the anterior rectus sheath. Fig. 18-21 SOME MORE HERNIAS.
If possible, insert suction drains. Apply pressure dressings, A, umbilical and inguinal hernia in boy of 3yrs. The inguinal hernia
and hold them in place with an abdominal binder, or plenty will need repairing, but the umbilical one will not.
of adhesive strapping. B,C, paraumbilical hernia containing most of the patient's bowel and
omentum. Note the healed ulcer on the fundus. The mass is knobbly
because of visible peristalsis. D, incisional hernia following midline
laparotomy. E, incisional hernia following Caesarean Section.
After Worsornu, External hernia - ventral hernia and summary. Tropical
Doctor 1975;5(2):56-61, with kind permission..
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If the whole length of the upper abdominal midline bulges 18.13 Incisional hernia
on sitting up, this is a divarication of the recti (18.11),
and rarely needs surgical correction (which is anyway not These range from a small bulge at the site of a stab drain,
easy). to the huge multiloculated swelling that follows the
breakdown of a major incision, usually a lower midline
laparotomy. Incisional hernias are more likely in the
following circumstances: poor suturing, particularly with
catgut (11.8), missed repair of the posterior rectus sheath,
infection either in the wound or from generalized
intra-peritoneal sepsis, a chronic cough, constipation,
ascites, HIV disease, advanced malignancy or
malnutrition.
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MANAGEMENT.
Unless you are experienced, do not operate on difficult
recurrent, large, incisional hernias, especially with HIV
or other systemic disease present (including obesity);
advise wearing a corset if the hernia is completely
reducible and symptomatic.
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Proceed to raise flaps of scar tissue as described below, DIFFICULTIES WITH INCISIONAL HERNIAS
and excise the ellipse and part of the sac together.
Take care to control all bleeding points carefully. If you cannot overlap the aponeurotic layers,
make parallel relieving incisions 10cm laterally into the
Raise flaps of aponeurotic scar tissue from the covering of sheath only, but beware this is likely to be bloody, so have
the sac on either side (18-23C) diathermy ready.
The neck of the sac will probably be diffuse, and not easy If the defect is so large so that you cannot bridge the
to define. Open it between haemostats, as for a laparotomy defect, you will need to suture in a mesh to close the
(18-23D), and incise the peritoneum far enough to see if defect. You can use sterilized insecticide-free mosquito
there are adherent loops of bowel. Free these adhesions netting; if you do not have any mesh; do not try to make a
and the omentum (18-23E), and return the bowel and repair under tension.
omentum to the abdomen. Put the mesh in under the rectus muscle, but over the
posterior rectus sheath (under-lay method); you need to
If you cannot easily free the bowel and omentum from dissect the rectus sheath quite far out laterally, inferiorly
the fundus of the sac, leave them attached to it; and superiorly to secure the mesh, and this really needs
free it from the skin, if you have not already done so, and diathermy. Use prophylactic cloxacillin intra-operatively.
fold the sac inwards into the abdomen. Check the viability Close the mobilized anterior rectus sheath, and advise
of the bowel (11.3, 11-6), and resect any non-viable part. wearing a corset. Do not lay mesh directly on bowel.
N.B. You can put the mesh over the rectus muscle,
Excise the redundant part of the sac (i.e. the peritoneum), under the anterior rectus sheath, though this may be very
and close this layer, taking good bites of the retracted deficient and tempt you to use the mesh as a sort of fill-in
posterior rectus sheath with continuous monofilament graft for the defect (onlay method), this is simpler but
(18-23F). much less effective, and if the wound becomes infected,
you may end up having to remove the mesh to control the
Dissect and trim the scarred flaps of aponeurosis, sepsis!
to expose the edges of the rectus muscles on either side.
If these have been stretched and thinned out, trim these If there is a recurrent incisional hernia, repair is likely
flaps away to leave a broad strip on one side, and a narrow to be very difficult indeed. If she is comfortable in a corset
strip on the other. Overlap these strips so as to bring the treat her non-operatively.
rectus muscles to the midline (18-23G).
If the pregnant uterus bulges through an incisional
Otherwise, if they do not come together easily, hernia, consider doing the repair immediately after
do not overlap them: you must avoid tension in your delivery, and tying the tubes.
repair. You can use continuous or interrupted #1
monofilament sutures. Take close small bites making sure If there is a persistent wound infection after a mesh
you get a suture length-to-wound length ratio of 4:1, repair, remove the mesh. Sometimes this gets ‘swallowed’
and do not tie the sutures so tightly that they strangle the by intestine, resulting in a fistula: you will then have to
tissues. In this way, a double-thickness layer of fibro- resect the affected portion of bowel as well as removing
fascia will replace the linea alba. Insert a few absorbable the mesh: this is difficult surgery!
sutures between the superficial and the deep fascia,
in order to obliterate any potential spaces where blood PERISTOMAL HERNIAS
might collect.
Stomas inevitably leave a weak area in the abdominal
Insert a multiple perforated tube through a stab wound, wall, through which bowel may herniate either alongside
let it lie under the flap, and attach it to a low-grade suction the stoma itself, or into the layers of the abdominal wall.
apparatus. Suture the skin edges, apply a firm pressure If the weakness in the abdominal wall is just a bulge,
dressing, and do not disturb it until the sutures are to be owing to weakness of the muscles themselves,
removed. A many-tailed bandage (an oblong piece of cloth do not attempt any repair (11.6). If there is a true bowel
with cut strip tied or overlapped and pinned around the herniation, you will probably need to re-site the stoma and
abdomen) will provide physical and psychological support. repair the old defect. Make sure you select the new stoma
site carefully pre-operatively (11.5)
CAUTION! If a cough develops postoperatively,
it is likely to disrupt the repair. Teach supporting of the Perform a formal laparotomy; start by mobilizing the
wound by pressing the hands on the sides of the abdomen. stoma as for its closure (11-16) till it is free, then deal with
Use a corset. the herniated bowel, and finally re-fashion a new
colostomy at the new site, making sure you have
mobilized the bowel enough to reach its new position.
Then carefully close the old stoma defect layer by layer.
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Room for Improvement There will be more health workers per delivery and the
Latin-America and North Africa have improved their economic benefits are likely to increase the budget for the
MMR figures impressively. There seems to be little Ministries of Health and Education. Educated women are
progress in sub-Saharan Africa. Income is an important far less likely to die of a pregnancy.
factor between and within countries but does not explain
all the differences. For example, people in Sri Lanka, Women who die often have not had antenatal care (ANC);
Vietnam, Ecuador, and Ghana have similar purchasing they are ‘unbooked’ and they are seen often late when
power. Their estimates of MMR are respectively 29, 49, there are problems. ANC detects some problems in time
87, 380. Countries such as the Netherlands, Sweden and (anaemia, syphilis/HIV/malaria infection, breech
Denmark had MMRs of 300-350 a century ago, presentation, high blood pressure, severe growth
mainly because of the presence of many well trained retardation) and makes it possible to discuss a plan:
midwives. The USA only caught up (in 1935 the MMR “Are you going to stay with your cousin near the hospital?
was around 600) when there were enough doctors to What will you do if your membranes rupture too early?
provide maternity care. What transport options exist at various times of the
The MMR varies widely as seen above. It used to be high month/week/day? How can we prevent the next potentially
all over the world. History shows how often kings lost dangerous pregnancy? Do you wish for and are you ready
their queens in childbirth. The natural MMR, which means for sterilization?”
no medical interference whatsoever, is around 1,600.
In some communities in Africa and Afghanistan it is still Saving pregnant women is not basically a question of
1,000 or more, which means that a mother has around a having beautiful machines, laboratories and computer.
1:100 chance of dying from pregnancy-related causes/per In North Western Europe before the Second World War
pregnancy, or a 1 in 14 chance in her lifetime, if she has (1939-1945), the perinatal and maternal mortality rates
7 pregnancies. The result is that a woman living in a were better than they are in many large African hospitals
remote area of Afghanistan has a 1,000 times greater now. At that time the Caesarean Section rate
lifetime chance of dying of a pregnancy than a woman in was <1%. There were no antibiotics, modern anaesthetics,
Scandinavia. The MMR in high-income countries makes safe blood transfusions, vacuum extractors, reliable IV
almost no impact on the global MMR. One of the oxytocin, anti-D and anti-tetanus injections,
problems apart from war is that in certain countries, prostaglandins, contraceptives other than condoms,
authorities discourage (higher) schooling of women, cardiotocographs, ultrasound, or Doppler machines,
as was the case in Europe 100 years ago, and male doctors or modern suture materials. There was little evidence-
are forbidden to attend to pregnancies, as in Europe 400 based knowledge. Polio, rachitis (severe pelvic deformity
years ago. due to vitamin D deficiency) and (then untreatable)
The deaths of mothers are more difficult to prevent than syphilis were common. The difference was that the
those of their children, because a good basically equipped facilities were provided and there were enough staff. They
hospital with well trained staff is needed. On the other received reasonable salaries and pensions. The exodus of
hand, reducing infant and under-five mortality by means of staff for more lucrative jobs was rare and they were
vaccinations, provision of clean water, improved nutrition revered for identifying with the suffering of their own
is less of a technical problem. However even though the people. So encourage such staff, and do what you can to
successful building a district hospital, including its staffing improve their working conditions!
and transport access, results often in good outcomes from
high-risk pregnancies of women staying in the shelters Never in history has a doctor, prepared to work in a rural
nearby, the low-risk pregnancies which still can have district hospital, had so much opportunity to save lives.
unexpected complications do badly because women arrive Saving their lives requires also improved education for
in hospital too late. This is related usually to traditional women and services at 3 levels: in the community,
customs and beliefs. Organising a ‘bed & breakfast’ in clinics and health centres, and in basically equipped and
industry for all women in the last 6wks of their pregnancy staffed district hospitals. Especially, it needs plenty of
near every good district hospital might prevent much well-trained midwives. The midwives alone made the first
misery. Something else which should be easy is providing large dent in the MMR in Europe. Furthermore
for the unmet need for contraceptives. You only need staff, non-doctors are easier to retain. A study from
dedication and the right contraceptives (for which donors Mozambique showed that over 7yrs 88% of the medical
are easy to find). Half of the pregnancies in the world are assistants were still working in the rural areas but NONE
unintentional. To prevent these would halve the number of of the doctors! Changing maternal mortality needs political
women who die of pregnancy. On a global scale this has will. To raise this you will need to know your
already happened: in 1950 the TFR (total fertility rate, local/regional MMR. To get an idea, ask adults what
or average number of children a woman bears) was 5; happened to their adult sisters and whether or not they died
recently it has become 2∙5. This is of course not in childbirth. Their mortality experience will be a measure
represented by the MMR because this refers to how of that of the community as a whole.
dangerous each pregnancy is. Nonetheless, in absolute
You can obtain more or less reliable figures plus much more statistical
numbers, it makes a big difference. Furthermore,
data like total fertility rate, contraceptive usage, infant mortality rate,
the MMR is likely to go down because high risk family planning and death rates from the UN Demographic Yearbook,
pregnancies will decrease when contraceptives are widely DHS (http://www.measuredhs.com) or from your Central Statistical
available. Office.
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A simple way in LMICs to monitor the very basic quality In some areas this population pressure is already finding
of obstetric care and associated transport facilities is its expression in desertification and starvation, in abject
recording everywhere the vesico-vaginal fistula (VVF) poverty, people risking their lives trying to flee to Europe
rate. These are easier to prevent and record than MM. and the US and in civil disorder. The slaughter in Rwanda,
Women with VVFs are very likely to present at some stage but also the Second World War, stimulated by the German
at a health facility. All VVFs with all details of the identity call for Lebensraum (space for living), were clearly related
of the woman involved and date and place of delivery, to deemed population pressure. The population in Rwanda
transport bottlenecks and so on should be sent once a year has since increased again to the previous level. Your own
to the Ministry of Health. At that level duplicate recording community may not have reached this point yet, but is it
of women can be sorted out and an annual VVF report already exerting such pressure on its environment that
made. This might be a very sensitive indicator of the year 'ecological collapse' is not far away? If it occurs your
on year difference in quality of obstetrical care. community may become 'ecological refugees', if indeed
VVFs caused by obstructed labour (not those made at there is anywhere to flee to. If birth rates don't fall, death
Caesarean Section) happen only when women have been rates may rise to their old values (of 100 years ago) or
in labour for >2days. It could also show very well, for higher, with a much larger population in a much
example, that an increase in the price of fuel results in impoverished environment.
more VVFs.
This is described as the demographic trap. Europe solved
its population pressure problems in the past by
19.2 Obstetric aims & priorities colonization. The result is that half the people of European
stock live in the ‘New Worlds’, where they drove away or
Between 5-10% of the babies of LMIC mothers die in the killed the indigenous peoples. Africa and the Middle East
perinatal period (from 28wks of pregnancy to 7days after do not seem to have that option. China, South Korea,
delivery), frequently related to the development of the Thailand, Singapore, and Sri Lanka have shown that
placenta. Preventable causes include malaria, syphilis, and limiting population increase can allow for enormous
obstructed labour. Most perinatal deaths are of normally economical boost, resulting in a rise in the standard of
formed, normal weight babies who die avoidably from living. This rise is not, however, without problems because
trauma, asphyxia, or infection. Statistics show that of risks of gender number inequality, where boys are
perinatal mortality decreases with the number of weeks of valued more than girls, who are therefore eliminated.
pregnancy. At around 36wks this trend reverses Increasing population also brings pollution, and land
because mechanical factors, especially cephalo-pelvic degradation. The chance for all the people in the world to
disproportion (CPD), is now playing an increasing role have a reasonable standard of living becomes more remote
while these deaths are, in theory, all preventable. if the world population keeps on increasing as the rate it
Many neonatal deaths also occur in babies whose low has done recently (1 billion people extra every 15yrs)
birthweight is due to their being born too soon despite HIV disease. If everybody has 2 children only,
(prematurity), or to not having grown normally before there might just be enough food globally if it is equally
birth (intrauterine growth retardation: IUGR). If a mother distributed. If everybody has 4 children, such equal
dies, the baby will also, even if it is born alive in a good distribution will not help. The rich must adjust their
condition. The baby will also often die without the breast standard of living, reduce their waste and the poor should
milk and the special attention which is nearly unique to the have fewer children. But without reduction in child
biological mother. The deaths of both mothers and babies mortality, women will still want many children as an
are largely due to the material, political, and socio- insurance for the future. Many politicians also believe that
economic conditions and traditions under which they live. a large population is important because it makes a country
Here we are concerned with obstetric causes of death. powerful. But Sweden (7million) has probably more
Despite the challenges of pregnancy and childbirth, influence than Bangladesh (145million). If China had not
an important task in many communities is to reduce had a population policy, they would have had 350million
the frequency with which pregnancy occurs. more people and the Chinese would be not such an
Most governments are in theory convinced that proper economic threat to the US as they are today. They would
development cannot be combined with women having probably be begging for food aid.
many children. The problem is often that governments
have many tasks and not enough resources. Facilitating Because so much obstetrics must be delegated,
free access to family planning, however, is a task the instruction and supervision of those to whom you
governments often do not see as a priority because there delegate it is critical. Some mothers will be delivered in
may be stiff opposition from various quarters. Reducing hospital, and some by midwives in health centres.
unwanted pregnancies will decrease the need to keep on Most of them will probably be delivered at home, attended
building new schools, hospitals, universities, create jobs either by their families, or by traditional birth attendants
and to import food. (TBAs), such as the dais of India. A study from Burkina
Populations especially in Africa and the Far East, and to a Faso showed that active encouragement from the local
lesser extent elsewhere, are growing so fast that they are chiefs increased the deliveries in health institutions from
causing acute pressure on land, on food, on the wood (to 25 to 56%.
cook the food), on jobs, on education, and on the health
and other social services.
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Another way to reduce the maternal and perinatal SOUND, uterine, malleable, metric, graduated shaft. Use this to measure
the depth of the uterus before inserting an intra-uterine device (IUD) or a
mortality in your district may be to start with the TBAs,
small suction curette in post-menopausal bleeding (PMB). A sound is a
to concern yourself with what they do, and to instruct them dangerous instrument in a recently pregnant uterus, because you can
where you can. If a specialist group of TBAs are at work easily perforate it.
in your area, each of whom delivers several mothers every RETRACTORS, Langenbeck (large). Useful as well for a mini-
laparotomy
year, try to run training courses for them.
FORCEPS, Babcock (small). Use these to grasp a Fallopian tube while
For example, as the main cause by far for maternal performing a tubal ligation or operating for an ectopic gestation.
mortality outside hospital is post-partum haemorrhage FORCEPS, ovum, curved, screw joint, McClintock 250mm. Use this to
(PPH) you might for example start a programme in which remove the products of conception from an incomplete miscarriage, after
you have dilated the cervix. If you don't have them, use sponge-holding
TBAs are provided Misoprostol x3 tablets (600µg)
forceps.
to dispense orally directly after the baby is born CURETTE, uterine, double-ended, blunt and sharp, 8mm & 5mm.
(if not a twin). The great danger with a curette is that you may push it through the wall
of the uterus, especially a recently pregnant uterus. Let a curette lie gently
in your fingers, so that you can feel the wall of the uterus: don't grasp it
firmly.
CURETTE, suction, stainless steel, reusable, sizes 8 and 10 Hegar.
Use this for evacuating a hydatidiform mole (it causes much less bleeding
than dilatation and non-suction curettage), and for terminating a
pregnancy which has lasted <12wks.
KARMAN’S CANNULA, Plastic, size 4-12mm. These are better than a
curette. Use small sizes for dysfunctional uterine bleeding (DUB, 23.3) or
PMB, and larger sizes for retained pieces of placenta of 22-42wks,
or a very large molar pregnancy). The in-between sizes are very useful
for removing retained products of conception from the uterus, best with
the help of an electrical suction machine.
CURETTE AND SYRINGE for manual vacuum aspiration (MVA), sterile,
plastic, disposable (but boilable though not autoclavable). They are also
very useful for non-septic incomplete miscarriages seen at the out-patient
department if there is no suction machine there.
CANNULA, cervical, Leech Wilkinson or Miller. This is for doing a
hystero-salpingogram (HSG: 38.1).
SCISSORS, episiotomy, Vant. These have straight blades and round
points.
VACUUM EXTRACTOR (VE), Bird's modification of Malmstrom's,
complete with 3 suction cups 40, 50, 60mm, one posterior cup, traction
handle, vacuum hand pump, chain, spare vacuum bottle and spare
baskets. Bird's modification is better than the original Malmstrom
extractor, and is quicker and easier to assemble. The anterior and
posterior cups are not absolutely necessary. An expensive disposable
KIWI will give you a luxurious feeling but the old-fashioned
well-maintained Bird’s is good enough. You need several sets of cups
and tubes because you should be able to do 2-6 vaginal examinations in a
weekend. Good simple maintenance of this basic equipment can make the
difference between life and death for mothers and babies.
FORCEPS, outlet, Wrigley. Outlet forceps are the only safe ones for
anyone but an experienced obstetrician. Even then becoming a master
with the vacuum extractor is easier and better.
FORCEPS, haemostatic, straight, Green-Armytage, 203 mm. Use these
for clamping the (digitally) cut edges of the uterus during a Caesarean
Section (the faster you become the less you need them), and for repairing
a ruptured uterus.
STURDY FOLEY’S CATHETER with balloon content >25ml. Use this to
Fig. 19-1 SOME OF THE EQUIPMENT you will need. deliver a dead breech presentation (21.8). Introduce the catheter via the
foetal rectum, inflate the balloon and then traction is very easy.
STETHOSCOPE foetal, plastic. These don't bend so easily as aluminium PERFORATOR, Simpson's. This is the standard instrument for opening
stethoscopes. the skull when doing a destructive operation. If these are not available,
DOPPLER FOETAL HEART DETECTOR, 'Sonicaid' pattern or Kochers forceps (large, straight or curved) will also do, or even large
equivalent. This is comparatively inexpensive (about $250) and very artery forceps.
useful. RETRACTOR, Doyen's. Use this for Caesarean Section, it has a curved
PORTABLE ULTRASOUND. This is so useful that you should really try lip which fits over the lower end of the wound and keeps the bladder out
to get one. of the way of the operation.
SPECULUM, vaginal, Sims', double-ended, medium size, 27-30mm. RETRACTOR, Kirschner. This gives an excellent exposure for
SPECULUM, vaginal, Cusco's, duckbill, small and large, stainless steel. laparotomy, with a good view for operating in the pelvis.
These specula open like the beak of a duck, and in doing so enable you to SAW, decapitation, Blond-Heidler, complete with ring, thimble and
examine the cervix. blades. Use this for decapitating a dead baby when labour is obstructed
SPECULUM, vaginal, weighted, Auvard's, chromium-plated. The weight by a transverse lie. It is a piece of wire with teeth on it, hooks at each end
on this speculum presses it downwards, and so keeps the vagina open. to fit handles, and pieces of tubing to prevent it from cutting his mother.
FORCEPS, uterine vulsellum, curved, 1-2 teeth and 3-4 teeth, box joint, It also has a thimble you can push round his neck to fix the saw.
230 mm. Use these to grasp the cervix when you curette it. SCISSORS, embryotomy, Queen Charlotte's pattern. Use these scissors,
FORCEPS, Post partum ring (sponge) are better to grasp the cervix. which were specifically designed for destructive operations, if you do not
DILATORS, cervix, double-ended, Hegar's set of 12 sizes, 1/2mm to have a saw.
23/24mm. Use these to dilate the cervix before curetting it.
MANIPULATOR, uterine. Use this to bring the uterine fundus up against
the abdominal wall when you perform a mini-laparotomy.
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Anti-TB medication is unlikely to make her fertile; If there are pus cells in the ejaculate, treat the infection
she has c.8% chance of conception, but only 2% chance of and of course his partner’s. It can take 3months after
a live child. She also runs an increased chance of an successful treatment before the sperm count improves.
ectopic gestation. Some men refuse to cooperate. Often the woman is not
Sometimes, you can make the diagnoses by histology from responsible, but she may well be sent away by the man if a
D&C scrapings on the 1st day of her period, or by seeing pregnancy does not appear.
miliary TB at laparoscopy or laparotomy. The history is very important. If a woman is now with her
3rd partner and has had no children at all, it is unlikely that
Repairing tubes that are blocked is an expert's task, the man’s semen is the problem, especially if he has
and even then the success rate is low, so you may decide children with other partners. Beware, though, of vague
that there is little point in investigating these patients if stories of men who say they have a child in a town 400km
they cannot be reliably referred. But sometimes it is very away! Sometimes these stories are backed up by his family
easy to open Fallopian tubes which are only closed at the to spare the man embarrassment.
distal end (like phimosis) using blunt small artery forceps.
If fimbriae are then visible and the tube can be kept THE POST-COITAL TEST will help if the husband
open by a few very small atraumatic nylon sutures, refuses to cooperate or if your laboratory cannot do proper
the prognosis is not that bad. You must then warn about semen analysis. It also gives extra information about the
the symptoms and signs of an ectopic gestation. quality around the ovulation of the cervical mucus
(sticky, clear, elastic up to 6-8 cm) and will also confirm
If you suspect blocked tubes, you can: that semen has been deposited in the right place!
(1).Perform a hysterosalpingogram (HSG, 38.1l) which
will tell you where a block starts and sometimes about Timing is very important. Only 1-3days around the time of
a fibroid in the uterine cavity. This investigation is the ovulation (if present) do sperms enter the cervix and
time-consuming and expensive, though. swim to the tubes; they may survive in the cervix for quite
(2).Insufflate the tubes, which is cheaper, but gives less some time (2-3days). It is satisfactory to examine the
reliable information. Also, the instrument can leak, cervical mucus the morning after evening sexual
and you can make mistakes. intercourse.
(3).Perform a laparoscopy which again is expensive and
time-consuming. Expose the cervix, use a syringe (without needle) to suck
some mucus from inside the cervical canal, put it on a
Fibroids (23.7) can be the cause of infertility especially if microscope glass (not easy as it will tend to adhere to the
situated in the uterine cavity or when compressing the syringe but the cover glass might help trapping the
tubes in the cornua. More often fibroids are the result of mucus). Examine under the microscope with 10x10
infertility. Typically though, a woman with infertility and magnification. Progressively mobile sperms will more or
fibroids is also found to have blocked tubes or an infertile less exclude a male factor, hostile cervical mucus
husband. Sometimes large or many fibroids cause repeated (a rare cause for infertility), and a faulty sexual technique.
miscarriages and should be (partly) removed. If the test is -ve repeat it, try if necessary, on consecutive
days to catch the ovulation.
You might succeed by removing the largest most N.B. In some cultures it is accepted that a woman
distorting and other easily accessible pediculated fibroids, becomes impregnated secretly by a male relative of the
but you might also cause many adhesions which will husband, if he is azoospermic. Note the risks of
subsequently interfere with fertility. Careful operating, tramsmission of HIV, and other diseases by this practice.
keeping tissues moist, no rough swabbing, and closing the
pelvic peritoneum will reduce such adhesions. IN WOMEN:
Try to remove several fibroids through the same incision, UTERINE CURETTAGE. (GRADE 1.3)
and avoid wounds on the posterior surface of the uterus. Don’t do this if periods are regular or she is taking the
contraceptive pill!
IN MEN: Perform the test very early when her periods start.
Examine the seminal fluid within 2hrs of production. Preferably use a microcurette, as an outpatient. Otherwise,
It is normal if: it has a volume of 2-6ml, it is liquid perform a D&C (23.4). Send half the curettings for
>30mins, it has 60% of motile sperms, and it has histology, indicating the request is for ovulation, and the
≥20million sperms/ml, <15% being abnormal. other half for TB investigation.
If there is a low sperm count, suggest abstinence from TUBAL INSUFFLATION (GRADE 1.4)
sexual intercourse until the 12th-14th day of the woman’s
cycle. Tight nylon underwear or other exposure to heat INDICATION. Although theoretically simple, false results
(e.g. sitting often on the engine of a truck, working in a are not uncommon. If insufflation is the only method of
bakery) and heavy smoking may be causes. Suggest loose investigation you have, this suggests that expert tubal
cotton boxer shorts. surgery is unlikely to be available, which should make you
question the value of insufflation.
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INDICATIONS:
19.4 Tubal ligation (TL) (1).Mothers who are sure they want no more babies.
(2).Medical diseases making pregnancy dangerous,
This should be one of the most common operations you do particularly severe heart disease, renal failure, HIV disease
and many women and couples will be very grateful for it. or severe diabetes.
Choose it after careful consideration of the alternatives (3).Previous Caesarean Section where another Caesarean
(a copper IUD is good for 8yrs and nearly as effective, Section would be impossible to organize.
a hormone IUD is good for 5yrs and at least as effective (4) Ectopic gestation in a multipara.
but expensive), so your operation must be as safe and as (5) Severe psychiatric disease.
painless as it can be. Try not to keep a mother waiting long
for surgery, or she may become pregnant meanwhile!
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If a woman is enthusiastic at once and she knows what you Fig. 19-3 CHOGORIA SUPPORTS hold the legs only partly flexed,
are talking about, it is patronising not to let her make use so that you can have simultaneous access to the abdomen and the
of the opportunity. Indeed, if you have to perform an perineum. They are from a mission hospital of this name in Kenya,
and are a cheaper locally-made alternative to Lloyd Davies stirrups,
emergency Caesarean Section, e.g. for failure to progress or to an attachment for an operating table that enables you to angle
in a para 4 woman who presented late in hospital but you its lithotomy poles.
deliver a well baby, it is quite possible that any subsequent
regret to consent to TL is far outweighed by the chance of Clean the abdomen, perineum, and vagina, empty the
death in the next pregnancy (from uterine rupture, placenta bladder with a catheter (if it is not empty already),
accreta, haemorrhage during a difficult Caesarean Section and cover her with an abdominal sheet. Pass a Sims or
etc.). Auvard's speculum.
In fact, most multipara regret not having been given the If >10days have elapsed since the 1st day of the last
option of TL at Caesarean Section. If in doubt, women will period, consider doing a D&C or suction curettage (23.4),
choose not to have a TL. There is no proof that women in to prevent implantation in this cycle. You may need
Africa choose recklessly in favour of a TL. paracervical anaesthesia.
DUDUZILE, a 40yr old para 7 arrived in shock in the nick of time from a INCISION depends on the position of the fundus.
remote area with a bleeding ectopic gestation. A junior doctor operated If delivery has occurred within 4days, and the uterus is
on her, removed the affected tube but did not tie the other tube;
he thought it unethical. When she understood that the next morning,
at the umbilicus or can easily be pushed there,
she refused to leave the hospital till the other tube was likewise tied. make a 2cm horizontal incision in the inferior fold of the
She remembered her fear of dying and wished never to go through the umbilicus. This is good cosmetically, and avoids the need
same ordeal again. for shaving. Also the abdominal wall is thinnest here.
LESSON: After one ectopic gestation with a contralateral tube open,
the chance of a further ectopic gestation is as high as 20-30%.
If she is not postpartum, make a short transverse incision
ARRANGEMENTS. It is best to perform TLs on a special just above the pubic hair. If you have inserted a uterine
operating list, and perform them early, so they are not manipulator, moving it helps you to decide where to
displaced by other elective operations and emergencies. operate exactly. Ask an assistant, with the manipulator,
You may be able to run a ‘TL camp’ or set up adequate to raise the fundus against the abdominal wall until you
preparations at a Health Centre. Normally intervention see and feel a bulge (19-4A). Alternatively manipulate it
under LA, with or without some sedation, is possible. yourself through the towels (experienced doctors can do
this operation if need be without an assistant).
METHOD. (GRADE 2.3)
Immediately before the operation, ask the patient to pass If you make an umbilical incision, stretch it and make a
urine, to prevent you cutting into the distended bladder. 2cm horizontal incision in its inferior fold. Spread (do not
This is important. Perform a careful bimanual examination cut) the subcutaneous tissue moving laterally with scissors
to make sure that she is not already pregnant (although you until you see the fascia. Insert 2 small narrow right-angled
can tie tubes during pregnancy without significant extra retractors, and pull them apart laterally, while using them
risk, to prevent the next pregnancy). to pull aside all tissues between the skin and the fascia.
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Pick up the fascia between two haemostats (one as much N.B. The tube is the middle (and top one) of the three
as possible to the right and one as much as possible to the lateral attachments to the fundus (dorsal ovarium, ventral
left), and inject another 5ml lignocaine just beneath the round ligament) and has a lumen.
fascia to anaesthetize the peritoneum. Open the fascia
horizontally with a knife over the ridge you create when Introduce some LA between the two blades of the
you lift the haemostats. You will find the fascia and the mesosalpinx near the tube where you plan to tie it.
peritoneum fused so lifting it up prevents you cutting too Excise a segment, having ligated a loop (19-2).
deep. CAUTION! Check very carefully that there is no
If the peritoneum is not open yet do it bluntly by pushing bleeding, cut the sutures on the tube, and then operate on
closed forceps or scissors through it and pulling this the other tube in the same way.
instrument out in open position. The incision in the fascia Close the fascia with continuous #1 monofilament.
should be large enough to admit your index finger. Close the subcutaneous dead space to minimize oozing.
The skin will stretch, so you can make the skin incision Close the skin with subcuticular absorbable.
shorter than the fascial one.
If you make a suprapubic incision, you have a similar DIFFICULTIES WITH A MINI-LAPAROTOMY
approach but the incision is somewhat larger (reverse If there is pain after you injected the LA, add sedation.
correlation with your experience). Enter the peritoneum as A wide area of LA should prevent this.
high as possible in your incision to stay away from the
bladder. In obesity, it will be difficult to pull the tubes into view
through a layer of fat. Enlarge the incision and apply more
head-down tilt. An umbilical incision may be easier than
you expect, because there is less fat around it
.
If you cannot find the tubes,
(1) The incision may be too far above the fundus; it should
be slightly below it. Turning the uterus with your finger
behind might help if you are desperate. You may find it
helpful not to release the first tube, until you have
moved across the fundus and found the other one.
Try passing Cusco's speculum through the incision to help
you look around.
(2).The uterus may be stuck down with adhesions.
A careful initial pelvic examination should have excluded
this. Dense adhesions require GA to enable you to operate
safely. If the tubes are adherent to the uterus or the pelvis,
you may have to make a standard incision, or abandon the
Fig. 19-4 MINI-LAPAROTOMY. operation. This is particularly likely to happen if there are
Use a special manipulator to push the fundus up against the adhesions following Caesarean Section.
abdominal wall, so that a very small incision can be made in the
abdomen. Do not use this immediately postpartum or post miscarriage. If you find any ovarian cysts, leave them if they are
<5cm. Often normal ovaries have some physiological
After delivery, use your finger to locate a tube and sweep cysts. If a cyst is larger or a possible dermoid, collapse it
it from behind the uterus medially, visualize it and grasp it. by draining it with a syringe and needle, pull it into the
You can easily move the uterus from left to right by wound, and excise it.
pushing against it through the abdominal wall to let the
tubes approach the umbilicus. Alternatively the incision If you open the bladder, close it with absorbable sutures
can be moved with the retractors from left to right. in two layers, and leave a catheter in situ for 7days.
In the elective situation, using your finger is not such a Prevent a full bladder by having her empty it just before
good idea. It tends to hurt the patient, causing her to push. she enters the theatre. If you find it full at surgery, empty it
Bowel then appears in your incision and you can get with a catheter or a needle and syringe.
stressed, operate more roughly, cause more pain, and so
more pushing. Try to visualize the tubes and then pick If you open the bowel, close it in two layers transversely,
them up (as distally as possible) with Babcock forceps. and observe closely for signs of sepsis, abdominal
Your chances of seeing them increases with an easily tenderness or distension suggesting a bowel leak.
directed light, a steep head-down tilt, a manipulator, the
availability of a special instrument to fish out the tubes Once you have mastered the mini-laparotomy technique,
(a small ring on the end of a strait wire attached to a you can also use it for ectopic gestation (or ovarian cysts).
handle), patience, and an assistant talking to the patient,
helping her to relax and breathe deeply. If all else fails,
100mg ketamine IV at this stage will help.
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N.B. There will be a normal range of insufflation If you have difficulty manipulating the tubes, try
pressures for your machine, shown in green on the dial. inserting the gas needle in the midline 5cm below the
If the pointer moves to the red area, the needle is probably umbilicus under direct vision of the laparoscope.
in the wrong place. Use the needle to help you manipulate the tubes.
Otherwise push the cervix down using a vulsellum forceps
and so elevate the fundus and identify the tubes.
Fig. 19-5 THE JHPIEGO LAPROCATOR. Fig. 19-6 USING THE CYSTOSCOPE FOR LAPAROSCOPY.
A, view through the eyepiece. B, instrument in use. (1) the round Fix the cystoscope with a purse-string suture on the abdominal wall.
ligaments. (2) the tubes. (3) the ovarian ligaments. Insufflate with air using a sphygmomanometer cuff. Use the biopsy
channel for instrumentation.
After Gnanaraj J, Diagnostic laparoscopies in rural areas: a different
Let the gas flow into the peritoneal cavity. A multipara use for the cystoscope. Tropical Doctor 2010(3):156
who is being sterilized needs up to 4l (2l is usually
enough). A nullipara who is having a laparoscopy for OPEN LAPAROSCOPY WITH THE LAPROCATOR
diagnosis needs 2-3l. Many insufflators do not measure
volume, but carbon dioxide flows at the rate of c.1l/min, so METHOD. Proceed as above under direct vision, so you
allow it to flow for 2mins. are able to introduce the laprocator with its cannula, but
Remove the Veress needle, and enlarge the skin incision without its trocar. Use 2 towel clips to tighten the skin
with a scalpel, until you have a 1∙5cm horizontal incision around it and prevent gas leaking.
at the lower border of the umbilicus. Insert the trocar and Fill the peritoneum with 2l of air. The laprocator control
cannula. Push it in the same direction as you (should have) box has a small air reservoir which is filled by a rubber
pushed the Veress needle. If you haven’t made the opening pump. Air is only slowly absorbed, so take care to let it all
big enough, you will have to push quite hard, especially if out when you have finished. If you allow air to get into the
the trocar is blunt: this is dangerous, and the trocar is wrong place, for example into the extraperitoneal tissues,
difficult to control. Keep it in the midline. When it is it will obscure the view. You will not be able to try again
through the peritoneum, withdraw the trocar, and insert the after a few minutes, because air takes hours to be
cannula fully. Then insert the laparoscope. Connect the gas reabsorbed, unlike carbon dioxide which is quickly
tube to the cannula for insufflation. absorbed.
Look for the Fallopian tubes. Make sure they are indeed
the tubes by confirming that they: DIFFICULTIES WITH THE LAPROCATOR
(1) join the uterus at the cornua, whereas the round and
ovarian ligaments join below the cornua. If there is extensive bleeding, cross-match blood, perform
(2) are in the middle behind the round ligaments and in a laparotomy and search for the source of bleeding
front of the ovarian ligaments. (usually mesenteric vessels). Pack the area if the source is
(3) end in fimbriae. not immediately visible, and then after 5mins, carefully
(4) easily form a loop when pulled up, much more easily remove the packs to look again.
than the round or ovarian ligaments.
N.B. You can clean the laparoscope lens by gently If you cannot see the tubes, try the manoeuvres
wiping it on tissues within the abdomen, but beware: described; if these fail, perform a laparotomy.
a long contact may burn tissues if the bulb is hot, and it
may be safer, taking it out and cleaning the lens with a
warm moist gauze.
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19.6 Vasectomy
After you have incised the skin, you will meet the
superficial fascia containing the dartos muscle.
Deep to this lies the connective tissue which surrounds the
spermatic cord. When you reach the vas, you will find that
this also has a sheath of its own. Take care:
(1) Don't injure the veins of the spermatic cord
(the pampiniform plexus), which will bleed during the
operation, and possibly afterwards also.
(2) Don't tie the testicular artery, or the testis will atrophy.
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VASECTOMY (GRADE 2.1) Use mosquito forceps to make a small window in a piece
Stand on the right. Find the vas where it is easily palpable of the mesentery of the vas which is free of blood vessels.
in the scrotum. Pull on the spermatic cord just above the Isolate a 1-3cm segment of vas between clamps keeping
testis, with the thumb and index finger of your right hand. far away from the epididymis.
Assuming you are right-handed, use the thumb and fingers
of your left hand to manipulate the cord, so as to push the Tie its clamped ends with absorbable suture, placing your
vas upwards and laterally. Isolate the vas from the other ties beyond the clamped area (19-7F). Leave one end
structures, by squeezing them out of the way (19-7A). outside the connective tissue by suturing it to the outside
sheath and the other end reflected inside in order to
Hold the vas well above the testis with your thumb over it minimize the risk of natural re-anastomosis. Excise the
and two fingers underneath it. If the skin is thin you will isolated segment (19-7G), and keep it for histological
be able to see it. Pulling on it will cause him examination. You may not need to send this but it is
some discomfort, and pain referred to the abdomen. worthwhile keeping in case there are subsequent problems.
This is a useful sign that you have indeed found it (19-7B).
CAUTION! Make sure you have isolated and anchored CAUTION!
the vas in the manner described. This is the critical step. (1) Don't put the ligatures over the crushed area.
Doing it without causing discomfort needs practice. (2) Don't tie them too tight, or they will cut out.
(3).To begin with, leave the ends of the sutures long,
ANAESTHESIA. so that, if the cut ends of the vas bleed, you can pull them
With the vas now anchored, find an area in the skin which back into the wound. Pull on the testis to separate the ends
is free of cutaneous blood vessels, and use 1% lignocaine of the vas. Inspect the wound. If it bleeds, pull out the ends
to raise a small wheal. Then push the needle deeper and of the vas, and tie any bleeding vessels with absorbable
inject 1-2ml as close to the vas as you can, while suture. Then cut the ends of the ligatures short and drop
holding it away from the other structures in the cord. them back.
If he has persistent discomfort while you are handling it,
inject more solution into its sheath. CAUTION!
CAUTION! Don't infiltrate the other structures in the (1) Don't damage the pampiniform plexus.
cord. This is unnecessary and dangerous, because you may (2) Control all bleeding carefully. A small vessel can form
injure the pampiniform plexus. If there is adrenalin in the a big haematoma later. Bleeding can also come from the
anaesthetic solution, it may constrict the vessels, and make skin edges, from the fascial sheath covering the vas,
the testis temporarily ischaemic and painful. or from the pampiniform plexus.
DELIVERING THE VAS. While still firmly anchoring the If the incision is <1cm, the skin edges may come together
vas, incise the skin 1cm over it transversely down onto the without any sutures. Otherwise, suture them with catgut,
vas. If you inadvertently divide the vas, it is not a problem! not long-lasting absorbable as the suture becomes mushy
Grasp the vas with the forceps (an Allis tissue forceps can and often infected.
substitute for a special vasectomy forceps) (19-7C).
Repeat the same procedure on the other side of the
If you cannot lift out the vas, gently cut deeper or push scrotum through a separate incision. You may prefer to
the tip of mosquito forceps through the incision, and split move to the opposite side of the patient.
the dartos vertically. Then push the vasectomy forceps Place swabs on both wounds, and hold them with a crepe
into the incision and lift out the vas. Confirm that the vas bandage tightly wound round the scrotum, held in place by
has not slipped away by feeling it with these forceps: tight underwear. Don’t use adhesive tape on the scrotal
it has a characteristic feel, and you will see the tiny lumen skin!
of the vas when you cut through it.
HAEMOSTASIS MUST BE ABSOLUTE
CAUTION! Don't mistake the vas for thickened bands
of cremaster muscle, thrombosed veins, thickened CHECKUP.
lymphatics, or calcified worms. Warn the patient that he may not become sterile for up to
3wks. His wife should continue to use a contraceptive:
ISOLATE THE VAS FROM ITS SHEATH by levering (1).until 2 examinations of the ejaculate have shown no
the tip of the forceps upwards by lowering its handle. sperm, or
Use a #15 blade to incise the connective tissue over the vas (2).until he has had 12 ejaculations after vasectomy.
vertically in line with it. Make sure that the connective
tissue is completely divided by continuing the incision into To examine the ejaculate, ask him to produce a specimen
the vas itself (19-7D). by masturbation, or from a condom after intercourse.
Hold a segment of the exposed vas with another forceps. Examine this for sperms under a low power microscope.
If you are confident this is indeed the vas, release the first There should be none.
forceps. If you have judged the site and depth of your
incision correctly, you can now easily pull out the vas, If sperms are found, repeat the test after a further 3wks,
leaving only a thin mesentery on its medial surface advising precautions as above. If they are again found,
(19-7E). re-explore the scrotum as below.
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If you lose the cut ends of the vas after dividing it,
the ligature may have slipped, or you may have released
the forceps holding the vas too soon, and let them be
drawn quite a distance into the scrotum. Don't injure any
blood vessels. If there is no bleeding, leave things well
alone.
If there is bleeding, try to recover the ends by
systematically palpating the vas, and feeling for its ends
with forceps.
If you cannot find the cut ends, strap the scrotum tightly
leaving the wound open and admit the patient for bed rest.
Tell him that you have had difficulty, and watch for
haematoma formation. Check later to see that the ejaculate
becomes sperm-free.
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Live birth is the complete expulsion or extraction of a Recurrent miscarriage is ≥2 consecutive pregnancy losses.
product of fertilisation from its mother irrespective of Delayed miscarriage may be late (12 to <20wks) or early
gestational age as long as there is any sign of life after (<12wks) but excluding preclinical/biochemical pregnancy.
delivery. This term is used when there are low positive urinary/serum
β-HCG values and it is not possible to localise the gestation
A full-term birth is delivery from ≥37 to ≤42 completed with ultrasound (gestation of unknown location, GUL).
weeks, i.e.>259 to <294 completed days. Post-dates implies
more than 40+ 0 wks, and a post-term birth is a live birth or Early miscarriage or gestational loss represents a loss
still birth after 41+6completed weeks. A preterm birth is a <12wks: this is an ultrasound-based diagnosis with a
live birth or still birth at ≥20 up till ≤37 completed weeks. persisting intra-uterine empty sac, loss of foetal heart
movement and/or failure of crown-rump length growth over
Neonatal death occurs within 28 completed days after 1wk (38.3).
delivery (after ≥20 completed weeks or when ≥400g at
birth.) N.B. Trimester is a term which should largely be Septic miscarriage is an incomplete miscarriage with signs
abandoned: it is rather unhelpful, vague and causes of intra-uterine and perhaps extra-uterine infection.
confusion. Use completed days or weeks.
Post-abortal sepsis is pelvic infection after a completed
MISCARRIAGES (excluding one caused by an miscarriage or termination of pregnancy.
incompetent cervix) most often go through these 4 stages:
(1);Threatened miscarriage (there is bleeding and perhaps Retained miscarriage is an intra-uterine death before
cramps, but the cervix is still closed), 20wks, after which the pregnancy is not expelled.
(2);Inevitable miscarriage (the cervix is open but no Carneous mole is a continuation of a retained miscarriage,
products of conception have been expelled; most of the time in which the dead conceptus is surrounded by shells of
there is no foetal heart movement), organized blood clot (a blood mole) and has become firm.
(3);Incomplete miscarriage (part of the products have been
expelled), Threatened miscarriage. Recommend refraining from
(4);Complete miscarriage (all the products have been sport, jolting movements (viz. horse riding, off-road
expelled, bleeding has virtually stopped, the cervix is closed, transport, sexual intercourse) and heavy duty work. Bedrest
and the uterus is now much too small in relation to the at home has no proven benefit. Arrange admission if:
duration of the pregnancy). (1);There is much bleeding (regardless of the gestational
age).
Gravida (G) refers to the number of times a woman has (2) Gestation is >14wks.
been pregnant, Para (P) the number of births >20wks’ (3);There is a bad obstetric history or she lives far away and
gestation, and Vivo (V) the number of living children. cannot get help if bleeding becomes much worse, especially
during the night.
If the pregnancy more or less ‘falls out’ without going
through the preceding stages and the foetus is recognisable Uncomplicated uninfected inevitable or incomplete
and alive at first (light reflections on a wet chest change with miscarriages.
its heartbeat), then there is probably an incompetent cervix;
this is unlikely to happen before 16wks. A miscarriage (a) Before 14wks:
caused by an incompetent cervix can also start with ruptured
membranes. An incomplete miscarriage and an inevitable Monitor the pulse, blood pressure, and temperature,
one (if there is no foetal heartbeat on ultrasound while the peripheral circulation, and the amount of bleeding. Measure
foetus is >10mm) should be evacuated with the help of the Hb, and group blood if indicated. Perform an ultrasound
instruments, misoprostol or both. scan if possible (38.3). Induce complete evacuation with
N.B. In an inevitable miscarriage, increasingly after misoprostol (400μg buccal or sublingual, or 600μg oral or
12wks, suction curettage alone might not succeed in rectal) or oxytocin (10IU IV) or ergometrine (0·25-0·5mg
removing the foetus. IM).
In the first 12wks the distinction between an inevitable and
an incomplete miscarriage is unhelpful, because you can If bleeding was copious, restrict oral intake and prepare to
manage them both in the same way. After 16wks, evacuate the uterus as soon as possible.
the distinction is important, because an inevitable Retained miscarriages (with intact membranes) have much
miscarriage is not ready for instrumental evacuation (access less chance of becoming infected than induced miscarriages,
to misoprostol treatment makes evacuation without so there is no hurry: use 800μg of misoprostol PV, followed
instruments quite feasible), whereas an incomplete one must if necessary by 400μg 3hrly x3 till complete expulsion
be evacuated. Before 14-16wks it is difficult to tell by occurs.
observation of the products, if a miscarriage is complete or
not, because the foetus, the placenta and membranes are not If expulsion does not happen, repeat the procedure after
sufficiently well formed for you to identify them completely. 3days. Such treatment may be carried out at home for
Even with ultrasound it is often not easy to make the gestations <10wks if access to hospital is easy in case of
distinction between retained products or blood clots in the brisk bleeding.
uterine cavity.
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SITI (27 years) was admitted with what looked like a threatened 16-week
miscarriage. It seemed to settle, and she was discharged, but she bled in the
bus on the way home and was readmitted. Foetal parts were extracted
through a dilated cervix, and traumatized pieces of bowel were seen
through it. The diagnosis had to be adjusted to complications caused
previously by an (instrumentally) induced back-street abortion.
A laparotomy showed a laceration in the descending colon, old clots and
pus in the peritoneal cavity, and a rupture of the uterus. The lacerations in
the descending colon and uterus were sutured and the abdomen closed.
Some days later she passed faeces through the cervix. She was re-explored,
and a proximal defunctioning colostomy was fashioned, after which she
eventually recovered. She was of course counselled at that stage on the use
of contraception. If this termination was performed because she thought the
family complete then a tubal occlusion should have been done together with
the uterine repair. There is quite a risk that if she ever gets pregnant that it
will be an ectopic or that she will rupture the uterus.
LESSONS This true story is an extreme case. It shows the magnitude of the
disasters that can follow the mismanagement of what might seem to be
quite a minor condition. She was fortunate to escape with her life.
The many lessons include: (1) Somebody had tried to terminate a 16wk
gestation, which is dangerously late for a non-expert outside a well-
equipped theatre. The availability of misoprostol in urban areas (including
the black market) will often now make these late terminations far less
dangerous because fewer skills are needed. (2) If an induced miscarriage is
incomplete, evacuation is mandatory. She should not have been discharged
before the uterus had been emptied. (3) Whenever the colon has been
damaged and faecal soiling is present, a proximal defunctioning colostomy
is indicated. Had this been done at the first laparotomy, she would not have
required another operation. (4) If an ultrasound scan had been performed,
the diagnosis would not have been missed or at least it would have been
clear that there was no foetal heart movement in the presence of retained
Fig. 20-1 EVACUATING RETAINED PRODUCTS OF products.
CONCEPTION. A, explore the uterus with your finger while your
other hand is holding the fundus. You may find it easier to use 2 fingers
N.B. There may be no pregnancy, but dysfunctional
or your middle finger. B, grasp the cervix with sponge forceps and use
them to pull it down. C, D, while holding the uterus with your other uterine bleeding (24.3), or bleeding from polyps or fibroids
hand, introduce ring forceps, grasp and remove any products of (24.7). Much bleeding remains unexplained.
conception, reinsert the forceps and do the same thing again. E, gently
aspirate the uterus with a plastic flexible Karman suction catheter.
EVACUATION: Mandatory indications are:
F, this is the disaster you are trying to avoid!
(1) Considerable bleeding (evacuation is urgent).
Many miscarriages don't need evacuating, but those that do, (2);Bleeding more than during normal menstruation, which
need evacuating quickly, so don't let incomplete continues >24hrs.
miscarriages wait unnecessarily. Evacuating a pregnant (3);Where retained products of conception are obviously still
uterus differs from curetting a non-pregnant one (23.4) in present on vaginal examination or ultrasound (38.3).
2 important ways: (4);Any indication of infection or physical interference to
(1) After a partial miscarriage the cervix is open, so there is the pregnancy.
rarely any need to dilate it.
(2);The wall of an uterus, especially if infected, is so soft (b) After 14wks:
that you can perforate it just as easily as the small atrophic
uterus giving rise to postmenopausal bleeding. If the cervix is open at least one finger, there is no foetal
heart activity on ultrasound or sonic aid, but the products of
BLEEDING BEFORE THE 20th WEEK conception, especially the foetus, have not been expelled,
assess and monitor as above. Don't evacuate the uterus
Miscarriage (induced elsewhere, or spontaneous) usually with instruments until the foetus has been expelled:
presents with vaginal bleeding. you can expedite this with misoprostol.
If evacuation is incomplete, complete it. If however the
DIFFERENTIAL DIAGNOSIS includes: foetus and placenta are expelled together, and the
(1);ectopic gestation (20.6) membranes are complete, there will be nothing left to
(2);gestational trophoblastic disease (23.10). evacuate.
If the foetus is still in the uterus and there is a serious
N.B. Bleeding in late pregnancy may be due to placenta infection, do not waste time! Use misoprostol and IV
praevia (20.11) or abruption (20.12) antibiotics and also organise an evacuation immediately
N.B. Remember gynaecological causes of a bloody even though you may need instruments to remove the foetus
vaginal discharge: trichomoniasis, candidiasis, venereal because it is too large for evacuation by suction curettage
warts, cervical polyps, cervical ectopia (defined as uterine alone. The misoprostol might not evacuate the retained
columnar mucosa extending further than average on the pale products, but will dilate the cervix and make evacuation
external cervix), and cervical carcinoma. easier. Do not wait >2hrs after administering antibiotics
before doing the evacuation!
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Do this several times, to remove pieces of placenta hanging POSTOPERATIVELY, monitor for further bleeding and
from the uterine wall, until the uterus is empty. If you can, check the vital signs. If all is well, discharge the patient and
check with ultrasound and/or use the suction curette with the advise her on contraception, which should always be part of
largest diameter (1cm normally) to make sure the uterus is the ward routine. Advice is often not good enough.
empty. Providing the means at the same time is much better.
If you have not inserted an IUD or an implant at the end of
If you cannot insert your finger or a metal curette, the evacuation, offer Depo-Provera at this stage or other
as occasionally happens in the first 14wks when the cervix is contraceptive medication.
not sufficiently dilated but the uterus seems enlarged, dilate Discuss the option of an early tubal ligation. Ensure that
it. First insert a small dilator, and then progressively larger good, preferably long acting, contraception is available to
ones. Don't dilate the cervix in this situation further than those whose pregnancy was (obviously) unintended.
necessary, especially if you intend to insert an IUD.
A rule of thumb is that the diameter of the Karman cannula If there has been a suspicion of vaginal interference to
should till <13wks be 2mm less than the number of wks if the pregnancy, or venereal infection, use an appropriate
the foetus is still in the uterus. The means at 12wks a 10mm broad-spectrum antibiotic (e.g. doxycycline and
cannula is fine; at 6wks 4mm will do. Of course, at 18wks, metronidazole). If you have the resources it is a good idea to
10mm will do if you only mean to extract a piece of use antibiotic prophylaxis for everyone. However, if there is
placenta. overt sepsis, IV antibiotics are required (23.2).
N.B. Syphilis can cause miscarriages: if you have the
CAUTION! resources check for this on the spot and have the results
(1) Don't put a sound into a pregnant uterus. If you want to ready within 30mins (just like with an ANC visit), otherwise
know how long the uterus is, insert a large Hegar dilator, only 50% will return for treatment. Treat with long acting
suction curette or sponge-holder and mark how far it goes in penicillin and make sure the partner is also treated.
with your finger. N.B. It is obvious that some patients will have a complete
(2);Be gentle, or you will perforate the fundus. family at this stage e.g. Para 5 of age 40yrs, or Para 3
Your exploring finger will have shown you how deep it is. HIV+ve. Some patients will be very grateful if you combine
With your left hand on the abdomen, explore the uterus a uterine evacuation with a tubal ligation. Regret is usually
again with your finger to make sure it is empty. only seen in young women <30yrs old. If the logistics of
your hospital make it possible, you should give women a
If you still cannot empty the uterus fully, use a suction choice.
curette to remove the remaining pieces of placenta.
While it is still well contracted (sometimes with the help of DIFFICULTIES EVACUATING THE UTERUS (23.4).
400μg misoprostol rectally or oxytocin 10IU), use the
largest suction curette you have or very gently scrape the If there is profound hypotension, the cause may be severe
inside of the uterus (20-1E). Let it almost rest in your hand blood loss because the placenta has become stuck or is half
as you use it. Leaving the retained products of conception hanging out of the cervix (common). The external os may be
behind is serious, but perforating it (20-1F) is more so. tight, while the internal os and cervical canal dilate to
accommodate the pregnancy. This is quite different from a
If you do perforate the uterus with a suction curette, cervical gestation (20.8).
first disconnect the suction tubing and then withdraw the Don't wait to put up an IV line. Remove the placenta with a
curette, otherwise you might pull bowel or adnexa out! gloved finger on the ward without anaesthesia. If this fails,
pass a Sims, Collin’s or Cusco's speculum. If you see
You will know that the uterus is empty by: products of conception in the cervix, remove them with
(1) A characteristic grating feeling. sponge forceps. Blood loss usually stops miraculously.
(2) Your failure to remove any more tissue. Shock may be caused by a vasovagal attack: you may then
(3).Resistance to movement with a suction curette: be fooled into thinking a blood transfusion is necessary.
the retained products act a lubricant, so when they are no
longer there, you will feel more resistance. If there is heavy bleeding, start resuscitation and administer
(4).An ultrasound performed during or directly after the misoprostol or oxytocin and at the same time evacuate the
evacuation. N.B. 10mins later retained products are uterus with a finger on the ward. Even if evacuation is not
indistinguishable from blood clot. complete, it will help stop the bleeding.
Finally, with a large uterus that is still bleeding, perform a If bleeding does not stop after evacuation and you have
bimanual compression (22-10) to encourage contraction and excluded a uterine perforation, it is probably due to poor
expel clots from the uterus. Put two fingers into the anterior contraction of the uterus, or there may still be products of
vaginal fornix, and your other hand on to the abdominal conception in the uterus. Often there is no obvious reason.
wall. Compress the uterus between them. Make sure the uterus is empty. Administer 800µg
Return the patient to the ward with a vulval pad. Inspect this misoprostol rectally or oxytocin IV (40 units/L), massage
from time to time during the first 3hrs after the evacuation. the uterus to stop it bleeding, and repeat bimanual
If bleeding recurs, inject another dose of oxytocin 5IU IV compression. Be patient at this stage: 5-10mins of bimanual
or IM, or use 400μg of misoprostol rectally. compression may be necessary, but it will usually succeed.
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If these measures fail to control bleeding, suction curette If there is severe bleeding or an extensive tear, tie the
the uterus if you have not already done so. Sometimes uterine arteries at several locations in the area just after they
packing the uterus helps; do not pack the vagina as that only enter the uterus (22-14). If this fails, a B-Lynch suture
conceals the problem; it will not usually remove the cause of (22-13, 22.11) or hysterectomy (22.17) may be necessary.
the bleeding. A torn cervix is occasionally the cause and If you have closed a uterine tear, warn that the uterus is in
suturing might be a technical challenge. In that case packing danger of rupturing in later pregnancies and an elective
the vagina near the cervix might solve the problem. Caesarean Section (21.9) is then mandatory.
If even this fails to control bleeding (very rare), tie both If you feel a fibroid in the uterus (uncommon), it may
uterine arteries or perform a hysterectomy. Very rarely a have been the cause of the miscarriage (unusual).
cervical ectopic gestation (20.8) is the problem. Leave it for 3months before you treat it.
If it is pedunculated and submucous with a narrow neck,
If serious anaemia results, do not jump to transfusion don't be tempted to twist it off vaginally at the time of the
unless the Hb is <4-5g/dl. Always supply iron to take home. miscarriage. This can cause severe bleeding. Leave it for
The younger the patient, the easier it is for her to cope with a 1month while treating with iron supplements. If the cervix is
low Hb. It is better to spend a few days extra in hospital closed, first use misoprostol 400μg vaginally 2hrs prior to
because of dizziness than to get a transfusion contaminated excision (23.7).
with HIV or Hepatitis B or C. In young anaemic, otherwise
healthy women on oral iron, the Hb can increase 2·5g/dl/wk. If there are very few curettings, the miscarriage is
Older women and those with sepsis, malaria, or heart disease probably complete. There is however a possibility that your
cannot, however, so easily deal with very low Hb levels. diagnosis may be wrong, and that she has a CHRONIC
N.B. Sometimes women abort because of malaria and ECTOPIC GESTATION (20.7).
therefore combine blood loss with haemolysis. This can be Material removed or spontaneously aborted from the uterus
an extremely dangerous situation if missed. The high fever with an ectopic gestation has no connective tissue-like
may then be diagnosed as sepsis as a result of the structure. It is endometrium/decidua. (If you put it in an
miscarriage (induced or otherwise) instead of the cause of ordinary household sieve you can easily make it disappear if
the miscarriage. Severe malaria can make the Hb drop in a you rub it with a brush under the tap.) On the other hand,
day by 5g/dl. The jaundice seen with severe malaria is also even the products of conception at 5wks have so much
seen sometimes in sepsis. structure that this is not possible.
If you find injuries to the vagina, cervix or uterus, or If you feel that she has a uterine septum, clean out each
physical interference with the pregnancy is suspected, side of the uterine cavity.
and there is shock, severe sepsis or more severe anaemia
than simple vaginal blood loss could explain, or there is free BE CAREFUL WITH THE CURETTE!
gas in the abdominal cavity, the uterus is probably
perforated. Perform a laparotomy immediately, and inspect
the uterus. Do not forget to counsel and get consent for a 20.3 Termination of pregnancy
tubal ligation.
Legislation related to termination of pregnancy differs
If there is no improvement after evacuation, enormously throughout the world. In some countries in Latin
reconsider the diagnosis. She may have an ectopic gestation, America doctors do not dare to terminate a pregnancy even
or be severely anaemic, or have a collection of pus. If you to save a woman’s life. In others, abortions are allowed on
find an abscess in the pouch of Douglas, drain it (10.3). request up to 22wks.
Historically these operations were of course quite dangerous
If you think you have perforated the uterus, before modern techniques, prostaglandins and antibiotics
(a) after emptying the uterus, and you have not seen fat, were available. The extensive use of misoprostol (replacing
omentum or bowel on the forceps or in the vagina, return the sticks, roots, catheters, soaps, poisons and uterine massage)
patient to the ward. Keep her nil orally on IV fluids with have made even late abortions far less dangerous.
gentamicin and metronidazole, and observe the pulse, Up to 7-9wks’ gestation a combination of 200mg
temperature, blood pressure, urine output and suppleness of mifepristone (blocks progesterone receptors), followed
the abdomen carefully. The perforation will probably heal 12-72hrs later by 800µg vaginal misoprostol tablets
easily, especially if she was in the 1st trimester. If there are, (prostaglandin E1 compound) is very effective. In most
unusually, increasing signs of infection or bleeding, perform countries mifepristone, the abortion pill, is not available.
a laparotomy to close the wound in the uterus. However, misoprostol (perhaps in repeated doses) without
(b) before emptying the uterus, try a digital evacuation and mifepristone is also quite successful.
accept that, perhaps, evacuation is incomplete. The disadvantage of this so-called medical abortion is that it
Observe carefully as before. is far less easy to combine with the insertion of an IUD than
an early suction evacuation. In most countries induced
If there is evidence of omental or bowel injury, abortions are performed with the help of suction curettes
start resuscitation and perform an immediate laparotomy, only up to around 13wks. GA is not essential but ketamine
and close the uterine perforation. Repair (11-5) or resect can be useful.
(11-7) the bowel and omentum.
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You should hesitate to remove pregnancies instrumentally There is 50-90% chance that spontaneous delivery will
which have proceeded further as you will need to use a occur within 4wks after foetal death, whatever the duration
combination of suction and forceps extraction. This needs of the pregnancy. But, as long as a dead foetus remains
experience, proper training and preferably guidance by inside the uterus, there is the remote but serious risk of a
ultrasound. serious coagulation defect, and catastrophic bleeding.
Induced abortions past 12weeks' gestation are prohibited This risk is low initially, but increases with time, particularly
under most conditions in many countries. You must acquaint 4-6wks after death.
yourself with the laws in force in your country before
intervening. Rupturing the membranes to induce labour is dangerous,
because the dead foetal tissues are easily infected by
anaerobes and antibiotics will not reach the foetal tissues if
there is no foetal circulation.
20.4 Foetal death: retained miscarriage &
intra-uterine death Use oxytocin and/or prostaglandins for a missed miscarriage
An embryo or foetus can die at any time during pregnancy. or intra-uterine death. Throughout pregnancy there is
What you can do about it depends on whether death occurs sensitivity of the uterus to prostaglandins, although the
before or after 20wks. Before this time this is termed a optimal dose varies according to gestation, but its sensitivity
retained miscarriage, afterwards an intra-uterine death. to oxytocin increases with each gestational week and
oxytocin in early pregnancy is ineffective. Misoprostol is
Before 20wks a dead foetus is usually expelled without easiest to administer (22.2).
maternal knowledge that the pregnancy has ended.
Occasionally however, uterine emptying is delayed for MISSED MISCARRIAGE
several weeks with failure of normal growth in size of the If a mother's uterus is small for her gestational age,
uterus and the mother feeling symptoms of early pregnancy perhaps with a brownish vaginal discharge, suspect foetal
diminishing. Alternatively, there may be a threatened death. Monitor the growth of the uterus carefully: it will not
miscarriage which stops bleeding spontaneously, grow, and may even become smaller. Pregnancy tests
and is followed by a brown discharge and no further true become -ve after some weeks. Methods of detecting the
blood loss. foetal heartbeat vary in their sensitivity: ultrasound scanning
Although the loss of a pregnancy may be tragic, a missed (38.3) detects it certainly at 8wks, Doppler ultrasound at 10-
miscarriage has few physical risks, there is little risk of a 16wks, and an ordinary stethoscope at 20-28wks.
clotting defect this early in pregnancy, and provided nobody
interferes with instruments, there is very little risk of DIFFERENTIAL DIAGNOSIS includes:
infection. (1).A normal pregnancy of shorter duration (wrong dates),
(2).A slow-leaking ectopic gestation,
After about 20wks: (3).A false (imagined) pregnancy (pseudocyesis),
(1).The mother is aware of the intra-uterine death of the (4) Fibroids.
foetus because foetal movements stop, or do not occur when
they should (18-22wks in a primipara, 16-20wks in a MANAGEMENT.
multipara). If spontaneous miscarriage does not follow after 4-6wks,
(2).The foetal heart movements are not visible (6·5-8wks) on proceed as follows:
ultrasound or not heard (10-16wks) with a Doppler.
Remember that using a foetal stethoscope is unreliable in If the uterus is smaller than 10wks, put 400μg misoprostol
obesity or polyhydramnios and enables you to hear the heart in the posterior vaginal fornix, or buccal cavity, and repeat
only at 20-28wks. this 3hrly for 12hrs. Spontaneous evacuation will usually
(3).The height of the fundus, as found by palpation, fails to occur; if not, dilate the cervix to Hegar (maximum 10),
match that expected from the dates. Instead, it either remains and then use a #6-10 Karman curette, depending on the
stationary or falls. For this sign to be useful, you must largest Hegar used, with maximum vacuum. Continue until
measure the height of the fundus above the symphysis pubis the uterus is empty, and you can feel the uterus tight round
accurately with a tape measure. So, when you suspect foetal the curette.
death, impress this on the midwives.
(4).Radiological signs of foetal death (after 28wks) show If the uterus is larger than 12-13wks, don't attempt an
overlapping of the bones of the foetal skull (Spalding's sign), ordinary dilation & curettage. Instead, use misoprostol.
hyperflexion of the spine, and gas in the great vessels though N.B. You can dilate the uterus to Hegar 10, and use a
it is rare that there is a real indication for radiographs in this #10 Karman curette, which works up to 12wks but not
setting. beyond because the foetal parts become too large!
N.B. β-HCG tests for pregnancy take 4 or even 8wks to Attempting to perform a standard dilation & curettage (23.4)
become -ve, so they are of little value. on a uterus larger than this can cause disastrous bleeding,
and perhaps infection.
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INTRA-UTERINE DEATH (i.e. after 19+ 6wks). If drowsiness or convulsions ensue whilst on an oxytocin
The mother notices that foetal movements stop, or do not infusion, suspect water intoxication. Stop the infusion and
occur when they should (at around 18wks). Or, a midwife let the kidneys excrete the water. Infuse 100ml 5% saline
fails to hear the foetal heart after 24wks. slowly IV.
CAUTION! EXTRA SPECIAL CARE is necessary when MPHO (16yrs), Gravida I, was admitted in labour in a district hospital with
stalled progress. The doctor diagnosed CPD with an enormous caput.
you use oxytocin!
At Caesarean Section, the routine incision was, by a large margin, not large
(1);You may have to use large doses. Oxytocin has an enough to deliver the head now found to be hydrocephalic. The doctor
antidiuretic effect, and fluid overload is a danger. So: perforated the skull and 2l fluid escaped. The head could now be delivered.
(a);increase the concentration of the infusion, rather than The baby also had a large spina bifida and club feet, and was wrapped in
towels and put on a table. During abdominal closure, the baby who
the volume you use,
everybody had thought had died, started crying. The wound in the skull
(b) use Ringer's lactate or saline, rather than 5% dextrose, healed afterwards but it was clear the legs were permanently paralysed.
(c) infuse a maximum of 3l IV fluid in 24hrs. The baby died 3months later probably from repeated urinary tract
(d);keep a fluid balance chart; if there is a positive fluid infections. The mother was severely stressed and depressed during this
time. Any further delivery should be under close medical supervision.
balance of >2l, stop the infusion.
LESSON Hydrocephalus drainage only needs a small needle. Mothers of
(2) Oxytocin (and misoprostol) can rarely rupture the uterus malformed babies need counselling before delivery if at all possible.
as early as 18wks, so don't use more oxytocin than you need.
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DIFFICULTIES WITH A DEAD FOETUS <30WKS Here we are concerned with the management of patients
If you are not sure about foetal death, perform an with ‘suspected cervical incompetence’. This means that the
ultrasound (38.3); alternatively, wait, and review in 2wks. cervix opens spontaneously between 14-30wks, without the
By this time it should be clear if the foetus is dead or not. uterus contracting. Sometimes this is owing to a previous
forceful dilatation of the cervix, or to a previous traumatic
If delivery is complicated by severe bleeding, delivery. Usually, there is no obvious cause.
disseminated intravascular coagulation (DIC) is a possibility The diagnosis is difficult. It is usually made by the history
(3.5). Maintain the blood volume, and try to administer fresh alone. A typical patient gives a history of ≥2 spontaneous
blood, as well as packed red cells and fresh frozen plasma. mid-term miscarriages, without much uterine contraction
If bleeding is not controlled when the uterus is empty, (until the membranes have ruptured), or bleeding.
use an oxytocin infusion with 400μg misoprostol PR. The first symptom is a watery vaginal discharge,
Try compressing the uterus, pack it for 24hrs, and then often followed by a sudden loss of amniotic fluid.
remove the pack. This is a useful temporary measure for any Soon afterwards the foetus is delivered, often still alive.
bleeding uterus, and may save the need to perform a The diagnosis is only certain in the present pregnancy if the
laparotomy. uterus is found to be effacing and dilating, without any
If this fails to control bleeding, apply a B-Lynch suture uterine contractions. When this is happening, it is often too
(22-13) and failing this, tie the uterine arteries (22-14). late to intervene surgically.
If this also fails, put a tourniquet round the cervix (22.11) If you have a vaginal ultrasound probe, it is easy to measure
which will give you time to arrange a hysterectomy (21.17) the length of the cervix. If the cervix is ≤1·5cm before
if necessary. 32wks, you have an indication for a cervical suture if there
is a history of repeated consecutive mid-term miscarriage.
If you know or suspect that an IUD has been in situ
N.B. In multiple pregnancies, however, 2-4cm dilation is
>4wks, check the platelets. If they are very low that is an
quite frequent without an imminent delivery although,
indication for administering heparin (paradoxically).
There is a risk of bleeding because of DIC. Use the dose of of course, multiple pregnancies are associated with pre-term
whatever heparin you have available normally used for deliveries.
prophylaxis. The platelet count will rise rapidly;
True cervical incompetence is probably quite rare.
start induction the next day.
Do not make this diagnosis too often or you will operate
upon many patients unnecessarily. So only operate on those
20.5 Recurrent mid-term miscarriages patients with a highly suggestive history.
N.B. Cervical incompetence does not cause miscarriage
before 14wks.
It is not easy to help women with a history of repeated early
A course of doxycycline (or erythromycin) & metronidazole
miscarriages. These are often the result of some foetal
before the next pregnancy or during this pregnancy may
abnormality for which nothing can be done. The best advice
help.
is to keep trying. Most women will eventually achieve a
successful pregnancy.
McDONALD’S CERVICAL CERCLAGE (GRADE 2.2)
Although recurrent miscarriage (RM) affects only 1–3% of
The simplest method is McDonald's, which is a variation of
couples, it has a major influence on the wellbeing and
the original Shirodkar suture. If you do it for the right
psychosocial status of patients. Anatomical malformations,
indications, it has a good chance of succeeding.
infectious diseases, endocrine disorders, autoimmune defects
Timing is critical. If you do it too early (<14wks), an early
as well as acquired and inherited thrombophilia are
miscarriage due to a foetal abnormality may arise,
established risk factors in RM. Treatment strategies like
and the suture is wasted. If you do it too late (>24wks),
aspirin and low molecular weight heparin are standard,
a miscarriage may have already happened.
although only a few placebo-controlled trials have proven
Don't insert a suture between pregnancies. This will cause
their benefit in respect to the live birth rate.
more trouble than it is worth. Remember that the benefits of
the procedure are related to good selection, especially by
Mid-term miscarriages are different. They are not usually
examination of cervical length.
caused by recognizable foetal abnormalities. Some are due
to maternal illness (HIV disease, syphilis, hypertension, SIFLOSA (20 years) had a McDonald suture inserted at 14wks, following
uterine fibroid vaginitis, cervicitis, diabetes, etc.), or to a 3 mid-term miscarriages. Her pregnancy continued uneventfully until term,
congenital malformation of the uterine cavity. A low level of when she was admitted for delivery. Unfortunately, the consultant who
progestagens may play a role. As in early pregnancy, inserted the suture was on leave, and it was not noticed by the duty team.
She complained of severe pain during the second stage of labour, but this
often no cause can be found. The prognosis of a mother with was ignored. Labour proceeded normally, and she delivered a live baby
repeated mid-term miscarriages depends on the cause, without help. Immediately after delivery she complained of urinary
and is excellent if syphilis can be treated, or cervical incontinence and collapsed. No-one took any notice of this, and she was
incompetence corrected surgically. discharged after 2days. On examination 2months later in another hospital
she was found to have a high 1cm vesicovaginal fistula, which was
Hypertension and diabetes are more difficult to treat, contiguous with the cervix, which was torn and ragged.
and the outcome of the pregnancy is less certain. This was successfully repaired abdominally.
Mothers in whom no cause can be found have a reasonable LESSON (1) Always explain clearly to the patient that she must have the
prognosis: about 70% of their pregnancies go to term. suture removed at 37wks or in labour. (2) Take her complaints seriously.
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INDICATIONS. ANAESTHESIA
Two or more consecutive almost painless miscarriages (1) Light GA
between 16-28wks especially when the foetus was alive just (2) Ketamine.
after birth, and/or there was initially premature rupture (3) Spinal. You must be able to retract the cervix and dilate
of membranes. There may be a scarred widely open the vagina widely to insert the sutures.
patulous cervix. Preferably insert the suture at 14wks,
when the danger of an early miscarriage is passed. METHOD.
Check the foetal heart with Ultrasound or Doppler.
Confirm the gestational age (38.3) .
Insert a speculum. Grasp the anterior & posterior
lips of the cervix with the same sponge forceps.
Insert a #2 monofilament nylon (or special cerclage suture)
superiorly in the outer surface of the cervix, near the level of
the internal os, about 3mm under the surface of the cervix
staying more or less at the same depth in the
cervix for 90-120º and then let your needle come out.
Continue to reinsert the sutures in the cervix near the place
where your previous insertion exited the cervix at regular
intervals as shown, so as to encircle it. Then tighten the
suture round the cervix and knot in such a way that when it
is tightened it would still be easy to insert scissors between
the knot and the cervix. This is so that, later at 37wks or
when in labour, you can cut on one side of the knot. The
canal must be just patent as the suture is tied. As the patient
is pregnant, don't insert a dilator. Admit her for 1wk: most
failures occur in this time.
Write on the notes outside and inside in large red letters,
CAUTION! Don't insert these sutures unless: In many parts of the world one in every 50-200 gestations is
(1) The mother has access to hospital where at all hours of ectopically (i.e. abnormally) implanted, of which 99%
the day and night there will be someone present who will see implant somewhere along the Fallopian tube.
her, and who is competent to remove the suture. Very occasionally implantation is in the abdominal cavity
(2) You have explained precisely what you are going to do, (20.9), or in the cervix. Trouble occurs either because the
and that the suture must be removed at 37wks, tube ruptures, or because the gestation aborts through the
or when labour starts. abdominal end of the tube, into the abdominal cavity.
How soon there is trouble depends on where implantation
occurs.
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Ectopic gestation is more common if the tubes are affected Symptoms start when an ectopic gestation grows so large
by previous PID, if an IUD is in situ, or if there has been that it ruptures out of the tube that contains it.
previous tubal surgery. The periods are usually a few days to a few months late, and
she may rightly think she is pregnant. Or, she may not think
she is pregnant because:
(1) the tube may rupture before she has missed a period.
(2) vaginal bleeding due to decreasing hormone levels may
begin at about the time of the expected period.
(3) she may have an IUD in situ, be taking a contraceptive,
or have had a tubal ligation and assume she cannot be
pregnant. If the period of amenorrhoea is short, before the
symptoms start, gestation is likely to be in the isthmus, and
the effects of rupture worse.
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Don't let anyone who might have an ectopic gestation go DIFFERENTIAL DIAGNOSIS
home; if you opt for observation, make sure you: (a) OF ‘ACUTE’ ECTOPIC GESTATION:
(1) monitor her carefully, If there is blood present:
(2) are able to operate at very short notice, (1) Uterine rupture (21.17),
(3) have discussed the option of sterilization if you decide to (2) Unsuspected abdominal trauma,
operate. (3) Abdominal tuberculosis (16.1),
As so often, ‘look and see’ is better than ‘wait and see’. (4) Ruptured haemorrhagic ovarian cyst (23.9)
These are rewarding patients, because they seldom die if you (5) Ruptured abdominal aneurysm (35.8),
treat them correctly, even if they have bled severely. (6) Acute haemorrhagic pancreatitis (15.13)
So be watchful.
DIFFERENTIAL DIAGNOSIS
DON'T FORGET ECTOPIC GESTATION (b) OF ‘SUBACUTE’ ECTOPIC GESTATION
IN A WOMAN OF CHILDBEARING AGE Most causes of an acute abdomen (10.1, 12.1), and other
causes of anaemia.
The main failures are not to:
(1) consider pregnancy as a possibility, If the amount of blood lost PV fully explains the extent of
(2) place importance on known risk factors, shock and anaemia, suspect a miscarriage.
(3) think of an ectopic gestation as a diagnosis,
(4) arrange suitable follow-up. LAPAROTOMY FOR ECTOPIC GESTATION
ACUTE & SUBACUTE ECTOPIC GESTATION Prepare the equipment needed for autotransfusion (5-1).
N.B. ABOUT TRANSFUSION: A healthy woman who
EXAMINATION. Look for general signs of blood loss loses blood fast without having an infusion of fluid will die,
(shock and anaemia), and for signs of bleeding within the if she does so, not from lack of red blood cells but from lack
abdomen. Tenderness may be mild, distension, rebound of circulating volume. This is the basis of hypovolaemic
tenderness and guarding are variable, and may be absent. shock, i.e. an insufficient response to acute volume deficit.
If there is a large tender mass in the lower abdomen, If then she arrives in shock and is operated immediately and
bleeding has been confined there by adhesions. her circulating volume is replaced with normal saline just
If you suspect free fluid in the abdomen, try to confirm this before and during operation she will have enough red blood
(as below). There is often a low-grade fever. cells left to survive.
Gently perform a vaginal examination. The important signs However, if she has had volume replacement before arriving
are pain on moving the cervix, tenderness in the posterior in hospital, or in hospital while waiting to be operated upon,
fornix and pouch of Douglas, and perhaps acute adnexal or whilst bleeding over a prolonged period, then her
tenderness, which is worse on one side (highly suggestive). circulating volume will not be the problem. Note that about
CAUTION! Don't do a vigorous vaginal or bimanual ⅓ of saline infused IV will remain in the circulation,
examination if you are not able to start surgery in 20mins, therefore losing 2l blood will be compensated in terms of
e.g. when visiting a rural clinic or when the theatre staff has volume by 6l saline or Ringers lactate. With volume
just gone home: you may make bleeding get worse or even replacement but continuous bleeding, the cause of death is
re-start! lack of oxygen because of lack of red blood cells.
So, in theory, a patient arriving in your hospital with a
TESTS. ruptured ectopic, operated upon immediately (with a very
Do a sensitive PREGNANCY TEST making sure your kit is low dose of ketamine) while the 1st litre of saline is being
not out of date! infused rapidly does not need a blood transfusion.
Check the Hb: it is normal to begin with and only drops as If the patient has had IV fluids for some time, then it is
tissue fluid or IV replacements dilutes the circulating blood. much more difficult to tell if she needs red blood cells.
A few days after a severe bleed, however, you may find an Also because the blood in her abdomen is now partly diluted
Hb as low as 3g/dl. blood, she might have received the saline infusion before
Check for ORTHOSTATIC HYPOTENSION with a she was really in danger, and she might have bled after the
Schellong test: take the pulse when the patient is sitting up; infusion was set up.
if it is >25 beats/min faster than when she lies down for at
least 10min, this is a good sign of hypovolaemia. If the total volume of blood (clots) in the abdomen is
Look for free fluid by ULTRASOUND (38.2,3). In case of <1-1·5l (the younger she is, usually the stronger) she does
doubt, run 200ml of normal saline via a giving set and not really need to be (auto) transfused unless she was
cannula into the abdomen. Then ask the patient to lie on her previously severely anaemic, e.g. due to malaria or sickle
left and then right side. Then place the bag on the ground. cell disease. If possible these patients (with infusions
If clear fluid runs back in the system you can exclude a running) should be operated immediately and perhaps
ruptured ectopic gestation. If blood runs down, especially autotransfused.
with small clots in it, this strongly supports the diagnosis.
Do not reject the diagnosis, though, on a doubtful result. If the patient is stable at the end of the operation and has
enough circulating volume and you are certain you have
stopped the bleeding, then a blood transfusion is often not
needed.
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What often happens, though, is that it takes so long to The bag with citrate in it may fill within minutes: hand it to
organise cross-matching of blood that the first bag is the anaesthetist for auto-transfusion (5.3). Scrub up, gown
connected to a stable patient 4hrs or so after the operation. up and operate while the patient is given that blood via a
Because she has not actually died, she probably did not filtered giving set.
really need the blood. However, the first signs of problems
are ‘oxygen hunger’: cardiac failure typified by crepitations Ketamine is ideal for anaesthesia. Do not use thiopentone
over the lung bases, an impossibility to lie horizontally, for induction: the blood pressure might crash!
and confusion. Rapid transfusion in this situation may well
NTABISENG (35yrs) was suspected of having an ectopic gestation in a
prove fatal due to cardiac overload.
small mission hospital. Her Hb was 8g/dl. The nurse anaesthetist there
The first step then is to administer 20-40mg furosemide IV. refused to take the risk of giving anaesthesia and referred the patient to the
Fluid overload can also produce this syndrome rather than nearest government district hospital where she arrived 2hrs later.
lack of red blood cells. Check the Hb: if <5g/dl, transfuse The Hb being 6g/dl by now, the nurse there even more strongly refused to
give anaesthesia. The patient was now transported to the provincial hospital
1 unit of red cells if available.
where on arrival 3hrs later her Hb was 4g/dl. Neither surgeon nor
Remember transfusions are often just giving you an extra anaesthetist wanted to intervene, so she was now referred to a Central
margin of safety. Therefore transfusion is justified if donors Hospital but did not arrive alive.
are abundant and safe. If this is not the case you should be LESSON. The message is clear: don’t think others in more sophisticated
surroundings can do better with a patient who is much worse.
extra careful with your haemostasis and manage with
smaller safety margins. The above applies also to women
bleeding from incomplete and /or induced miscarriages. PREPARATION.
In those cases bleeding can be often stopped immediately If you have time, insert a urinary catheter: leave it in situ.
even without access to a fully equipped theatre. Since one ectopic gestation is followed in 30% of cases by
Therefore miscarriages very seldom need transfusions. another, discuss whether the patient wishes any further
Make doubly sure bleeding is not still continuing! pregnancies and, if not, ask for permission to tie the normal
N.B. Some teenage or premenopausal women arrive very tube.
pale after weeks of dysfunctional uterine bleeding
TSITSI (39yrs) was a Para 6 and lived more than a day’s travelling away
(DUB: 23.3). Other women have a fibroid prolapsing from the hospital. She arrived in severe shock from an ectopic gestation
through the cervix. over the weekend but was operated with success. The next year, the same
Often women who are bleeding are extremely anaemic. thing happened but because there were floods, her journey to hospital took
much longer and she died en route.
The reflex of some health workers is to give them a fast
LESSON. If she had had the other tube tied, or access to proper
infusion of saline when there is nothing wrong with their contraceptives or had at least an IUD inserted, this totally avoidable death
circulating volume. This extra fluid gives extra work to the could have been avoided.
heart which is already working to capacity because the heart
muscle is anoxic having to circulate the remaining red blood
cells much more frequently. This fluid might actually kill
the patient as a result of inducing cardiac failure.
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Put your hand into the pelvis and feel for the uterus and lift
it out if possible. Find the ruptured Fallopian tube, and if it
is still actively bleeding, grasp its broad ligament between
your finger and thumb, so as to compress the vessels in it
(20-4). Apply long curved haemostats across the tubes on
either side of the ectopic gestation (20-5) so that the points
meet and you leave no part of the broad ligament
unclamped. Preserve the ovary.
N.B. You can put the distal clamp either over the distal
tube (20-5X) or over the remaining broad ligament (20-5Y)
which will result in removal of the distal tube.
If however, the other tube looks satisfactory apart from a Examine the specimen. In the middle of an ill-defined
closed distal end, and the patient is stable, it is occasionally placenta and blood clot you will see the amniotic sac.
responsible to open that distal end bluntly with a small If there is evidence of gestational trophoblastic disease
artery forceps and fix the ‘petals’ with 5/0 nylon to keep the (23.10), send the specimen for histology.
tube open.
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POSTOPERATIVELY, monitor the urine output until the If one tube is grossly swollen and full of pus, it is better to
patient is out of danger. Treat the anaemia with folic acid remove it anyway if you have opened the abdomen: try not
orally and/or iron or if the Hb is <5g/dl with blood to spread infection, and lavage the pelvis afterwards with
transfusion. Very rarely will you need >1 unit blood warm water. If there is bilateral severe pyosalpinx in a
transfusion. woman with no children, you might prefer to aspirate the
pus with a needle and treat with antibiotics.
DIFFICULTIES WITH ACUTE AND SUBACUTE ECTOPIC
GESTATIONS If there is a tubo-ovarian abscess (23.1), drain it.
If you cannot find the tube with the ectopic gestation, don't
panic. Allow yourself time to scoop out blood and clots. If you find the appendix adherent to the tube, peel it off.
Make sure you have tipped the head of the table down If you damage it, perform an appendicectomy (14.1).
(the Trendelenburg position), so as to make the blood and
the bowel move away from the pelvis. Feel for the uterus in If there is no ectopic gestation, and you find copious
the midline in the hollow of the sacrum. Lift it into the bleeding from the ovary as a result of ovulation,
wound. If it is stuck down by adhesions, divide them with control bleeding with sutures.
gentle traction, or cut them with scissors. Having found the N.B. Very occasionally there is blood in the abdomen
uterus, feel for the affected tube. If this is also stuck down from a spontaneous rupture of the spleen (15.17) or even
by adhesions to the omentum or bowel, separate them from the needle hole you created trying to diagnose an
(usually not too difficult). ectopic gestation!
(a) If the tube is stuck to the broad ligament on the same
side (more difficult), try to get your fingers under it and the If there is a 2nd gestation in the uterus (very rare),
ovary, and lift them into the wound, by scraping the tip of removing the ectopic gestation may not disturb it.
your fingers along the back of the broad ligament. If amenorrhoea continues, its presence will soon be obvious.
If necessary, cut adhesions between the tube and the rectum.
(b) If the ovary is stuck to the tube, or you have torn it as If there is a large purple haematoma in the broad
you mobilized it, you sometimes have to remove it. ligament, the ectopic gestation has ruptured into it, and not
CAUTION! Before you remove the ovary (if you have into the peritoneum, and may be quite large (12-16wk size
to), make sure you separate adhesions between it and the or larger).
broad ligament. If you don't do this, you may clamp the CAUTION!
broad ligament too low down, and so include the ureter. (1) Don't burrow into the lower part of the broad ligament:
(c) If adhesions obscure everything, search for the uterus, you may damage the large venous plexuses there, or the
or the infundibulopelvic ligament (23-21). On the right this ureter.
comes away from under the caecum and appendix, and on (2);Don't try to control bleeding by suturing deeply,
the left from under the mesosigmoid. unless this is absolutely essential: you may tie the ureter by
mistake.
The blood supply to the tube and ovary comes from: Try one of the following 3 methos:
(1);The ovarian vessels in the infundibulopelvic ligament. (1) Clamp and divide the round ligament on the same side
(2);The ascending branches of the uterine vessels. 2-3cm from the uterus. Check the anatomy (23-20,21).
If you can put a clamp across the infundibulopelvic (2) Clamp the tube and ovarian ligament close to the uterus,
ligament, and another one across the tube and broad but don't divide them at this stage (if the anatomy is
ligament next to the uterus, you will interrupt the blood confused, leave this and do it later). Cut the peritoneum
supply to the ectopic. from the round ligament in the direction of the
infundibulopelvic ligament. This will open the top of the
If there is a raw area in the peritoneum which oozes, broad ligament. As you approach the infundibulopelvic
after you have removed the ectopic gestation, it will usually ligament, find, clamp and divide the ovarian vessels without
stop spontaneously, if there are no obviously bleeding including the ureter! This will have isolated the blood supply
vessels. Try compressing if firmly for 5mins. If is continues to the ectopic gestation. Now you can clamp and divide the
to ooze, insert a drain for 24hrs, and monitor the patient tube and ovarian ligament. If the ectopic is not already free,
carefully. a little blunt dissection should free it from the base of the
broad ligament. If oozing from the base of the broad
If you find inflamed tubes with some pus discharging from ligament does not stop spontaneously, clamp and tie the
their fimbriated ends, or evidence of inflammation without bleeding vessels.
pus or abscess formation, this is salpingitis (23.1), not an (3) Or, mobilize the uterus by removing blood clot and
ectopic gestation. Don't excise the tubes: take a pus swab dividing light adhesions. Apply two large artery forceps to
and administer broad spectrum antibiotics. the tube as before (20-5), but don't excise the ectopic
gestation at this stage. Cut a ½cm opening in the back of the
If there is a chronic pyosalpinx, excising it will be very broad ligament, and squeeze out the haematoma by pressing
risky if it has stuck to the bowel, but this may be possible if it from below.
it is not too friable and adherent. Monitor the patient.
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There are several consequences possible: The diagnosis of a chronic ectopic can be difficult, and is
(1);The haematoma does not reform because the artery often missed. Its symptoms are like those of PID;
forceps have controlled the bleeding. Excise the ectopic if she has had several similar attacks of pain without any
gestation, complete the operation in the usual way, and then missed periods, she probably does have PID (23.1).
suture the hole in the broad ligament.
(2) The haematoma reforms. Open the broad ligament more
widely, look for a bleeding point, and tie it off.
If you find a ‘chronic’ ectopic (20.7), an angular or Fig. 20-6 CULDOCENTESIS can be used to confirm the presence of
cervical (20.8), or an abdominal gestation (20.9), blood or pus in the pelvic peritoneum, and to distinguish between PID
see below. and a pelvic heamatocoele (chronic ectopic gestation) as the cause of a
pelvic mass. If you find clear fluid, this might be from a gestational sac
in the pouch of Douglas.
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Pull the cervix firmly down and insert one long-acting Other, rarer, presentations are:
absorbable suture from the 2-4o'clock and one from the (7).An abdominal mass after 26wks adjacent to an empty
8-10o'clock positions, as high as you can at the level of the uterus (or a uterus enlarged to the size of a 12-16wk
cervicovaginal junction. Provided you do not go above this gestation), which is quite separate from it, and which you
level the ureters will be safe. Also if you stay very near or may think is a fibroid.
better inside the cervix with your suture you will not tie (8).A distended abdomen which is like a full term gestation,
(but perhaps kink) the ureter. Don't try any dissection. and a mass which is less cystic and rubbery than a
normal gestation, with accompanied ‘menstruation’.
Then insert a large (50ml or more) Foley catheter into the On questioning, the patient may later admit having missed
bleeding cavity in the cervix, inflate the balloon, and leave it some periods, possibly several, in the past.
for 24hrs. Fluid from the uterus will be able to drain through (9).An abscess in the abdomen rupturing through the
the tube. It helps to infiltrate the cervix with 10-20ml abdominal wall. You see foetal bones emerging!
1:80,000 to 200,000 adrenaline solution. (10).An abscess ruptures into the bowel with passage of
foetal bones in the faeces.
If this fails, perform a laparotomy and tie the uterine arteries (11).A firm mass which you presume to be an ovarian
bilaterally (22-14, 23.15) after they enter the cervix and tumour in an elderly lady: it turns out to be a petrified foetus
uterus bilaterally. This way you cannot tie the ureters. (lithopaedion).
You can insert 2-3 sutures on each side 0·5-1cm medially to (12).Loss of weight and general ill health.
the lateral margin in the cervix (first from anterior to
posterior then the same suture posterior to anterior entering The diagnosis depends on recognizing that the patient is or
2-3cm in the direction of the fundus) parallel to lateral was pregnant and that the gestation is not in the uterus.
margin and then tie them. Do the same in the lower uterine
area. Be careful not to penetrate the bladder as sometimes it The history is seldom helpful, but:
needs to be dissected down. If this too fails, perform a (1) she may have had episodes of pain in early pregnancy;
hysterectomy (21.17). (2) she may have a history of a previous ectopic gestation; or
(3) if she is an experienced multipara, she may say that the
pregnancy 'feels different'.
20.9 Abdominal gestation MARY (19 years) was found to have a transverse lie at 7months.
External version failed, so she was allowed to go to term. At 40wks she had
abdominal pains, but the lie was still oblique. On pelvic examination the
An ectopic gestation occasionally slips backwards down a cervix was in a curious position in front of the foetal head.
tube, or bursts out of it without causing excessive At Caesarean Section she did not seem to have a uterus, instead the
membranes were close against the abdominal wall. After a live baby girl
haemorrhage, and embeds itself elsewhere in the abdominal had been delivered, the placenta was found to be attached to the left
cavity. Sometimes, an ovum is fertilized outside a tube on Fallopian tube. It was left in place and as many of the membranes as
the surface of an ovary, and then implants itself in the possible removed. She recovered uneventfully.
abdominal cavity. Such an ectopic gestation may die at any LESSONS (1) If something rather unusual happens, think of the possibility
of an extra-uterine gestation. (2) If you cannot easily remove the placenta,
stage, or proceed to term. An abdominal gestation is thus a leave it.
rare consequence of a simple ectopic gestation, so that in
areas where ectopic gestations are common and not DIAGNOSIS.
immediately attended to, the incidence of abdominal Perform a vaginal examination feeling with the finger
gestations is increased also. An abdominal gestation causes through the cervix (often easy in a multipara at term).
comparatively few symptoms. Often the diagnosis depends You will note an empty space, the membranes or presenting
on the sum of many clues. part being missing. Sometimes you can feel the fundus
opposite from the inside.
A patient with an abdominal gestation may present with:
(1).Persistent abdominal pain from c.26-28wks onwards of On ULTRASOUND, note the gestation attached to an empty
variable severity, which is not well localized. uterus (which you may think, at first, is a fibroid)
(2).The 'uterus' (in reality the gestational sac) is ill-defined, N.B. You may miss an abdominal gestation on ultrasound
and feels 'odd', when you palpate it. The foetal parts may be if you concentrate on the foetus itself without verifying that
abnormally easy or abnormally difficult to feel. The foetal it is inside the uterus.
lie is often abnormal, and may be persistently transverse or
oblique. RADIOGRAPHS.
(3).The foregoing features accompanied by the failure of the (1) The foetus may be in an abnormal attitude and remain in
'uterus' to enlarge, typically at 32wks, and foetal death. it over a long period.
(4).The foregoing features combined with a 'uterus' that (2) In an upright lateral film the foetal parts may overlap the
distends more than it should, so that you suspect shadow of the maternal spine. This is rare in a normal
polyhydramnios. pregnancy.
(5) Postmaturity >40wks).
(6).Foetal death which is neither expelled spontaneously nor
with misoprostol nor oxytocin (20.4).
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MANAGEMENT.
Before 24wks, perform a laparotomy. This may be
difficult, so try to refer.
GERALDINE (38 years), after years of infertility finally became
pregnant. She kept having abdominal pains but was the last to
complain about it. She was so happy and besides she lived far from
the nearest clinic. She was referred to the Central Hospital after
she was checked by a midwife in the clinic for oblique lie.
That evening she complained about abdominal pains. The junior
doctor was summoned and arrived after quite a delay and
diagnosed PID in pregnancy and prescribed antibiotics. The ward
nurse had phoned the consultant because the junior doctor took so
long in coming and, arriving 5mins after the junior doctor had left,
he examined the patient properly abdominally and vaginally.
He found what he thought was an acute abdomen due either to an
abdominal gestation or a uterine rupture. Luckily the patient got to
theatre within 15mins. Upon opening the abdomen, much arterial
bleeding was seen, but a live baby was delivered. The bleeding
caused by the placenta being partly separated from the left adnexa
was stopped by compression; the placenta was then removed
together with the left adnexa and a large part of omentum.
Some large Z-sutures were placed to secure haemostasis against
the inside of the abdominal wall.
LESSON. Do not diagnose PID in pregnancy unless you have
convincing proof: other diagnoses are far more likely.
The foetus can implant itself anywhere, but because the Open the abdomen with care, because bowel may be
placenta is so large, it is nearly always attached to bowel or adherent to the abdominal wall. Search for the amniotic sac
omentum somewhere. The common sites are: and placenta. Open the sac through a thin area where there is
(1) the pouch of Douglas. no placenta. If necessary, remove any bowel and omentum
(2) the broad ligament, where it is attached to the uterus. from the front of the sac. Dissect away the sac and remove
(3) the pelvic wall. the foetus.
(4) the adnexa.
If the placenta is not fixed to the bowel, or some other
After 24wks, if the foetus is still alive, keep the mother in essential structure, and you think you could shell it out
hospital to wait until 34-36wks, so as to improve the chances quite easily, then remove it. But if it is fixed to the bowel, to
of foetal survival. Often, she has few children or none, and the mesentery, to the parietal peritoneum over a large area,
will be grateful for a live child. Bleeding before term, or some other vital structure, leave it. Disturbing it will
though uncommon, is a real risk, so this is only a useful cause severe bleeding.
option if there is always a theatre team available at short
notice and there is easy access to blood. If the gestation has arisen in a tube and/or ovary, and the
sac has a vascular pedicle which you can clamp and divide,
After 24wks, with a dead foetus, postpone intervention for remove the sac completely with the placenta.
3-4wks after the foetal movements have stopped, so that the
vascularity of the placental bed is reduced.
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The placenta may have started to separate and cause Decide on the probable duration of gestation (don't use the
bleeding, giving you no choice but to remove the rest of the surfactant test (22.1), because the amniocentesis needle may
placenta as gently as possible. If you have adequate blood go through a low-lying placenta).
available for transfusion, removing the placenta will reduce Record the foetal position, presentation, and lie.
the risk of postoperative adhesions, which may be even Feel for rhythmical contractions. Listen to the foetal heart.
more difficult to deal with later. Don't do a vaginal examination with your fingers!
CAUTION! CAUTION! If you find an abnormal lie, don't try to
(1);Don't dissect in the region of the placenta. correct it.
This may cause catastrophic bleeding, especially if the She may be:
foetus is still alive. (1) An emergency with severe bleeding (≥500mL), in shock,
(2);Take care not to injure the mesentery, or its blood or in labour.
supply: part of the bowel may necrose, causing fatal (2) A non-emergency with none of these things.
peritonitis. Ask yourself 3 questions:
(3) Take special care not to injure the large bowel! (1) Has the uterus ruptured (21.17) due to obstructed labour?
If you decide to leave the placenta, cut and tie the cord as (2) Has the scar from a previous Caesarean Section (21.14)
short as possible and expel from it as much blood as ruptured? Both these are uncommon causes of vaginal
possible. Then remove as much of the sac as you safely can. bleeding before labour and even then most bleeding will be
(4);Don't insert a drain: the placenta will be absorbed intra-abdominal.
anyway, and a drain might only introduce infection. (3) How likely is she to have placenta praevia?
Close the abdomen in standard fashion (11.8).
Suggesting placenta praevia:
If you cannot control bleeding pack the bleeding area (1).Painless bright red bleeding which may be mild to
tightly, taking care not to include bowel loops in your pack, severe, especially after 32wks, and tends to stop and start
close the abdomen with one end of the pack sticking out of a again.
separate opening lateral to the rectus muscle. (2).A soft non-tender uterus that relaxes between
It is often feasible to pull out the pack 12-24hrs later by contractions if there are any contractions at all.
injecting LA around the opening and gently pulling on the (3) An audible foetal heart.
pack. If bowel is adherent or does come out, or there is (4) Shock commensurate with the measured blood loss.
evidence of further bleeding, proceed to a formal (5) A high-lying head or a transverse lie.
re-laparotomy. N.B. You can only exclude placenta praevia, if the head or
the breech are deeply engaged in the pelvis.
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If there is no obvious abruption, or you do not have an If there is a placenta praevia, you may see a normal
ultrasound (or you suspect the placenta is hidden in the cervix, a haemorrhagic mucous plug, a blood clot in the
shadow of the foetal head), and the patient is not in labour, external os, active bleeding from the cervix, or an open
you may perform a very careful speculum examination to cervix with placental tissue prolapsing out of it.
see where the blood is coming from, and to diagnose the Ask an assistant to press the foetal head into the brim of the
incidental causes of bleeding. pelvis.
N.B. It is not easy, and can precipitate bleeding if you do Explore the lateral fornices of the vagina very gently with
it roughly. Even probing to find the cervix can cause your finger; determine whether there is thickening between
bleeding if there is a placenta praevia. the presenting part and the lower uterine segment.
Resuscitation may need to start immediately. Cross-match If so, ask yourself if this is just on one side of the os
blood and make sure that there are always 2 units ready. (marginal placenta praevia), or all around it (major placenta
praevia).
SPECULUM EXAMINATION N.B. If you mistakenly do a digital examination inside the
You should know how long it will take you to prepare for os, there will be a boggy feeling of placenta in front of the
transfusion and Caesarean Section, before you do this! foetal presenting part, followed often by torrential bleeding
Pass a sterile speculum if the membranes have ruptured. as you remove your finger!
Use gentle speculum examination only.
CAUTION! Never perform a vaginal examination with If there is an abruption, you will see blood coming out of
your fingers except in theatre with preparations for a the cervix. If you mistakenly do a digital examination,
Caesarean Section ready: if there is a placenta praevia, you you won't be able to feel the placenta.
may cause massive bleeding. N.B Finding an incidental cause (such as a small polyp)
Look for: does not mean there cannot also be a placenta praevia,
(1) Cervical erosions. so beware! Does the incidental cause look as if it could have
(2) Cervical polyps. caused the bleeding observed? It is wise to assume there
(3) Vaginitis. might be a placenta praevia until proved otherwise.
(4) Carcinoma of the cervix.
(5) Varicose veins (rare). If there is trichomoniasis, you will see a red vaginal wall
(6) Placenta in the upper endocervix. and a pale green frothy discharge. Treat this with
(7) The presenting part, i.e. a hairy vertex or a buttock! metronidazole, and aim to treat any sexual partners also.
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If there is severe abruption, DIC will make it dangerous. If the patient is obese or a multipara, with an
The foetus is often dead, and is usually growth-retarded and unfavourable cervix, she is particularly at risk; assess the
premature, so cephalopelvic disproportion is seldom a progress of labour by careful vaginal examination.
problem. The 2nd stage is usually rapid: the dead baby, the placenta,
Here is a rule of thumb with abruption and a dead foetus and clot may however all be expelled suddenly, and tear the
with a longitudinal lie: if you would be able to do a vagina, perineum, or cervix. These tears may bleed severely
Caesarean Section, you do not need to do it (because the in the presence of DIC. Try to prevent this by controlled
situation is not desperate, and clotting factors are still expulsion of the head. If bleeding does occur, correct the
adequate); if you do need to do a Caesarean Section clotting disorder with whole blood, FFP and fibrinogen, and
(because bleeding is severe) you can’t do it (because there pack the vagina (22-10C). Repair the lacerations (21.15,16)
are almost no clotting factors left in the patient’s blood and and remove the packs 4hrs later.
your incision will cause further bleeding).
After delivery of the placenta, there are often problems,
The principles of management are therefore: because of a clotting defect, and because there may be
(1) Replacement of blood loss. an atonic uterus. There is a serious risk of postpartum
(2) Delivery without delay, preferably vaginal. haemorrhage, so encourage uterine contraction immediately
(3) Prevention of: postpartum haemorrhage, DIC, and renal after delivery, and administer IV ergometrine with oxytocin
failure. ('syntometrine'). Add 15U oxytocin in 500ml of Ringer's
lactate or saline, and infuse this fast to keep the uterus well
MANAGEMENT OF SEVERE ABRUPTION contracted. Add also 800µg misoprostol rectally.
Massaging the uterus and expressing the clots at this stage
Start a rapid IV infusion of 0.9% saline, or Ringer's lactate, are essential. If bleeding continues, compress the uterus
through a wide-bore cannula. Take blood for clotting time bimanually (22-10A).
and an emergency cross-match. If the systolic BP is
<80mmHg, infuse 1·5-2l of fluid fast; if the BP is Do not leave the patient alone trusting that the medication
80-100mmHg, infuse 1l fast. Continue infusion to try to will do its work. She needs continuous hands-on attention
maintain the BP at 100mmHg. for at least 1hr after delivery. A short period of inattention
might result in relaxation of the uterus and the loss of a
Start whole blood transfusion as soon as it is available. critical quantity of clotting factors.
If you cannot maintain the BP, use un-cross-matched O-ve, N.B. Avoid a 'trial of a Caesarean scar' (21.14),
or even in extremis O+ve blood. If you have fresh frozen when there is an abruption, because you will not be able to
plasma (FFP), infuse 2-4 units rapidly, and add fibrinogen recognize or exclude uterine rupture (21.17).
4g twice, if available. Be aware that:
(1) Heparin is contraindicated. INDICATIONS FOR CAESAREAN SECTION include only:
(2);Don't use plasma expanders, such as dextran, because (1) A previously scarred uterus.
these may precipitate further DIC. (2).Failure to progress, despite artificial rupture of her
(3) Do not try to insert a central venous line: bleeding from membranes, oxytocin and traction.
puncture of a major vein may, in combination with DIC, (3).A patient who is bleeding to death with normal clotting
be fatal. time. Caesarean Section is a desperate step and may save her
life.
Rupture the membranes. Insert a urinary catheter and (4) A live foetus >2kg, with signs of foetal distress.
monitor the urinary output, which should be >50ml/hr. (5) The transverse lie of a foetus at term for whom vaginal
Start a partogram & continue careful monitoring. Stimulate delivery is impossible.
labour with an oxytocin infusion, unless there is a previous N.B. If you decide on a Caesarean Section, do it
Caesarean scar, or the patient is para ≥2. Labour is usually immediately! Do not delay till clotting factors are lost!
fast. Try to effect delivery in 6-8hrs. Once in the active
phase, labour should progress rapidly. If bleeding does not stop after emptying the uterus,
deliver it out of the abdominal wound and administer
If the cervix is unripe, insert 200μg misoprostol rectally oxytocin and misoprostol. If bleeding continues, put a
(not vaginally as it may be washed out) but then do not use tourniquet round the lower segment using a rubber urinary
oxytocin within 3hrs of misoprostol. catheter (22.11). This may give you time to replenish the
circulation, organise blood transfusion, and for the clotting
If the foetus is already dead, which is often the case, factors to recover.
expedite delivery by attaching clamps on its head,
or inserting a Foley catheter in the foetal rectum. Inflate the If bleeding continues, apply a B-Lynch suture (22-13) and if
balloon with 50ml water in the case of the breech necessary ligate the uterine arteries (22-14) or proceed to
presentation, and apply steady traction with the help of a hysterectomy (21.17).
weight and rope (21.8).
This has saved many a mother’s life, because pressure of the
presenting part speeds up cervical dilation and so delivery.
N.B. The tense, tender, woody-hard uterus will make
contractions difficult to monitor.
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How can you help a woman like this? She may have no 21.2 Obstetric anaesthesia
antenatal care in the next pregnancy, and be unable to reach
hospital for the next delivery. How can obstetrics be adapted
to the needs, without being dominated by the practice of the Anaesthesia is often the most dangerous part of a difficult
industrial world? delivery. In many district hospitals you can avoid GA in
The answer is to make good use of the alternatives to obstetrics; consider also avoiding it for Caesarean Section.
Caesarean Section, and one of the main purposes of this When the patient is bleeding, or is already hypovolaemic,
chapter is to describe them. or very ill, you’ll need to manage GA expertly.
Unless you use ketamine, you’ll need to intubate the patient.
Unfortunately, in many hospitals the methods used to assist Full GA is dangerous in the circumstances of many labour
a woman who has prolonged or obstructed labour are wards, and the operating theatre may take dangerously long
unnecessarily limited. If an oxytocin infusion and a vacuum to get ready.
extractor fail and in some settings, not even those two You can perform most Caesarean Sections under
life-saving options are employed to overcome non-progress subarachnoid (spinal) anaesthesia, provided you take the
in labour; Caesarean Section is automatic, and no-one thinks necessary precautions. You can also use ketamine and LA.
of other possibilities. If cephalopelvic disproportion (CPD) For a vacuum extraction, use a pudendal block, with LA for
is mild, perform a symphysiotomy (21.7). If the foetus is the episiotomy if used, though it is not always necessary.
dead, perform a destructive operation (21.8). At all counts it For a destructive operation, other than a transverse lie,
should be possible to learn how to manage a breech delivery use a pudendal block combined with IV ketamine.
(22.7) and other abnormal presentations without resorting to For a transverse lie, use ketamine or spinal anaesthetic.
Caesarean Section, except as a last resort. For manual removal of the placenta, use ketamine.
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Epidural anaesthesia is excellent, but may be impractical, In order to manage delay in labour, you must know as early
except in specialized well-staffed well-maintained obstetric as possible that it has occurred. To know this you will need
units, where rigorous aseptic procedures are in place. an effective method of monitoring labour: the partograph
You will need staff to monitor the patient carefully (21-2). The most important part of this is plotting the
post-operatively. dilation of the cervix in cms, and the descent of the head in
fifths above the brim, against the duration of labour in hours.
PUDENDAL BLOCK FOR AN OPERATIVE VAGINAL
DELIVERY The purpose of the partograph is:
This is not 100% effective but may still be useful in certain (1);To prevent neglected obstructed labour and ruptured
situations. The danger of a needle-stick injury with a uterus (which cause 70% of maternal deaths in some areas)
transvaginal or perineal pudendal block is high; you have to by enabling peripheral health workers to monitor labour,
locate the ischial spines by palpation through the vagina to detect deviations from the norm more effectively,
canal on either side at 4 & 8o’clock. and thus to refer women at the optimal moment, before it is
too late. This is the purpose of the 'alert line'. Ideally, you
should only use the partograph to monitor those women
whose labour is expected to be normal; women with obvious
'risk factors' should already have been prepared for assisted
delivery.
(2);To monitor all women in labour in hospital, so that you
know when to intervene. This is the purpose of the 'action
line'. If the 'progress line' of a woman's cervical dilation
moves to the right of the alert line, be extra vigilant.
If the ‘progress line’ reaches the action line, you must
intervene, if you have not already done so.
Fig. 21-1 REGIONAL BLOCK FOR AN OPERATIVE VAGINAL
DELIVERY. A, position of injection sites for pudendal block through The partograph depends on the principles that:
the perineal skin. B, direction of block from each side. C, or from a (1);The duration of the 1st stage of labour (though this is
single central puncture site. After Howie B. High Risk Obstetrics difficult to define as it may include false contractions)
Macmillan 1986 Fig. 14-6,7 with kind permission. should not last longer than 8hrs, hence the thick vertical line
at this point.
Raise a skin wheal of LA half way between the vaginal (2);The latent phase ends and the active phase starts when
opening and the ischial tuberosities or centrally (21-1A,C). the cervix is 4cm dilated (3cm was used in the past; it is best
Use a 12cm x 1mm needle to reach the ischial spines. to stick to WHO guidelines if these are the rule nationally).
Inject 12·5ml of 0.5% lignocaine or 1% procaine (both with (3);During the active phase of the 1st stage, the cervix should
adrenaline) on each side. Supplement this with superficial dilate quickly at ≥1cm/hr.
infiltration for most operative vaginal deliveries. (4);A lag time of 4hrs is usually acceptable between the
Withdraw the needle while you inject 25ml of solution slowing of labour and the need to intervene; this is the
in the directions shown. Use a total of 50ml. distance between the alert and the action lines.
For an episiotomy and vacuum extraction, superficial N.B. This lag time of 4hrs is obviously too long if there is
infiltration alone may be enough. a scar on the uterus.
CAUTION!
(1) Premedicate with pethidine. The WHO partograph uses fixed alert and action lines and
(2);Distinguish the ischial spines from the ischial transfers the patient to the alert line as soon as she reaches
tuberosities. 4cm, as has been done for one particular patient (21-3C).
(3);Always aspirate with the plunger before you inject.
If you withdraw blood, move the needle to avoid injecting Dilation of the cervix and its relation to the action line is
the anaesthetic solution IV. only one of the factors measuring the progress of labour,
(4) Allow the anaesthetic at least 3mins to act. and the necessity to intervene. It and the descent of the
foetal head are the 2 most useful and the most easily plotted.
Other important factors are:
21.3 Delay in labour (1) the presentation,
(2) the moulding (foetal skull bone overlap) score (21.5),
Labour is seldom any problem if it goes at its proper pace.
(3) the presence of foetal distress,
Most trouble starts when it is prolonged or the foetus cannot
(4) the woman's condition,
cope with the temporary lack of exchange caused by
(5) the duration and frequency of contractions.
contractions interfering with the blood supply to the
placenta. Even if the foetus can cope but reacts, for example,
Consider all these factors, and do not be guided only by the
to cord or head compression by cardiac deceleration, it is
dilation of the cervix in relation to the action line and by the
difficult to be sure that no intervention is needed.
descent of the head, critical though these are. The position of
Most unnecessary interventions have no serious
the action line is to some extent arbitrary, and some
consequences in rich countries but they may have deadly
obstetricians like the alert and action lines closer together.
results in other circumstances, directly or a few years later.
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403
In some circumstances there is a line half way in between Partographs have proved so useful in reducing both maternal
and parallel to the alert and action line. and perinatal mortality, that not to introduce them might
This is called the transfer line and is used, for example, almost be considered criminal neglect. If you do not already
in peripheral urban clinics to indicate the best time that the use them, you must! (21-2) N.B. Partographs do not tell you
woman should be referred to a nearby hospital. about risk factors present before labour!
Intervention needs to be earlier in a multipara than in a
primipara, so some partographs have 2 action lines, one at ARE YOU AND YOUR RURAL CLINICS USING
3hrs for multipara and one at 4hrs for primipara. PARTOGRAPHS?
Some hospital partographs leave out the action line
altogether and take the alert line as the action line.
The important point is that the further the progress line is
from the alert line, the greater should be your vigilance, and
usually the greater your need to intervene.
When the patient approaches the action line, assess all the
factors listed above (and others) and decide what to do next,
using the guidelines described for normal labour and for
obstructed labour (21.4).
N.B. Some hospitals consider that the requirement for
some intervention if there is no dilation ≥1cm/hr is 'too
active', and leads to an unnecessarily high Caesarean Section
rate, which is not suitable for populations with an average of
perhaps 4-6 children, and when Caesarean Section has to be
done under less than ideal circumstances in small hospitals,
so they give the alert line a flatter slope. This is justifiable at
4-7cm of cervical dilation, but >7cm 4hrs delay is too long.
Woman B, was admitted at 9am 1cm dilated; the latent phase lasted
8hrs and the active phase 3hrs. She quickly passed to the left of the
Fig. 21-2 THE PARTOGRAPH is a very useful tool for managing alert line.
labour. The vertical scale on the left measures cervical dilation in cm
and the descent of the head in fifths above the pelvic brim. ‘LIQUOR’
represents rupture of the membranes and release of amniotic fluid.
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404
Woman C, was admitted at 1pm 1cm dilated with the foetal head 5/5 N.B. If you artificially rupture the membranes and start
above the pelvic brim. At the next vaginal examination (5pm) the head
an oxytocin infusion, you inevitably pass the point of no
was 4/5 above the brim and she was 5cm dilated. She was therefore
transferred to the 'alert line'; the cervix continued to dilate, the head return and increase the chance of needing to perform a
descended, and she delivered normally. Caesarean Section. This is only really indicated if you want
to stimulate labour for example because of pre-eclampsia,
Woman D, was admitted to a health centre with the foetal head gestational diabetes, or sickle cell disease.
4
/5 above the brim and the cervix 4cm dilated, so she was put on the
alert line. At 12 noon she was only 6cm dilated and had moved to the
right of the alert line, so she was transferred to hospital. When she If the latent phase is truly prolonged, the cervix is
arrived at 4pm she was still only 7cm dilated and had reached the completely effaced, but remains undilated at c.2-3cm,
action line. The head was 3/5 above the brim, with a moulding score of or effaces and dilates very slowly, you have 2 choices:
3 (21.5); it was not possible to put a finger between the head and the
pelvic wall. So, following the indications outlined (21.4), she underwent (1).Use sedation with pethidine 50-100mg IM, repeated if
a Caesarean Section. If however she were a nullipara, the foetal heart necessary, and allow mobilization,
action excellent and an anaesthetist available within 1hr, a trial of (2).Administer very low dose misoprostol 20μg 3hrly
oxytocin (for a maximum of 1hr) might still prevent a Caesarean
(4ml of a 100μg (½tablet) dissolved in 20ml water) if there
Section. Alternatively a symphysiotomy (21.7) may allow a normal
delivery. is an indication to induce but not strong enough to risk a
Caesarean Section by rupturing the membranes. Once labour
starts, stop the misoprostol!
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405
You may even decrease the drop rate if the foetal head is NB. For a multipara whose membranes have ruptured,
coming down and is well applied to the cervix. for example, it is acceptable to start labour carefully with
If good contractions (3-4 in 10mins lasting >40secs) do oxytocin and reduce or stop the infusion as soon as labour is
not clearly give rise to progress, and the membranes are established. This applies also to a breech presentation.
ruptured, then there is an indication for a Caesarean
Section unless the cervix is nearly fully dilated. If you are sure labour has started (the cervix is >3cm)
N.B. It is difficult to know what good contractions are, and the membranes have not already ruptured, rupture
however. The frequency is easy to monitor, but the intra them, but take cautions regarding HIV exposure.
uterine pressure is measureable however only with a Labour goes faster in multipara and prolonged exposure to
transducer in the uterus and even then although low pressure vaginal HIV is less likely. Under close supervision, it is
is an indication for oxytocin, proper pressure does not mean reasonable to start oxytocin at 4-6cm cervical dilation and if
the pressure is directed by coordinated contractions in the good contractions ensue, then to rupture the membranes.
right direction.
Consequently estimate the length of contractions as an If you are in doubt, observe for 2hrs more with adequate
indicator of their strength: <20secs is weak, 20-40secs analgesia, and then reassess the patient. Feel the contractions
moderate, > 40secs is strong. yourself. She may progress to full dilation even when there
is major CPD. You can only detect this by finding severe
If you are sure labour has started, the cervix is dilated moulding and caput, with failure of the head to descend, and
≥4cm and the membranes are not already ruptured, no progress or movement (>20secs in the 2nd stage,
rupture them. Remember the risks of prolonged rupture of 21-5B,C).
membranes! Monitor the mother’s progress and the foetal CAUTION! Some women have 6 or 8 normal labours,
condition carefully. Monitor the heart and watch for signs of and then need Caesarean Section for CPD with their next
foetal distress, especially a slowing of the foetal heart pregnancy. Do not forget to offer a sterilisation with the
N.B. Meconium staining of the liquor is common, Caesarean Section in such a situation.
but is an unreliable sign.
DIFFICULTIES WITH DELAY IN LABOUR
If you detect signs of foetal distress, stop an oxytocin If there is delay in the latent stage, look carefully for
infusion if one is running. hidden CPD. Provided there is a vertex presentation, it is
always worth sedating the patient and waiting a little to see
N.B Oxytocin itself can, of course, cause such strong, what happens.
long, or frequent contractions that foetal distress ensues. N.B. CPD is almost impossible to diagnose when the
Stopping the infusion and restarting it later at a lower rate membranes are intact and rupturing the membranes might be
might still result in the vaginal delivery of a healthy baby. a good idea if the cervix is very ripe. Even if you are using
On the other hand, some foetuses just cannot cope with oxytocin properly, its use with an unripe cervix will
inadequate contractions; if the contractions are optimised increases your Caesarean Section rate.
with oxytocin to cause further cervical dilation, the foetus is
in danger. This is then definitely an indication for a If there is foetal distress with an oxytocin infusion
Caesarean Section, with poor descent of the head or even running, stop it; turn the patient onto the left side, do a
when almost full cervical dilation has been reached. vaginal examination to exclude prolapse of the cord,
and make sure she is adequately hydrated and administer
If there is severe CPD, which you can recognize by oxygen. If the signs are not relieved, proceed to Caesarean
(1);inadequate cervical dilation and foetal descent, Section.
especially associated with foetal distress,
(2);cervical dilation proceeding at <1cm/hr at the end of
4hrs, with no descent of the foetal head, or
(3) the foetal head remaining high, with moulding, perform a 21.4 Obstructed labour
Caesarean Section
N.B. Inadequate cervical dilation and foetal descent The exact point at which lack of progress (21.3) becomes
without foetal distress may suggest the option of a vacuum obstructed labour is arguable. This is the failure of the
extraction (sometimes combined if necessary with a presenting part to descend despite good uterine contractions.
symphysiotomy, 21.7). What really distinguishes prolonged labour from obstructed
labour are the secondary signs and complications that
DELAY IN THE ACTIVE PHASE IN MULTIPARA. follow: severe moulding (21.5), caput (21.3), intra-uterine
If progress line for a multipara approaches the action infection, prolonged suffering, fear of death, pain between
line, this is serious, and you will need to assess the carefully. contractions, foetal distress, a stretched lower segment
Do not try to stimulate the uterus with oxytocin, unless you (21-5), bloody urine, fistulae and rupture of the uterus.
are as sure as you can be that there is no CPD (21.6). Whereas delay in labour is usually inevitable and often
This is difficult to be sure about, and if you are wrong, readily treatable, and is comparatively harmless, obstructed
and there is CPD, the uterus may rupture. A good rule is: labour is none of these things. It should never be neglected if
no oxytocin for augmentation of labour in multipara unless care is adequate. Arguably, obstruction is not uncommon
you supervise it personally (not over the telephone) and (e.g. a failed properly executed vacuum extraction)
certainly not for multipara >3, and for not longer than 2hrs! but obstructed labour should never be neglected.
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406
Recognized scenarios are, for example: (2).Avoiding teenage pregnancy where a girl has to deliver
(1) needing 3hrs to organise a Caesarean Section after a before the pelvis has reached its maximum size.
failed vacuum extraction, without knowledge of how to (3) Universal antenatal care, so that obstructed labour can be
perform a symphysiotomy (21.7); or anticipated from the history, and any risk factors identified.
(2) having waited for 2hrs with the mother actively pushing, (4).The monitoring of labour by skilled staff, so that a
without having attempted a probably easy vacuum extraction woman can be referred at the first sign of danger, before she
and needing 3hrs to organise a Caesarean Section. obstructs.
Obstructed labour may be due to: The detailed preventive measures are:
(1) An abnormality in the pelvis (a contracted pelvis): a true (a) screening for risk factors, especially short stature, and
conjugate (antero-posterior diameter at the pelvic inlet) (b) the routine use of the partograph.
should be >9cm, and the diagonal conjugate (transverse When adequate antenatal care is impossible, and where
diameter) 1·5-2cm larger. health centre and hospital beds are limited, the establishment
(2) An abnormality in the foetus (hydrocephalus, etc.). of a 'mothers’ waiting area or temporary village' is a useful
(3) An abnormality in the relationship between them, either: alternative.
(a) An abnormal lie or presentation (breech, brow, face,
shoulder presentation, or prolapsed arm in a transverse lie),
(b).An unfortunate coincidence of their relative sizes.
Cephalopelvic disproportion (CPD) means the foetus may
be too big for the mother, or vice versa.
(4).A marginal CPD and/or soft tissue resistance combined
with contractions which are not optimal, or poor pushing by
the mother.
(5).Rarer causes, such as stenosis of the vagina, locked
twins, or a pelvic tumour, particularly fibroids or an ovarian
cyst.
N.B. CPD is the most important cause (>65%),
and an impacted transverse lie is the next most.
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407
Alas, the poorest communities with the worst health services The bladder was distended. Catheterizing it was difficult, and the foetal
head had to be dislodged by putting two fingers into the vagina,
are usually those with the most CPD.
and pushing it up.
A warning sign that labour is going to obstruct is a The bladder was drawn up so high that the catheter had to be passed a long
prolonged 1st stage, but this may be normal or even short. way before any urine flowed; when it did so, it was blood-stained.
The membranes rupture, and amniotic fluid (liquor) escapes. The foetus was alive, and the foetal head was 4/5 above the brim, so neither
symphysiotomy nor vacuum delivery were suitable. She was therefore
The uterus contracts and retracts, and forces the foetus into
resuscitated with IV fluids, treated with antibiotics, and delivered by
its lower segment, which gradually becomes overstretched. Caesarean Section. The baby survived with a neurological handicap,
Foetal escape is obstructed, so the lower segment moulds but the wound became infected, and she developed a pelvic abscess,
closely round and thins. The contractions of the uterus which was drained. She was in hospital a month, and was lucky not to
develop a fistula.
become hypertonic, and relaxation between them poor.
LESSONS (1) The decision to perform a Caesarean Section was correct.
The placenta is poorly perfused, there is foetal distress, (2) She was only 14, and so the pelvis will continue to grow. (3) She is at
and the foetus dies. risk of a ruptured uterus in future, so she must deliver in hospital.
Obstructed labour has 3 main dangers: If the fistula is successfully repaired, and she becomes
(1) Stuck between the foetal head and the pelvis, the vaginal, pregnant again, she must have a Caesarean Section to
bladder, and rectal walls become squeezed, and eventually prevent the repair breaking down. If the fistula is not
become necrotic, slough, and develop fistulae. repaired (in which case she is less likely to become
(2) Often in a primipara, the contractions stop while the head pregnant), stenosis of the vagina is likely to prevent vaginal
is wedged in the pelvis causing sepsis and/or fistulae. delivery.
(3) In a multipara, the uterus keeps contracting till it ruptures
or a (nearly) dead severely moulded baby is delivered. A multipara may show the same failure to dilate as a
primipara, or the cervix may dilate normally to begin with,
A primipara begins to have trouble when the cervix fails to and then slow during the active phase, only to dilate finally
dilate normally. An oxytocin infusion may speed up labour if she is left untreated. Meanwhile, the presenting part fails
if the CPD is minimal or the lack of progress is caused by to descend.
poor contractions, but cannot do so if CPD is gross.
The result is that the labour usually obstructs before she is MAPULESA (35yrs, para 8, gravida 10) arrived at hospital just before the
uterus ruptured. She too was anxious, distressed, and febrile. The cervix
fully dilated, although she will usually reach full dilation
however was fully dilated. The lower segment had continued to retract and
eventually. thin, so that the junction between the upper and lower segments had risen in
The results, if the situation is not rapidly relieved, are dire: the uterus as far as the umbilicus. She had a 'three-tumour abdomen' when
(1);Asphyxia and infection in the foetus ensue, owing to viewed from the side: an oedematous distended bladder, a distended, tender
lower segment, and a tonically contracted upper segment. A (Bandl's) ring
prolonged uterine contractions reducing the placental blood
could be felt through the abdominal wall between the upper and lower
flow. segments (21-5G). The round ligaments (21-18) stood out on either side of
(2);The foetal head is damaged, so that brain injury may the ballooned lower segment, like the guy ropes of a tent.
result. A brow presentation was felt on vaginal examination. She was resuscitated
with IV fluids, and had a Caesarean Section. At operation the uterus was
(3);Pressure necrosis and sloughing of the vaginal wall
found to have ruptured into the abdominal cavity. The foetus was alive,
occur. As this slough separates, a fistula develops anteriorly but was asphyxiated, and died within 1hr. The uterus was repaired,
between the vagina and the bladder (21.18), or posteriorly the tubes ligated, and she recovered uneventfully.
between the vagina and the rectum (21.19). LESSONS (1) Even a patient who has had many normal deliveries may get
an obstructed labour from a malpresentation, malposition, or just because
The fistula may involve the proximal half of the urethra
babies tend to become larger with higher parity and males are also on
and/or the neck of the bladder, up to its ureteric orifices, average larger and have larger heads than females (2) A partograph would
or involve the rectal sphincter mechanism. have given earlier warning of the impending obstruction. (3) Tubal ligation
Later, as the ring of necrosis in the vagina heals and was essential.
contracts, it stenoses. If the mother does not die, she delivers
an injured, severely moulded dead baby. She is also at risk The critical event, in a patient like this, is rupture of the
from septicaemia, peritonitis, peritoneal abscess, atonic uterus. This usually starts in the thin lower segment,
postpartum haemorrhage (22.11), and foot drop from the and extends downwards on one side into the vagina, as well
pressure of the foetal head on the pelvic nerves. Even if the as upwards towards the fundus. Several things can then
fistula can be repaired, she may be infertile, and the vagina happen:
may be so stenosed that sexual intercourse is difficult. There (1) The presenting part may remain jammed in the pelvis.
are of course also serious psychological consequences. (2) The foetus may be expelled through the rupture into the
peritoneal cavity.
MPHO MOKETE (14yrs, para 0, gravida 1) became pregnant after her (3) Bleeding from the ruptured uterus may be seen in the
1st period. She hid the pregnancy from her parents, and so received no vagina.
antenatal care. She arrived at hospital exhausted, anxious, and febrile, with
(4) Occasionally, the bladder also ruptures, especially if it is
a fast pulse. Her contractions were strong and painful, with little relaxation
between them. The head of the foetus, showing signs of foetal distress, was stuck to the scar of a previous lower-segment Caesarean
high, and overlapped the brim of the pelvis. The liquor had drained, so that Section.
the uterus was moulded around the foetus.
The vulva and cervix were oedematous, and although the foetal head could
be felt just inside the cervix, this was not because it had descended,
but because it was severely elongated. Abdominal examination showed that
most of it was still above the pelvic brim. The vagina was dry and 'hot',
and the cervix not fully dilated.
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408
Before rupture, the signs that it is imminent are: An assisted vaginal delivery (apart from shoulder dystocia
(1).Failure of labour to progress. Lack of progress should which needs a combined vaginal and abdominal approach) is
therefore alert you to the possibility that rupture might be absolutely contraindicated if the uterus has already
imminent. ruptured: perform a laparotomy. Often, you will not know
(2) Bandl's ring. whether the uterus has ruptured, nor whether it will rupture
(3) A distended bladder which is difficult to catheterize. in the next 30mins: so perform all vaginal procedures for the
(4).Frequent strong uterine contractions, with little or no relief of neglected obstructed labour in the operating theatre,
pause between them. with equipment and staff available instantly for a
(5).Persistent pain between contractions in a restless, laparotomy.
anxious patient. Caesarean Section has a limited role in the management of
obstructed labour, especially if neglected, and is likely to be
After rupture, a woman may have little or no pain. If you ask a serious risk, so do not undertake it lightly. It is mainly
her, she will tell you that contractions were strong, but then indicated when the foetus is alive and the mother is in
suddenly stopped, and were replaced by a lesser continuous reasonable condition. However, make sure that the foetal
pain, or no pain at all. She may be alert and even talkative, heart beat is still present just before you start the incision!
or quite obviously collapsed in severe hypovolaemic shock, A destructive operation (21.8) is indicated when the foetus is
with cold, sweaty skin, and a weak or absent radial pulse. dead, the cervix is fully dilated or nearly so, the presenting
She might survive only 10mins or 72hrs. You feel no uterine part is fixed in the pelvis, and the uterus has not ruptured,
contractions, but you can usually feel the foetus through the and is in no danger of doing so. If you are in any doubt,
abdominal wall lying free in the abdomen. Often the perform a mini-laparotomy as above. Occasionally, when a
presenting part, when examined vaginally, has disappeared destructive operation for foetal death would be difficult,
and cervical dilation has decreased (21.17). because the foetal head is mobile and ≥3/5 above the pelvic
brim, you might have to resort to a hysterotomy (21.5).
A multipara who is not steadily progressing in the 2 nd stage
(when the cervix has dilated fully) and she has started to SYMPTOMS.
push but has not delivered after 60mins is in great danger. A woman in obstructed labour is in great pain, anxiety,
N.B. Most fistulae occurring after uterine rupture are and distress. In the bustle of treating her, do not forget to
complications of the surgery, not the labour. comfort and reassure her.
If the foetus is already dead, inform her. If you do not,
she may blame you for its death, and not come to hospital
when she is pregnant next time.
21.5 Managing obstructed labour DIAGNOSIS.
Suspect obstructed labour or neglected obstructed labour if
If a woman with obstructed labour is admitted from you find:
home, she may have been in labour for days, and tried many (1).No cervical dilation despite what appear to be good
home remedies. Her stomach is likely to be full, and she can contractions.
inhale its contents only too easily if she vomits. She is thus a (2).Increasing moulding (21.5) and caput (21.3), but without
major anaesthestic risk. There are several ways in which you descent of the foetal head.
can deliver her foetus, but you should never use midcavity or (3) Anxiety and restlessness.
rotational forceps, such as Kielland's (21.1). (4).Hypertonic uterine contractions, with poor relaxation in
Vaginal delivery is often possible, but try to predict when it between.
is going to be difficult, so that you can avoid a 'failed (5) A stretched lower segment with a Bandl’s ring.
vacuum', and perform a symphysiotomy (21.7) or a (6) Bloody urine.
Caesarean Section (21.9) from the start, especially when (7) Unexpectedly easy dislodgement of the presenting part
there is foetal distress. followed by a gush of vaginal bleeding: then abandon
However, judging whether vaginal delivery will be vaginal delivery and open the abdomen.
successful by clinical vaginal examination can never be (8).Variable or poor application of the cervix to the head.
perfect. If you are prepared to perform vacuum extraction (9) Offensive discharge or fever.
combined, in case of failure, with a symphysiotomy, (10).A vesico- or recto-vaginal fistula (usually found
you will be able to avoid around 25 subsequent Caesarean 2-3days after delivery).
Sections if your judgement is only wrong in 10% of cases.
This statistic is only invalid if you perform a tubal ligation at N.B. Now determine if the uterus is ruptured.
the same time as the Caesarean Section. The side effects of
one symphysiotomy are different but certainly not more If you are in doubt about uterine rupture, make a mini-
dangerous than the side-effects of one Caesarean Section, laparotomy to check the uterus: if it is intact proceed to a
and the side-effects of 25 Caesarean Sections are naturally vaginal delivery while the incision is covered with sterile
overwhelmingly more serious and frequent than those of one towels, then recheck the uterus and perhaps, when indicated
symphysiotomy. and desired, tie the tubes.
N.B. Of course a symphysiotomy is nearly absolutely
contra-indicated if the foetus has died.
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This is far less risky as an operation than a Caesarean An easy way to document moulding is to add the moulding between the
parietal bones (PP) and the moulding between the occipital and one parietal
Section, because the contaminated fluids in the uterus do not
bone (OP). So if PP 2+ and OP+, total moulding is 3+.
enter the peritoneal cavity and do not soil the uterine and (3);Watch for foetal distress. Count the foetal heart rate for
abdominal wall incisions. 30secs, before, during and after a contraction. Foetal distress
Otherwise, with ultrasound guidance, you can try aspiration is shown by a rate of <120 or >160/min or slowing which
with a long needle lateral to the uterus to reveal meconium- persists after a contraction (slowing during it is normal).
stained fluid (more commonly than rather than bright red CAUTION!
blood). This confirms the diagnosis of rupture. (1);Do not use an oxytocin infusion if there are signs of
N.B. Ultrasound, on its own, is unreliable unless the obstruction. On the correct indications (see later), you can
rupture is obvious. use it for delay.
(2) Do not use Kielland's forceps, or try internal version.
DIFFERENTIAL DIAGNOSIS (3);Never attempt an operative vaginal delivery if the uterus
There is, in the main, a prolonged latent phase. If the patient has already ruptured.
was made to push during the latent phase, she may be N.B. You may not know if the uterus has ruptured, so do
distressed and dehydrated, and the vulva and cervix may be all vaginal procedures for the relief of obstructed labour in
oedematous. The cervix will however not be dilated, or only the theatre, with a set of laparotomy instruments ready for
slightly so, the membranes are likely to be intact, and there instant use. Alternatively, perform a mini-laparotomy.
will be no Bandl's ring. Reassurance, observation, (4).Choose an appropriate method of delivery:
analgesics, sedatives and IV fluid replacement may be all
that is needed. Episiotomy. This is sometimes all that a primipara needs,
especially if the foetal vertex is in an occipito-posterior
MANAGEMENT. position. Putting her into the lithotomy position may make
Hypovolaemic and/or septic shock are very common. delivery easier. Beware of ‘routine’ use: the cut may become
Resuscitation must be rapid, because delivery is urgent. bigger, be painful, get infected and cause excessive blood
Admit the patient directly to whatever high-risk area you loss.
have, usually the labour ward or the theatre, and resuscitate
her there. This will allow you to operate as soon as she is in Vacuum extraction (21.6)
an optimal condition. INDICATIONS.
Correct the dehydration, the electrolyte deficit, and the (1) A live foetus with <2/5 of the foetal head above the brim:
acidosis with warmed Ringer's lactate; there is usually no the more moulding there is, the lower the head should be for
need to use bicarbonate. She may rarely need blood, a successful vacuum extraction.
preferably red cells only. If the haematocrit is raised as the (2).An occipito-transverse or occipito-posterior position,
result of dehydration, a transfusion, even of safe blood, without CPD, or with only mild CPD, especially
may be harmful: her primary need is IV fluids. (3).Definite CPD combined with a symphysiotomy (21.7).
Administer IV chloramphenicol, benzylpenicillin and rectal (4).For an unconscious patient, e.g. with eclampsia,
metronidazole. If, in spite of adequate resuscitation, shock perhaps combined with fundal pressure to make up for the
persists, try a titrated infusion of dopamine. This will cause lack of straining.
peripheral dilation, so correct it immediately with more IV CONTRAINDICATIONS.
fluids. Do not however waste time with sophisticated (1) A live baby with >2/5 of the foetal head above the brim.
methods if your team is not familiar with them; proceed (2) Severe moulding.
simultaneously with delivery. (3) Definite CPD unless combined with a symphysiotomy.
CAUTION!
MONITORING. Record the pulse, and blood pressure every (1) Delivery with a vacuum extractor or outlet forceps
5mins. Monitor the urine output hourly. should never be a difficult operation. If foetal asphyxia is
If the presenting part stops descending, the cervix usually already present, it should merely be a 'lift-out'.
stops dilating, although this may not be so in multipara. (2) Use a systematic technique of pulling.
On the partograph, the 'progress line' will have crossed the Do not be afraid to use an old machine which works even if
'action line'. you do not have a modern Kiwi device!
If it has taken >3hrs for the cervix to dilate from 7-10cm
MANAGEMENT on the partograph, or the fundal height is >40cm,
(1);Assess the height of the foetal head. Do not assess this suggesting a large baby, perform the vacuum extraction in
by vaginal examination only. There will be much caput the operating theatre, and prepare for symphysiotomy or
(21.3), and this will mislead you. It’s the descent of the skull Caesarean Section.
that matters, not the descent of the foetal scalp swelling! Fundal pressure may save the day. Such situations are:
(2) Calculate the foetal moulding score: foetal distress, or an exhausted mother where her straining is
0 Bones still separate.
1 Bones touching just not forceful enough to deliver, and where a little bit of
2 Bones overlapping, but separate when you press with a finger. extra force will deliver the baby. Or else, even without foetal
3 Bones overlapping but not separable. distress, when there is no working vacuum extractor present
Feel where the foetal parietal and occipital bones touch one another. and transport to a suitable venue with better facilities will
Overlapping at both the sagittal and the lambdoid (between the parietal and take too much time, or there is the risk of delivery in an
the occipital bones) sutures, is more serious than at the lambdoid suture
alone. unsuitable vehicle (or oxcart) during transport.
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410
Even in a sophisticated hospital, when a vacuum extraction If the foetal head is:
0
is almost successful but that little extra force needed pulls /5 above the brim, with minimal moulding, apply the
off the cup, fundal pressure may solve the problem. vacuum extractor and see, in the course of delivery, whether
an episiotomy is needed or not.
1
Symphysiotomy (21.7) /5 above the brim, with a total moulding score
INDICATIONS. (PP+OP) 0-1 and foetal distress, perform a trial of vacuum
A live foetus, of fundal height <40cm, (2·5-4kg), extraction in the operating theatre, with everything ready for
in a cephalic presentation, with these scores: symphysiotomy.
1
Head above Total foetal moulding score /5 above the brim, with a total moulding score 2-3
the brim (PP+OP) and foetal distress, combine vacuum extraction with a
≤2/5 <6 if the head is on the pelvic floor symphysiotomy, or perform a Caesarean Section.
2
≤3/5 ≤3 /5 above the brim, with a total moulding score of 0-2,
maybe 3, perform a trial of vacuum extraction in the
Destructive operations (21.8) operating theatre, with everything ready for symphysiotomy
INDICATIONS. Make sure that all these conditions are met: or Caesarean Section.
2
(1) Foetal death or severe foetal malformation incompatible /5 above the brim, with a total moulding score of 4 or
with life. possibly 5 and foetal distress, perform a trial of vacuum
(2) An impacted foetal head with ≤2/5 above the pelvic brim, extraction in the operating theatre, with everything ready for
or a transverse lie. symphysiotomy or Caesarean Section.
3
(3) Cervical dilation at least 7cm, and preferably full. /5 above the brim, with a total moulding score of 0-2,
(4) No uterine rupture, nor imminent danger thereof. perform a trial of vacuum extraction. If necessary and if the
CAUTION! A multipara who has been in labour for a pelvis is big enough (you can get your finger between the
long time will have a lower segment which will be very thin. head and the symphysis) perform a symphysiotomy.
3
If it is also tender and distended, it is certainly very thin and /5 above the brim, with a total moulding score of >2
on the point of rupture. perform a Caesarean Section, unless you can get a finger
Do not push an instrument against the foetal head without between the head and the pelvic wall, indicating that a
somebody supporting the fundus; otherwise your pushing symphysiotomy might be possible.
might rupture the uterus if the head dislodges upwards.
N.B. When the lower segment is paper thin, any If the foetus is dead, with an impacted head with ≤2/5
destructive operation will rupture the uterus, unless you are above the pelvic brim and the cervix is ≥7cm dilated,
simply decompressing a hydrocephalic head with a needle. perform a destructive craniotomy, provided you can get a
finger between the foetal head and the pelvis.
Caesarean Section (21.10)
INDICATIONS. If the foetus is dead and its head is mobile or ≥3/5 above
(1);A live foetus whose head is too high for vacuum the brim, get an assistant to push the head into the pelvis as
extraction or symphysiotomy. you perform a destructive craniotomy. If this fails, and the
(2);A dead foetus <2/5 above the pelvic brim, whose head foetus is mobile enough in the uterus, see if you can insert a
cannot be pushed down into the pelvis to perform a balloon catheter into the foetal rectum and apply traction for
destructive operation safely. a breech delivery (22.7). Only as a last resort, perform a
CONTRAINDICATIONS. hysterotomy.
(1) A head which is deeply engaged in the pelvis (≤2/5 above
the brim). MENTO-POSTERIOR PRESENTATION.
(2) A dead foetus which can be delivered by a destructive If the foetus is alive and the cervix is fully dilated,
operation. perform a Caesarean Section.
Here we are mostly concerned with a vertex presentation, and a
few curiosities. See elsewhere for a breech presentation (22.7), If the foetus is dead and the cervix is fully dilated,
a transverse lie, and a brow or a face presentation (22.8). perform a destructive craniotomy
410
411
If there is a history of neglected obstructed labour, Fig. 21-6 TWO TUMOURS OBSTRUCTING LABOUR.
examine her early in the puerperium for signs of peripheral A, an ovarian cyst. B, a cervical fibroid. If a patient has an ovarian cyst
nerve injury. She may fail to complain about sensory or tumour, you can remove it at Caesarean Section. If she has a fibroid,
changes and weakness, so you will have to look for them. leave it unless it has a thin pedicle and remove it later if necessary. After
Young J. A Textbook of Gynaecology A&C Black 5th ed 1939 Figs 125,168.
If she has sensory changes & weakness in her legs, she has
an OBSTETRIC PARALYSIS, which may vary from mild
OXYTOCIN
footdrop to extensive paralysis of her legs, including her
Oxytocin is an invaluable drug for making the uterus
gluteal and quadriceps muscles. If you are not careful, she
contract: (1) To induce labour.
may develop contractures. So put her joints through their
(2) To accelerate labour.
full range of passive movements regularly, and encourage
(3) To stop bleeding after abortion or delivery. Always have
her relatives to do the same. If she has a foot drop, use a
a secret cache of this drug so that you never run out.
posterior plaster splint to keep her ankle fully dorsiflexed at
night (32.11). During the day, typical high basketball shoes
The main dangers are that:
make walking much easier. She is almost certain to recover,
(1) The uterus may rupture if you administer too much too
but this may take 2yrs.
fast to a multipara late in labour. The sensitivity of the
uterus to oxytocin varies greatly. Early in pregnancy it is
If despite infusion of large amounts of fluids,
comparatively insensitive; it becomes much more sensitive
only <400ml urine is passed in 24hrs, she is in renal
later, especially in a multipara. So in a pregnant patient
failure. Put her on an accurate fluid balance. This is serious,
always use an IV infusion, starting with a small dose. If you
but potentially curable. Early treatment will improve her
do not get the effect you want, use more in incremental
prognosis, so watch for it. Try furosemide 40-320mg IV.
doses. After delivery, or during an abortion, this rule does
If this fails try dopamine if obtainable. Start with
not apply, and you can safely use a bolus injection IV or IM.
2-5μg/kg/min. Increase in steps till an effect has been
(2) The supply of oxygen and nutrients to the foetus via the
attained, this is usually at <20μg/kg/min.
placenta will be inadequate if uterine contractions take too
long or are too frequent. The foetus might not cope,
If labour was obstructed with cephalic presentation for a even if there is a normal placenta. If, however, there is
long time (active labour for ≥6hrs) insert a catheter for
already marginal placental function, e.g. in the presence of
14days: it might just prevent a fistula. If one does develop,
high blood pressure and/or growth retardation, the effect on
keep the catheter in situ for at least 6wks.
the foetus may be catastrophic.
Remember: oxytocin might kill a foetus if you do not
The neonate has a greater chance of brain damage in a monitor its use properly. Even normal contractions may be
difficult delivery. This may be caused by:
too much for the foetus if placental function is very poor!
(1) Direct trauma from the procedure itself.
(3) You can add too much fluid at the same time when
(2) Lack of oxygen.
infusing oxytocin IV, especially when you use oxytocin to
(3) Poor foetal blood flow.
induce labour early in pregnancy, when you may need high
doses. So when you use escalating doses, avoid the danger
Watch him carefully for signs of twitching, irritability,
of water intoxication by using 0.9% saline or Ringer's
or fever.
lactate, not 5% dextrose.
411
412
The primigravid uterus is sufficiently insensitive for N.B. If there is absolute CPD, do not use a vacuum
oxytocin to be safe enough for midwives to give routinely to extractor; it will be ineffective and potentially dangerous
accelerate labour. But, using oxytocin to accelerate labour in unless you combine it with a symphysiotomy (21.7).
multipara can be dangerous, so only use it if you are (5);A need for haste because of foetal distress without or
experienced, and do not let your midwifery team use it with only mild CPD.
unsupervised. (6) In an unconscious patient, e.g. with eclampsia, with near
In Africa, the head is often high through much of the (8cm) or full cervical dilation and a moderate-sized foetus.
1st stage. Speeding its descent with oxytocin is dangerous (7);Failure to progress, or exhaustion in a 2nd twin with a
for the inexperienced. If labour in a multipara is slow, and cephalic presentation, when the cervix is closing down even
her previous deliveries were normal, she will probably if the membranes have been ruptured and an oxytocin
deliver the present foetus eventually, provided he has a infusion is in progress. The height of the head does not
cephalic presentation. So it is likely to be safer to leave her, matter in this situation, provided you can get the cup on the
after examining carefully to exclude a brow presentation, occiput. (This is not easy because the head is often high and
than risk rupturing the uterus by using oxytocin the flabby cervix and the cord of the 1 st foetus tend to find
unnecessarily. their way into the cup)
Oxytocin is used otherwise in many situations: evacuation of (8) Prolapse of the cord in a multipara.
incomplete or delayed miscarriage (20.2), and retained (9) In combination with a symphysiotomy in order to control
miscarriage (20.4), inducing labour (22.2), breech the delivery better and keep the head away from the
presentation (22.7), multiple pregnancy (22.10), temporarily poorly supported urethra
and post-partum haemorrhage (22.11).
Always use the ‘protocol on the wall’ CONTRAINDICATIONS.
(1).Prematurity <36wks, because of the risk of intracerebral
AVOID OXYTOCIN IN MULTIPARA haemorrhage.
(2) A brow or face presentation.
(3).CPD, unless you combine vacuum extraction with
21.6 Vacuum extraction (Ventouse) (GRADE 1.3) symphysiotomy (21.7).
(4) Foetal death
You will find a vacuum extractor invaluable, so if you are CAUTION! Do not apply a vacuum extractor before full
not already using one, you must! A properly functioning one or nearly full (8cm) cervical dilation because it is usually
will save many mothers and babies. It has many advantages dangerous: the only exceptions are (5,6,7) above. Do not use
in the confined space of the commonly small pelvis of many it for delay late in the 1st stage (21.3). (If this does not
women seen in many low-income communities. respond to oxytocin, it is likely to be due to CPD).
Unlike forceps, the vacuum cup takes up no extra space If (a) it has taken >3hrs to dilate from 7-10cm on the
beside the head in the birth canal, and it is difficult to partograph,
injure the mother seriously. The foetal head can rotate or (b) the fundal height is >40cm (suggesting a large
spontaneously at the optimum level, and if it is not baby), expect difficulty. Perform the vacuum extraction in
flexed enough, vacuum extraction will often flex it. theatre, and prepare for Caesarean Section.
Most importantly, a vacuum extractor is less likely to
damage the foetal brain than forceps. The indications for its REQUIREMENTS.
use in a hospital are somewhat broader than those in a health (1) A cephalic presentation.
centre. (2) The foetal head must be ≤1/5 above the pelvic brim.
N.B. Make it a habit to clean and grease your (manual) N.B. Always determine the position of the head in relation
vacuum apparatus weekly. Machines which do not function to the pelvic brim, and not to the ischial spines; if the pelvis
at the critical moment might kill babies and even mothers. is shallow and there is much caput, you may be able to feel
If somebody offers donations to your hospital, ask for extra it below the spines before it is engaged.
cups (preferably the model Bird type, including one (3) The head must descend, or at least move somewhat, with
posterior cup) and tubing so that you have a few autoclaved contractions and bearing-down efforts.
packs ready, particularly over a long weekend. Invest in the (4).You should preferably know where the occiput is,
best quality: there are very poor quality sets on the market. because traction will be more effective if you can put the
Before you start applying the cup to the head, try it on you cup there. This is often not that easy and sometimes you are
gloved hand first to see if there are any leaks. forced to put the cup at the lowest point. An ultrasound
might help, if you are not sure, to locate the back of the
INDICATIONS. occiput (21-7).
(1).Delay in the 2nd stage of >1hr in a primigravida,
and 30mins in a multigravida, especially delay caused by If a bimanual examination indicates that the head is
malrotation of the occiput. wedged solidly in the pelvis, and you are unable to rock
(2).To reduce maternal effort if a woman has cardiac failure, it up and down at all, then a vacuum alone is unlikely to be
gestational hypertension, or exhaustion. successful. It there is severe moulding >4, you will need to
(3) To minimize the strain on a scarred uterus. add a symphysiotomy at least. However, seeing the foetal
(4).Relative CPD due to deflexion and malrotation of the head in the introitus especially between contractions is a
head. good reason for optimism.
412
413
413
414
On the other hand with the stuck aftercoming head in a Moreover, there will often be an infection at this stage and
breech presentation, a shoulder dystocia or a failed vacuum by opening the uterus, infected material contaminate the
extraction, it will take only 15mins to execute your first operative field including the peritoneal cavity.
symphysiotomy slowly and methodically. If all goes well The wound in the uterus and the abdominal wall is likely to
that might be a watershed for introducing the value of this become infected. An infected uterine incision is likely to
procedure. result in a weak scar.
If you have sufficient helpers, ask your staff to prepare for a (3).A woman living in an isolated location, who comes late
Caesarean Section, but get on with the symphysiotomy in to hospital, and who is likely again to present late with the
the meantime! next delivery, and especially whose foetal outcome is likely
to be poor. She may subsequently be tempted to deliver at
home with fatal consequences, about which you will hear
nothing. If she has a symphysiotomy her pelvis will be
somewhat larger and there will be no uterine scar.
(4).Mild or moderate CPD with a live foetus, particularly in
a primigravida, when the foetal head is 1/5 or 2/5 above the
brim, and is too tightly held for vacuum or low forceps
alone.
(5).To deliver the arrested aftercoming head of a breech
presentation (if you are quick!) or a shoulder dystocia.
N.B. Never do this as your 1st ever symphysiotomy.
(6).Extreme anaemia when there is no blood available or the
patient is a Jehovah’s Witness, who refuses transfusion.
(7).When there is a long lag time between taking the
decision to perform a Caesarean Section and actually doing
it, especially if this delay might kill mother and/or child.
Moreover the longer the waiting list is for Caesarean
Sections, the more likely it is that somebody else will die
who is even later in the queue.
(8).In a health centre, where a symphysiotomy is an
emergency delivery method, thus securing a live baby,
when referral is impossible.
CONTRAINDICATIONS.
(1) Severe CPD.
(2).Malpresentations, with the exception of the aftercoming
Fig. 21-8 SYMPHYSIOTOMY. A, position of the symphysis on the head of a breech (22.7).
anterior abdominal wall. B, position of the symphysis in relation to the (3).Foetal death; if there is minor CPD and a
clitoris. C, structures to cut. D, incision in relation to the urethra symphysiotomy would be feasible, a craniotomy will
pushed laterally, and the bladder. E, situation in shoulder dystocia. likewise be possible; if there is no CPD a symphysiotomy is
After Pust RE, Hirschler RA, Lennox CE. Emergency Symphysiotomy for
trapped head, Tropical Doctor 1992;22(2):71-75 unnecessary. Only in very exceptional circumstances would
a symphysiotomy be an option with CPD and foetal death:
SYMPHYSIOTOMY (GRADE 2.1) when a woman is highly likely to have CPD in the next
INDICATIONS. pregnancy and she is very unlikely then to deliver in hospital
Mild or moderate CPD associated with any of these next time. A larger pelvis after the symphysiotomy for a
problems, most of which are interrelated: dead baby could help with the next delivery.
(1).A failed trial of vacuum extraction even after applying (4).A complete family when the patient would like a
fundal pressure. This is the most common indication. sterilisation. The chances are that there will be fewer
It is difficult to be sure that vacuum extraction won't work combined obstetrical problems now and in the future if a
without having a try! A difficult vacuum extraction may tubal ligation is performed together with a Caesarean
succeed, but only after prolonged traction and the risk of Section.
damaging the baby. Symphysiotomy will make delivery (5) Abnormalities of the maternal pelvis or legs.
easier and safer. At the strategic moment, preferably before (6).A large foetus >4kg as estimated by the fundal height
there are any signs of foetal distress, it is ideal. being >40cm (who is too big to deliver by symphysiotomy),
If the indications are right, it is better than Caesarean or <2·5kg (who does not need one).
Section, and it avoids a difficult vaginal delivery. (7).A foetal head which remains >3/5 above the pelvic brim
(2).Neglected obstructed labour with a live foetus. after rupture of the membranes, e.g. in hydrocephalus (22.6).
If the foetal head is deeply jammed into the pelvis, perhaps Relative contraindications are:
with caput visible at the vulva, symphysiotomy will be safer. (8) Severe obesity,
If you try to perform a Caesarean Section, the foetal head (9) Previous symphysiotomy, or
will be difficult to deliver, and cause a laceration of the (10) Previous VVF repair.
lower segment into the large vessels or deep in the cervix or
even into the bladder.
414
415
If you have the opportunity, see what happens to a cohort of women who Push the point of the still vertically held blade about 1cm
delivered by Caesarean Section and who could have had a symphysiotomy
deep in the space between the pubic bones (in the mid-point
instead. Record the complications, and not only those around the index
delivery but also from subsequent deliveries, say over the next 10yrs. between the superior and inferior margins) with the cutting
Such a study in your region will probably show that many women who had edge of the knife facing downwards. In order to avoid
a Caesarean Section, but could have had a symphysiotomy for failed damaging the vagina, or urethra (which you are pushing to
vacuum extraction, or for failure to progress or foetal distress in the
the side with your index finger of your non-dominant hand),
2nd stage, die of complications of a subsequent delivery or become infertile
because of postoperative peritonitis. There will then be evidence to stop cutting downwards, but swing the blade towards you,
challenge inappropriate use of Caesarean Section in your region. so that you are now cutting upwards (away from the vagina).
The fibres of the upper part of the ‘joint’ will then act as a
METHOD fulcrum for the blunt part of the end of the blade.
Check the cervical dilation, the descent and position of the The sharp part of the blade will cut the fibres of the lower
foetal head. At this point decide if symphysiotomy is part of the ‘joint’; you will feel them giving way as they part
indicated or not. (Symphysiotomy is normally done at full under tension.
dilation, but you can do it when there is still a 1 or 2cm ring The skin is usually so flexible in this area that the skin
of cervix). incision will only be enlarged a little because of this
If the foetal head is 1/5 above the pelvic brim, manoeuvre. Once you have cut the fibres of the lower part of
a symphysiotomy is unnecessary, unless combined with a the ‘joint’, taking care never to go beyond the arcuate
failed vacuum extraction. ligament (which arches across the inferior aspect of the
If the foetal head is ≥2/5 above the pelvic brim, symphysis), withdraw the knife, hold it again vertical and
symphysiotomy may be indicated. rotate it in such a way that the belly of the blade is now
If the foetal head is ≥3/5 above the pelvic brim, facing upwards. Re-insert the knife through the stab wound
try to insert a finger vaginally between the foetal head and and now swing the blade away from you, thereby cutting
the pelvis. If your finger passes too easily, symphysiotomy is the fibres near the superior margin of the ‘joint’.
unnecessary. If it passes with difficulty, symphysiotomy is When the ‘joint’ is almost divided, it will begin to open,
indicated. If it does not pass at all, CPD is too great, sometimes audibly: 2cm is ideal, it should never open >4cm.
so proceed to Caesarean Section. Often, though, you will not have cut enough fibres and will
Listen to the foetal heart to make sure that the foetus is alive. have to divide some more. The best way to do this, keeping
Place the patient in the lithotomy position. your non-dominant finger in the vagina pushing the urethra
CAUTION! Find 2 assistants and ask them to support away from the midline, is to insert the blade again under the
each of the legs, so that the abduction angle between the two skin in the ‘joint’ but keeping it nearly horizontal, and push
upper legs is at maximum 90° (each upper leg 45º angle with the belly of the blade (not the point though) against the tense
the horizontal). This must be their only job; they must do fibres. Do not make a sawing motion, but you can move the
nothing else. If they allow the legs to flop apart, the fibres of handle up and down somewhat in a 20º rocking action
the sacroiliac joint may rupture, and the patient will have against pressure of your finger in the vagina. Gentle pressure
much postoperative pain, and maybe pelvic instability. usually suffices.
You will value these assistants anyway, even if you have
reliable lithotomy poles, to prevent too much abduction. If you cut 90% of the fibres that is enough; do not be
Palpate the bony margins of the symphysis pubis. Infiltrate persuaded to cut more in the superior part of the ‘joint’
the skin and subcutaneous tissue over the symphysis and the because it is more difficult to dislodge the proximal urethra
‘joint’ between the pubic bones with 12-15 ml of 1% and bladder base in this area. Alternatively, when nearly
lignocaine with adrenaline. Infiltrate also the area for an through the fibres, use the top of your thumb through the
episiotomy with the remaining LA in your syringe. wound as a wedge to force open the ‘joint’ so that the knife
Although normally a vacuum extraction does not stays far away from the vagina. (This works well, although
automatically mean an episiotomy, it does with a your thumb will be somewhat tender for a few days!)
symphysiotomy. By controlling the descent of the head and N.B. Sometimes the ‘joint’ is not completely vertical and
keeping it away from the urethra, you will prevent a tear. you have to hold the blade aiming somewhat out of the
Clean the skin and vulva well with betadine or midline (therefore not completely vertically down).
chlorhexidine. Insert a stiff catheter. You may need to push Be careful not to do exert too much rotating force on the
the foetal head a little to pass the catheter. Apply the handle (clockwise or anticlockwise) because you could
vacuum extractor. wrench the blade out of the handle or break it. However it is
Place your index finger (do not use two fingers, because the usually easy to retrieve a large blade.
urethra tends to slip between them) of your non-dominant N.B. Often the ‘joint’ opens suddenly and the head comes
hand in the vagina, to displace the catheter in the urethra down very fast and it is a struggle to apply the vacuum and
away from the midline. perform an episiotomy. So it is better to apply the vacuum
CAUTION! You must displace the urethra, or you may before the symphysiotomy.
cut it. This could be a major disaster! You will find anyway that most of your symphysiotomies
Use a large blade, preferably a solid knife, so that the blade will be done after a failed vacuum. It is very difficult to be
does not come off or break. Make a 2-3cm incision in the sure, where there is an indication for symphysiotomy,
skin and subcutaneous tissue over the symphysis pubis in the that an extraction will fail. It is better to perform the
midline. Then hold the knife vertical, and find the exact episiotomy as late as possible because there might be
position of the ‘joint’. (This you should have located when significant loss of blood with greater chance of HIV
you injected LA). exposure.
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416
CAUTION! If urine does not pass when the catheter is removed on the
(1).Always keep the urethra to one side with your 3rd day, replace it and try again on the 5th day.
non-dominant hand.
(2).Do not cut above the symphysis pubis, because the uterus If there is incontinence of urine, it may be:
or bladder may be protruding there. (1).stress incontinence which happens often in the first
(3).Do not cut below the symphysis pubis, in case you weeks after operation but will usually recover spontaneously
damage the clitoris. within 3months, or
(4).Never perform a symphysiotomy without an episiotomy. (2).evidence of a fistula. In this case, keep the catheter in
(5).Make sure the legs of the patient are held firmly in situ: it might close or at least the hole might become
position, and strapped together before moving her from the smaller. However, check that there is not in fact a large
delivery bed. fistula kept open by the catheter balloon!
If you have operated on the right indications, the mother If, later, she develops chronic pain & discharge,
will deliver easily, usually after bearing down with she has chronic pubic OSTEITIS. This is rare, and treatment
1-2 contractions. is difficult; use NSAIDs, and rarely antibiotics. It probably
CAUTION! Do not apply delivery forceps after only occurs when the incision involves bone, so keep strictly
symphysiotomy; they may stretch the sacroiliac joint too to the midline in the fibrocartilage of the joint.
much or damage the initially poorly supported urethra.
If the patient has difficulty walking with an uneven gait,
If the incision continues to bleed, suture the subcutaneous this may well be because her hips were not held firmly, and
tissue, and skin with 1-2 vertical mattress sutures. Lie the the sacral ligaments were stretched or disrupted. A corset is
patient on her side, and press on the wound for 5mins. rarely required, but active physiotherapy is necessary.
Leave a self-retaining catheter in place for as long as the If you injure the urethra, see 21.18.
patient is immobile because lifting the buttocks on a bedpan
will be painful. Normally after 2days when she is able to sit
on the side of the bed, remove the catheter, provided the
urine is not blood-stained. The usual cause of this is 21.8 Destructive operations
obstructed labour or a balloon blown up still partly in the For an obstructed labour with a dead baby a destructive
urethra because the foetal head prevented it being passed all operation is usually better than a Caesarean Section.
the way in the bladder. These operations are sometimes said to be old fashioned,
and to have no place in modern obstetrics. Old-fashioned
If the indication was for prolonged obstructed labour perhaps, but they have some useful features:
(>6hrs), the patient is at risk of developing a fistula; so (1) They need few instruments and only simple anaesthesia,
leave the catheter in situ for 10days to try to prevent this so that they can be done in a health centre where a woman is
from developing or to help a tiny fistula close completely. first seen. If she cannot be referred, they may save her life.
If referral is difficult, they avoid the risks and delays of a
Apply a stretch bandage around the knees for 2days. long journey.
Allow walking with the help of a chair, frame or trolley as (2) They leave the mother with an intact uterus, which will
soon as the legs can move independently without pain be less likely to rupture if she has a home delivery the next
(usually 72hrs). Some patients can do this easily, others, time.
especially the heavier ones, fail to walk until the 5 th-7th day. (3) If there is already infection present, they are less likely
Remove sutures on the 7th day. Most patients are walking than Caesarean Section to spread the infection into the
well, and fit for discharge, on the 10th day. There is no need peritoneum.
to bind the pelvis: the symphysis will heal leaving the pelvis (4) Hospital stay is shorter.
larger that it was before.
The case for destructive operations is strongest in
DIFFICULTIES WITH SYMPHYSIOTOMY communities where a woman is married very young. She
If spontaneous delivery does not occur, pull with the may not be fully grown when she first becomes pregnant, so
vacuum extractor. Use oxytocin with the birth of the anterior that the pelvis is small and the first labour obstructs.
shoulder or very soon after, because an infected, exhausted The pelvis will continue to enlarge until she is 19yrs,
uterus tends to contract poorly, so there is then a risk of so, if she delivers vaginally with the first pregnancy,
PPH. the later deliveries may be possible vaginally without the
risks of scarring the uterus. Besides their distasteful
If the wound shows signs of local infection, use ampicillin messiness, the main argument against these operations is
or chloramphenicol, which are not passed through breast that, in inexperienced hands, they are liable to be even more
milk as are tetracycline or sulphonamides. dangerous than Caesarean Section. This is unlikely to be
true, if you follow the instructions carefully!
If there is postoperative fever, suspect urinary or puerperal To those who decry them, we reply that as long as there are
infection because of prolonged labour, or both. fistulae resulting from neglected obstructed labour,
symphysiotomy and destructive operations are not obsolete.
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INDICATIONS.
(1) For a cephalic presentation, all the following conditions
must hold:
(a) Foetal death.
(b) ≤2/5 (3/5 if you are experienced) of the foetal head must
be above the pelvic brim. The foetal head must be impacted.
(c) ≥7cm cervical dilation, preferably full.
(d) No uterine rupture, present or imminent.
N.B. If a multigravida has been in labour for a long time,
the lower segment will be very thin, and if it is tender and
distended, it is extremely thin. Any destructive operation,
except pushing a needle into a hydrocephalic head,
will rupture the uterus.
(2) For a breech presentation (22.7) when a normal or
hydrocephalic aftercoming head has ‘stuck’.
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Remove any loose pieces of sharp bone. Attach 3 or 4 strong INTRA-UTERINE FOETAL DECAPITATION
forceps to the foetal scalp and the remains of the foetal skull. (GRADE 2.5)
Pull on them and try to bring the foetal posterior fontanelle
under the symphysis. If sharp edges of bone stick out, INDICATIONS.
protect the vagina with a Sim’s speculum. For a transverse lie, all the following conditions must hold:
(1) Foetal death.
Wait until there is a contraction. Hold the 3 pairs of forceps (2) A transverse lie.
together, and pull and twist. The collapsed foetal head (3) Cervical dilation ≥8cm.
should now deliver. Sometimes descent does not go very (4) No uterine rupture, present or imminent.
fast; instead of struggling impatiently and panicking it is
better to connect a strong traction rope to the handles of the PREPARATION. As for craniotomy above.
instruments and connect that to a weight of 2-3kg over the
foot end of the bed and observe for 20mins. The foetal body METHOD
will follow. If a piece of the foetal skull pulls off, reattach Put one hand into the vagina and support the fundus with the
the forceps taking a deeper bite of skull closer to its base. other. Measure the cervical dilation. Examine the condition
Make an episiotomy if indicated and deliver the remains of of the lower segment; explore it as far as you can without
the foetal head. using force.
Assess the exact position of the foetus. Which of the foetal
CAUTION! arms have prolapsed? Where exactly are the foetal head and
(1) Do not include folds of the vaginal wall or cervix. neck, chest, abdomen, and back? Can you reach the foetal
(2).Use a good light and a large Sims' speculum, neck easily?
to make sure you grasp only the foetal skull. CAUTION!
(1).Do not try an internal version without doing an
If delivering the foetal shoulders is difficult, put a hand evisceration first: you will rupture the uterus.
behind the foetus and try turning it through 90º or 180º. (2) Do not attempt decapitation, or evisceration, through the
Then try delivering the foetal shoulders again. vagina if the foetus is still high in the birth canal; you will
not be able to protect the vaginal wall and cervix adequately.
If you cannot bring down the foetal shoulders by
turning, bring down the foetal arms one by one. Put a hand Bring a foetal arm down or pull on a prolapsed arm with one
behind the foetus in the vagina and feel for the foetal hand, and apply a weight connected to the arm; if you can
posterior arm. Gently pull it down. Do not worry if the arm bring the foetus down even a little, the operation will be
breaks, but do not damage the vagina. much easier and if it is a premature foetus, this will often
Then turn the foetus through 180º and deliver the other arm achieve spontaneous delivery! It also prevents the foetus
in the same way. Delivery should now be easy. being pushed upwards by your hand in the uterus, prevents
Alternatively, cut the foetal clavicles (cleidotomy, 21-9). the distended lower uterine segment being stretched,
and brings the foetal neck lower, which you can now feel
with your other hand. Feel how large it is, and how easy it is
to put a finger around it. If the foetus is small and
macerated, you can usually cut the foetal neck with strong
scissors.
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INDICATIONS
For a transverse lie when the foetal neck is difficult to reach,
but the foetal body is well down, or after decapitation if this
fails to effect delivery.
METHOD
Ask your assistant to pull on the foetal prolapsed arm, and
find the foetal axilla. Protect the vaginal wall with 2 specula.
Grasp the foetal abdominal wall with strong long forceps,
and with strong scissors make a large opening in the foetal
abdomen. Put one or two fingers into the opening and
remove all the internal organs. Make sure you remove the
liver, heart, and lungs. If necessary perforate the foetal
diaphragm with the scissors. Now reassess the situation, and
try whichever of these manoeuvres seems best:
(1),Put two fingers behind the foetal pelvis and hook the
foetal breech down.
(2);Inflate the balloon of a Foley catheter placed in the foetal
pelvis with 50-60ml and apply traction (as in a breech
presentation, 22.7).
(3) Grasp a leg or foot and bring that down.
(4).Try to bring the foetal neck down for decapitation by
pulling on the foetal arm.
Fig. 21-11 DECAPITATION FOR A DEAD FOETUS will leave a (5),Divide both clavicles (cleidotomy) to reduce the width of
woman with an intact uterus, which will be less likely to rupture if she
delivers at home next time. Cut through the foetal neck with a Blond-
the shoulders of a large dead baby. Use long scissors to
Heidler saw. A, push the thimble round the foetal neck. B, pull the loop make a small cut in the skin of the foetal neck. Through this,
of the thimble down the other side of the foetal neck. C, saw through it. guided by the fingers of your other hand, feel inside the
D, remove the foetal head with forceps. Pieces of rubber tube cover the foetal skin, until you can divide a clavicle between the tips
outer ⅓ of each end of the saw. Kindly contributed by John Lawson.
of the opened blades of the scissors. The ends of the foetal
clavicle will then overlap and narrow the foetal shoulders.
To deliver the foetal head, put a hand in the vagina, and
Be sure it is the foetal clavicle and not the spine of the foetal
turn the foetal head so that the neck points downwards.
scapula that you are cutting.
Grasp the stump of the foetal neck with large forceps, and
Or, finally,
put a finger in the foetal mouth. Then deliver the foetal head,
(6).Separate the foetal prolapsed arm at the shoulder. Push
as if it were the aftercoming head of a breech.
the embryotomy scissors (19.2) through the foetal axilla and
This will prevent the stump from injuring the birth canal.
divide the internal structures from inside the foetal skin,
If the foetal head is very large, you may need to perform a
while keeping your other hand between the foetal body and
craniotomy. If you delivered the foetal head first, deliver the
the uterus, as a constant guide. Finally, divide the foetal skin
foetal body by pulling on the other arm. Do not try version:
and superficial tissues under direct vision, and deliver the
the cut foetal neck might lacerate the uterus.
foetus in 2 halves.
If you are using scissors, hook one or two fingers round the
DIFFICULTY WITH DESTRUCTIVE OPERATIONS
foetal neck and pull it down. Ask an assistant to protect the
If you have difficulty delivering the foetus, try to visualize
vaginal wall with 2 specula. Gently pull the foetal arm.
carefully the foetal lie and identify its anatomy. Ultrasound
When you do this, you will feel the foetal neck. Try to see
may help. Remember, there is usually no rush to perform
what you are cutting with each cut, because you could
this procedure.
otherwise easily cut the uterus or bladder. Cut the foetal
neck a little at a time, then deliver the foetus as before.
POSTOPERATIVELY AFTER A DESTRUCTIVE OPERATION
Remove the placenta manually, and immediately feel for
CAUTION! Do not cut if you cannot see the foetal neck.
tears of the uterus and lower segment. Administer oxytocin
After each cut, pull on it. It will come a little further down
IV as the foetus is delivered. Check the uterus by feeling
with each cut until you have cut right through.
inside it to make sure it has not ruptured. If it has, perform a
laparotomy and repair it (21.17). Check the cervix, vagina,
and vulva for tears, and repair them (21.15).
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If the uterus is not well contracted, set up an IV oxytocin There are still some problems, though:
infusion with 5-20U in 500ml. Continue the saline infusion (a) A lower segment operation needs more skill.
for 24hrs as well as perioperative antibiotics. (b).It is still dangerous if there is intrauterine infection,
Monitor for: although less so than the classical incision.
(1) Postpartum haemorrhage in the first 24hrs. (c) You may injure the bladder.
(2) Acute urinary retention in the first 24hrs. (d).Bleeding from the ends of the incision is more difficult
(3) Infection of the genital tract after 24hrs. to control, especially if there are lateral extension tears,
(4) Infection of the urinary tract at 7-10days. as may happen if the lower segment is thin and distended,
(5) A fistula (21.18). or the foetus is an awkward position, as in a transverse lie.
These tears may bleed severely, and in trying to control
If the foetal head has been impacted in the pelvis for bleeding you may tie or cut the ureters.
many days, leave a urinary catheter in situ for 14days. (e).You may find it difficult to extract a distorted
This will help to prevent a fistula. However, obstructed presenting part through a lower segment incision, and tear
labour with a transverse lie does not cause pressure necrosis the uterus as you do. This tear will be dangerous, and the
of the vagina. only way to avoid such, is to extend it. If you can do this
curving the incision upwards at the edges, well and good;
CAUTION! After any destructive operation, be sure your otherwise you may have to resort to a T incision, which does
assistant wraps up the foetus immediately on delivery. not heal well, and is a very bad incision to have to make.
Try wrapping it in such a way that the mother can still see So only make the standard transverse incision if it is safe.
the face if she wishes, without exposing the débris of the (f).The risk of spontaneous rupture is low, but not
operation. This will help her in the grieving process more insignificant, at 1%.
than simply disposing of the dead foetus. In some cultures,
the family may wish to bury the foetus with all due Because of these dangers, we describe 5 other methods:
ceremony. Be careful that you respect such traditions. (2).Transverse classical, through a transverse incision low
in the upper segment. This is occasionally needed if there is:
AVOID CAESAREAN SECTION (a) a transverse lie,
WHEN THE FOETUS HAS DIED (b) a contraction (Bandl's) ring,
(c) a very vascular lower segment, with many thick veins,
(d) a placenta praevia (20.11),
(e) a poorly developed lower segment especially if it is a
21.9 Which kind of Caesarean Section? premature delivery, or
Caesarean Section is the commonest emergency procedure (f) a uterus which is a mass of fibroids in its lower part.
after episiotomy and evacuation of retained products of
conception carried out in a district hospital. If you are (3).Midline classical, through a vertical incision in the
inexperienced it will also be the one which you will be most upper segment (21.12). This is really only indicated, then
frightened of doing. In unskilled hands it is often fatal, rarely, if:
as a result of: (a) the lower ½ of the upper segment which is very
(1) anaesthetic-related problems such as obstruction of the vascular, or inaccessible as a result of adhesions from
upper airways and the inhalation of gastric contents, spinal previous surgery,
shock or ventilatory paralysis and overdose, (b) a previous classical incision has healed poorly,
(2) haemorrhage, often related to inexperience or technical (c) you will proceed to hysterectomy anyway,
problems after earlier operations, (d) in the rare case of post-mortem delivery.
(3) sepsis. N.B. You should combine a classical incision with a tubal
ligation unless there is a very good reason not to, because
There are several methods of Caesarean Section: uterine rupture may occur spontaneously in pregnancy and
(1).Lower segment, through a transverse incision (21.10). occurs in up to10% of all cases.
It has long been the standard operation because:
(a) a scar here ruptures 10 times less often than the scar (4) De Lee (Kronig or Cornell), through a vertical incision,
from a classical incision, ⅔ in the lower segment, and ⅓ in the upper. Use this if:
(b) when it does rupture it does so less dangerously, (a) a lateral tear is likely, as can happen if the lower
(c) the incision in the uterus heals better, segment is very thin,
(d) the danger of spreading infection is reduced, (b) the foetus is in an abnormal position, e.g. transverse lie,
(e) the placenta is less often directly underneath the uterine especially if the foetal back is presenting.
incision, N.B. It is difficult often to know where the lower segment
(f) the bowel is less likely to stick to the scar in the uterus, ends and the upper segment starts, so a De Lee may actually
(g) there are fewer postoperative complications. become a midline classical incision. Risk of spontaneous
rupture is up to 5%.
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(6) With hysterectomy. Indicated occasionally for: WAMBUE (35yrs) had had 3 previous Caesarean Sections, and went into
premature labour one evening. The duty doctor took her to the theatre.
(a) rupture of the uterus (21.17),
The lower segment was very vascular, and there were many adhesions from
(b) severe bruising of the lower segment, previous operations. When he incised it, he cut into a placenta praevia,
(c) laceration of the uterine artery, which is normally not a problem but it is better to open the uterus with your
(d) established uterine infection, fingers (and then it is easy to go through or past the placenta as long as you
are quick). The operation was otherwise uneventful, the uterine incision
(e).severe placenta accreta after previous Caesarean
was repaired, and all bleeding carefully controlled. He noted that the
Sections, bladder was distended, but assumed that the catheter had come out. When
(f) early proven cervical carcinoma she left the theatre the blood pressure was normal, and she was transfused
(N.B. you can easily confuse this macroscopically with one unit of blood. The urine was however noted to be bloodstained.
He was summoned urgently to the ward 15mins later because she was lying
cervical schistosomiasis).
in a pool of blood, with no pulse and a systolic blood pressure of 30mm Hg.
The uterus was well contracted, she was given ergometrine, and rushed
back to the theatre. She was resuscitated and the abdomen was reopened;
there was no blood in it. She died on table. At postmortem she had a large
tear in the bladder; the upper edge of the uterine incision had been
21.10 Lower segment Caesarean Section mistakenly sutured to the upper margin of the anterior bladder tear, so that
the lower edge of the uterus had been able to bleed freely into the bladder
and vagina. The doctor was overcome by grief and felt very incompetent.
LESSONS (1) The anatomy of a patient having a 4th Caesarean Section can
Experienced surgeons often use a Pfannenstiel or Joel- be complicated. (2) Do not make your incision too low, especially with a
repeat Caesarean Section. (3) If you find an abnormally adherent or
Cohen abdominal wall incision for a Caesarean Section.
vascular lower segment, perform a high transverse incision. (4) As so often,
This is justified if this will be the patient’s last Caesarean disaster was the result of the combination of risk factors. A lower segment,
Section, or is combined with a tubal ligation, or if she will which has been the site of adherence of a placenta praevia, is apt to bleed
have access to equally experienced surgeons in the future. postoperatively. Had she not also had a placenta praevia, she would
probably have escaped with her life, and merely had a vesico-uterine fistula,
Otherwise there are further problems: the surgeon who will
which could have been repaired. (5) If you have to try to do your best in 20
perform the next Caesarean Section may not be experienced, expert fields simultaneously (see the frontispiece), you will, by the
and may not be able to cope with adhesions behind a standards of 20 experts, not be as competent as they are. You will inevitably
Pfannenstiel incision, likely especially after infection or meet tragedies of this kind, for which you cannot be blamed. You can but
do your best.What is reprehensible is not to care, and not to strive to
keloid formation: this can be very difficult. A lower midline
improve your standards. (6) A colleague in this condition needs support.
incision is safer if future circumstances are uncertain.
ANTIBIOTICS halve the incidence of wound infection after
PREOPERATIVE COUNSELLING. Caesarean Section: use prophylactic pre-operative
Always think of discussing with the patient the advisability benzylpenicillin, chloramphenicol IV and metronidazole PR
of performing a simultaneous tubal ligation. Indications are: stat as soon as you make the decision to perform surgery.
(1) >1 previous Caesarean Section.
(2) Parity >2. If you wait till the cord is clamped, it is too late to help
(3) >30yrs of age. prevent foetal sepsis.
(4);Hypertension, diabetes, sickle cell disease, or heart
disease. If you have difficulty catheterizing the bladder before
(5) Advanced or untreated HIV infection. operating, raise the foetal head with your hands. If you fail
(6) Previous classical incision. to pass a catheter on the first occasion, try again after the
patient is anaesthetized, when pushing up the foetal head
It is always a good idea, especially in resource-poor will be easier. If you have to operate with a full bladder,
countries, to discuss, preferably halfway during pregnancy, be very careful as you open the peritoneum. Open it as far
whether a parous pregnant woman would like a tubal cranially as you can, and empty the bladder with a long
ligation in case she needs a Caesarean Section. She has then needle via the abdomen.
time to think about it and discuss it with the relevant
persons, and is not rushed into making a decision in an Clip the hair where you intend to make the incision.
emergency. A pre-printed questionnaire on her antenatal (Avoid shaving, which increases the risk of infection).
record will help remind staff and also make it routine. Prepare the skin of the lower abdomen (21-12B), drape the
This is important as patients must not feel the question is abdomen with 4 plain towels, and cover these with a towel
specifically directed at them, but that it is the routine to ask. with a slit (21-12C).
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ANAESTHESIA. You can use GA, Spinal anaesthesia, Feel and observe the uterus to find how it is rotated,
Ketamine or LA, or a combination. Do not let the lack of an and identify the presenting part. It is usually rotated to the
anaesthetist inhibit you in performing an emergency right, so that the left round ligament is usually more anterior
Caesarean Section. and closer to the midline than the right. If the uterus is
markedly rotated, turn it towards the midline.
METHOD (GRADE 3.) If you do not allow for rotation, you may cut the left uterine
POSITION. Stand on the right side of the patient. artery, because your incision will be too far to the left.
Prevent the supine hypotensive syndrome (pressure on the If you find that the left side of the incision always bleeds
vena cava) by tilting her about 5º to the left. Do this, either excessively, this is probably what you are doing wrong.
by tilting the table, or by putting a pillow or sandbag under
the right buttock. Find some way of preventing her slipping If the foetal head is impacted in the pelvis and needs to be
off the table. A moderate head down (Trendelenburg) disimpacted from below, ask yourself if a symphysiotomy
position, after the spinal anaesthetic is fixed at the correct (21.7) would not have been better, and remember this next
level, will give you better access to the lower segment. time! Ask an assistant, with sterile gloves, to put his hand
It will make delivering the foetal head easier if there is a into the vagina, and to disimpact the foetal head. He should
vertex presentation. It will also be an additional safeguard do this before you incise the uterus. If he waits until
against vomiting. after you have incised it, the foetal shoulders may
prolapse into the wound, and make delivery difficult.
INCISION. Unfortunately, it is difficult to predict that the head needs
Make a cut through the skin and subcutaneous tissue down disimpaction, until after you have opened the uterus.
to the level of the rectus sheath (21-12D) from within 3cm
of the umbilicus downwards, not beyond the upper limit of Pick up the loose peritoneum of the vesico-uterine pouch
the pubic hair. with dissecting forceps (21-12H). Make a small cut in the
N.B. Take care if there has been a previous Caesarean peritoneum over the uterus, just below the point where the
Section (21.14). loose peritoneum becomes firmly attached to its anterior
Separate the rectus (18-22B) and pyramidalis muscles, wall. This is the abdominal marking of the lower segment.
if present, in the midline as far as the symphysis. Then tear the peritoneum with your fingers to left and right,
If necessary, extend the skin incision further down. so as to separate it from the uterus underneath: you are less
A short downwards extension is more effective in improving likely to cut bowel at the lateral edges if you use fingers
access than an extension upwards. rather than scissors, and you can quickly free a large area of
the uterus. (21-12I). As you reach the edges of the uterus,
N.B. If you use a Pfannenstiel incision, use your fingers aim your fingers in a more cephalic direction, so that the tear
in a similar way for the tissues under the skin and above the in the peritoneum is curved (21-12J). Try to leave a bare
fascia, even the fascia and also, now directed vertically, area about 2cm wide and 12cm long.
to separate the rectus muscle in the midline. This approach
will push some nerves and blood vessels to the side instead CAUTION!
of cutting them. (1) Take great care to avoid injuring the bladder, especially
Use sharp and blunt dissection to expose the transversalis if this is pulled up high and is oedematous.
fascia and the peritoneum. Use two haemostats to pick up (2) Do not denude the lower segment for >5cm: if the cervix
peritoneum near the upper end of the incision (21-12E). is effaced and dilated, you may enter the vagina by mistake.
This is especially important if the labour is obstructed, Put the Doyen's retractor over the bladder, to protect it for
and the bladder is displaced upwards. Feel the fold of the rest of the operation.
peritoneum you have picked up, to make sure there is no Place moist abdominal packs on either side of the uterus
bowel or bladder in it. Make a small opening in it with a before opening it (21-12K), so as to prevent blood, liquor,
scalpel (21-12F) or your finger, and then open the rest of it and meconium from soiling the peritoneal cavity,
with scissors (21-12G) or tearing it with your fingers, and to keep the bowels out of the way. Meconium is irritant,
longitudinally from above downwards to just above the and if it becomes infected peritonitis may follow.
reflection of the bladder. Attach artery forceps to the tapes of these packs, to prevent
CAUTION! If the patient has had a previous them being lost. N.B. Never use small swabs!
operation, including a previous Caesarean Section, You may find it helpful to place a stay suture into the lower
omentum or bowel may be adherent to the abdominal wall segment (21-12L), and hold it in a haemostat.
and can be easily damaged. If you cut the bowel by mistake, Make a superficial incision over the full trajectory of the
clamp it and close it later (11-5). If there have been several planned opening in the uterus, c.10cm long, with its ends
previous Caesarean Sections, the anatomy will be much curving gently upwards directed to the attachments of the
distorted by adhesions. round ligaments (the ‘smile’ incision). This should be
Clamp any active bleeding vessels if they are big, ≤2cm below the peritoneal reflection, and at least
but postpone tying them until later in order to save time. ≥2cm above the detached bladder.
They usually stop bleeding on their own anyway, although Do not make your transverse incision too low in the lower
this does not always happen if you use a Pfannenstiel segment. Place it where normally the empty bladder reflects
incision. (so not where a bladder pulled up by adhesions reflects) or
Do not use diathermy until the foetus is delivered, 1-2cm higher. Then go somewhat deeper in the midline
because the current may cause foetal cardiac dysrhythmias. without at this stage entering the uterine cavity.
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To do this, push an index finger in the midline through the Now ask your assistant (or the anaesthetist groping under the
uterine wall and put the other index finger beside it and tear drapes) to press on the fundus to assist delivery. He may
the uterus along the path of the superficial incision. have to press firmly, but carefully and without hurrying.
This is easy. The not-so-neat edges of the arteries cut by CAUTION! Do not try to aspirate the nose especially
fingers bleed less and the extent of the opening is easy to with a big Yankauer sucker: it may push maternal blood into
control. A major advantage is that you cannot in this way cut the nose and/or traumatise the nasal passages.
into the foetus and transfer HIV, HBV, or HCV.
ERGOMETRINE OR OXYTOCIN.
If the patient has had previous Caesarean Sections, If there is hypertension, or eclampsia, or you are operating
and the uterus is very fibrotic, you may have to extend the under LA, avoid ergometrine, and administer 5U oxytocin
incision with scissors, curving it upwards laterally IV or IM. Ergometrine occasionally makes a conscious
patient sick, and may raise the blood pressure. Because you
CAUTION! are manipulating the uterus and can easily make sure it is
(1);The lower segment varies considerably in thickness. empty (leaving placenta behind is embarrassing), the uterus
It is thick before labour and becomes thinner during labour, is usually well contracted during closure. But after that you
so be careful not to cut the foetus. Protect it with a finger will often not notice relaxation because bleeding will not be
between the membranes and the uterine wall if you use overt. An oxytocin infusion at the end of the operation and
scissors instead of tearing with your fingers. the first postoperative hours can save lives.
(2) Do not make the incision too small, or the uterus will tear
as you remove the foetal head. THE BABY.
(3) If you decide to enlarge the incision, curve it upwards at If there is placenta praevia, clamp the cord quickly,
its ends, so as to avoid the uterine vessels. Also, when you because blood loss from the injured sinuses of the placenta
suture it, you will be less likely to suture the ureters. may be significant. Otherwise delayed cord clamping,
placing the baby below table level and milking the cord all
If there is a scar in the lower segment from a previous serve to increase the Hb level of a neonate, especially if
Caesarean Section, make a shallow cut along it, where you pre-term.
want to open the rest of the uterus.
CONTROLLING BLEEDING.
If you can feel the foetal vertex through the uterine wall, Now deliver the uterus by lifting the fundus out of the
the placenta is probably lying in the fundus or posteriorly, abdomen; it is easier then to see what you are doing.
so you can expect a delivery without difficulty.
If you are a quick operator, apply one Green-Armytage
If you tear the placenta as you open the uterus, try to clamp (or sponge-holding forceps) at one angle of the
detach it, and deliver the foetus around it. Only tear through uterine opening, and start suturing at the opposite end.
the placenta if you have to. There can be severe bleeding
from a lacerated placenta, so clamp the umbilical cord If you are a slow operator, apply several Green-Armytage
quickly (21.11). clamps (or sponge-holders) all round the cut edges of the
uterus, particularly at the angles. Make sure they do not
If the ends of the opening in the lower segment bleed grasp the posterior wall of the empty uterus, as it lies on the
severely, before the foetus has been delivered, quickly promontory of the sacrum; you can easily do this by mistake
proceed with delivery, and then control bleeding as if bleeding has been brisk. The difficulty in applying many
described below. clamps is that they will get in your way. Do not pull on the
clamps during suturing as this will result in an asymmetric
If there are large veins over the lower segment, closure.
place your uterine incision towards or in the upper segment,
or place clamps across the veins and incise the uterus REMOVING THE PLACENTA
precisely and carefully between the clamps, and deliver the When the uterus is contracting firmly, remove the placenta
foetus rapidly. The veins will probably stop bleeding soon by a combination of controlled cord traction and fundal
after. If necessary, ligate the veins. pressure (21-12S). If necessary, help it to contract
by massaging the fundus from inside the abdomen.
DELIVERING THE BABY Pull gently on the cord, and press the uterus back with your
Remove the Doyen's retractor. Put your finger (only) into left hand. This should deliver the placenta easily.
the uterus under the baby's head to decompress a vacuum,
and make it easier for the foetal head to rise in the incision. If there is a placenta praevia grown into a previous
Then put your hand outside the lower flap of the incision, Caesarean Section scar, there is serious danger of serious
and lift the foetal head up (21-12P). blood loss at this stage.
If you cannot remove the placenta manually (the practical
If the incision is not long enough to deliver the foetus definition of placenta accreta) then you may be forced to
without a lateral tear, extend its ends upwards and laterally proceed to hysterectomy. While deciding or organising
with your fingers, so as to make a U-shaped flap. blood, apply a tourniquet round the cervix (22.11)
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When the placenta is delivered: If you find an ovarian cyst >5cm diameter, perforate it,
(1);Inspect the uterine cavity to make sure it is empty. unless it is very large (23.9)
Remove pieces of membrane. Now is the time to tie the tubes (19.4). The Fallopian tubes
(2) Make sure that the placenta is complete. in pregnancy are swollen; do not use rings or Filshie clips
CAUTION! Do not probe the cervix to improve drainage: on them: they tend to slip off or break and are costly!
keep out of the contaminated vagina!
CLOSING THE ABDOMEN
CLOSING THE UTERUS Clean all blood and debris from the peritoneal cavity,
Do this in 2 layers using 1 long-acting absorbable sutures and especially from the paracolic gutters. They will be much
on a large round-bodied Mayo's needle. Do not use non- cleaner if you have previously inserted abdominal packs
absorbable sutures, particularly not on the inner wall. beside the uterus (21-12K). Wash out the abdominal cavity
Ask your assistant to hold the lower edge of the uterus with copious warm water if there was soiling present.
forwards, while you suture from the angles inwards Replace the uterus if you have exteriorized it. Place the
(21-12T). Start the first sutures just beyond the lateral greater omentum over the uterus: it will usually reach the
extremity of the wound. Knot with good tension and protect bladder. Close the abdomen (11.8). Do not insert a drain.
the point of your needle with the needle holder; then start
with a different suture and needle holder just beyond the BONDING
other lateral extremity, make a similar knot and work As soon as the mother has delivered, after any necessary
towards the first knot, and tie this second suture to the short resuscitation, give her the baby to hold. This close early
end of the first. Then re-start with the first suture and contact is important in developing the bond between them.
continue in the opposite direction (21-12U), finally knotting If she has had a GA, place the baby in a cot beside her,
this to the short end of the second suture. In this way, so she can see her child when she wakes up.
you secure the angles first. You will, if you use 90cm
sutures, have at least enough material left to tie the tubes POSTOPERATIVE CARE AFTER CAESAREAN SECTION
(if desired), and the rectus sheath. Estimate the blood loss: it will probably be more than you
Unless the sutures are tight, they will not stop the bleeding. think, but if the membranes were intact, some of the liquid
will be liquor. The average loss is 1l. Unless you have expert
CAUTION! staff, check the vital signs yourself. Check and chart the
(1);Start suturing just lateral to the wound extremity with an pulse, temperature, and respiration ½hrly, until she is awake,
adequate bite through the whole uterine wall. and then, when the condition is satisfactory, hourly for
(2);Do not suture the lower edge above the upper one, 12-24hrs. Continue an IV infusion for 24hrs; start oral fluids
because this may advance the bladder up the uterus. as soon as she is fully awake. Do not forget analgesia. It is
(3) Do not include the bladder in your sutures. If you find at wise to administer oxytocin 20U in 1l IV over 6hrs
the end of your closure, that you have included it, post-operatively to ensure good contraction of the uterus.
you will probably be wise to leave a catheter in for a few It is worthwhile making a postpartum vaginal examination:
days, rather than removing the sutures and starting again, you will instantly diagnose a urinary leak, if present.
which can cause severe bleeding. If bleeding was excessive, make sure there are 2 cannulae in
(4);Do not suture too deeply with a large needle at the situ and IV saline or Ringer’s lactate fluid replacement
angles of incision; you may obstruct the ureters. is flowing nicely. Review the patient yourself in 1hr.
(5);Do not suture the front and back walls of the uterus You will be surprised how often a patient who left the
together. So, before the first layer of sutures is completed, theatre in reasonable condition is now collapsed.
put two fingers into the uterine cavity, to make sure that its CAUTION! Look for signs of infection:
walls are free. If necessary, release the sutures and start (1) Fever.
again. (2) A large, soft, tender uterus.
(6);Do not suture the bowel to the back of the broad (3) Tender thickening in the lateral fornices.
ligament. Suture only the uterus, and not too deeply
downwards towards the vault of the vagina. If you are in any If the membranes were ruptured for >24hrs before the
doubt, put your fingers down behind the uterus before you operation, or there are other reasons for suspecting
start to close the lateral extremities of the opening so that the infection, continue antibiotics for 3days.
peritoneum stays out of your suture. N.B. Do not use antibiotics routinely postop.
When the uterus is no longer bleeding, close the peritoneum
of the vesico-uterine pouch with continuous sutures of If vomiting ensues with abdominal distension,
non-absorbable (21-12V). Again avoid including the bladder insert a nasogastric tube.
with the lower edge of the peritoneum. CAUTION! Before the patient goes home, make sure that
she and her relatives know that future deliveries must occur
COMPLETING THE REPAIR in hospital: this is ESSENTIAL! When next pregnant, she
Look carefully at your completed repair. If there is still must attend regularly for antenatal care. Give her a card
bleeding, put in some more 'figure of 8' sutures at the which explains why Caesarean Section was done,
bleeding points. Do not close the peritoneum until you have or add these details to the baby’s birth card.
controlled all bleeding, but minimal oozing is allowed.
If there was obstructed labour and the urine is
bloodstained, leave a catheter in the bladder for 10days.
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21.11 Difficulties with Caesarean Section CAUTION! So, after repairing a tear, check visually that
the ureter has not been caught in a stitch by mistake. If you
have a doubt, inject dye into the ureter to see if it leaks.
Many difficulties attend Caesarean Section, and many If these measures fail, the only way to control bleeding
disasters can follow it, so the list below is long. Torrential may be to tie the both uterine arteries, just after they
bleeding when you cut through a placenta praevia can kill a have entered or branched into the uterus or cervix.
woman quickly. Disasters with the urinary tract are usually If you are not able to repair the uterus, perform a subtotal
the result of very poor technique. Fortunately, most of the hysterectomy (21.17).
other problems are rare. Some of the many difficulties are
only seen in poor resource settings, where inexpert operators DIFFICULTIES WITH PARTICULAR PRESENTATIONS
find themselves working under difficult circumstances. If there is obstructed labour with a cephalic
presentation, enter the abdomen just below the umbilicus so
DIFFICULTIES WITH THE INCISION as to avoid the bladder. If catheterization before the
If a patient has had a previous Caesarean Section, operation was impossible, empty the bladder now with a
dense adhesions may have formed between the uterus and needle and syringe. Much of the swelling will be oedema,
the abdominal wall. which will not go away. Mobilize the bladder free from the
Do not excise a keloid scar: the keloid will probably get lower segment as usual. If necessary, get an assistant now to
bigger. Just go through the middle of it. Excise redundant push the foetal head up from below through the vagina,
skin if you intend simultaneously to repair an incisional before you open the uterus. Otherwise, the foetal shoulder
hernia (18.13). If the sides of the abdominal wall might may prolapse into the incision and make delivery more
prove difficult to line up accurately, mark a transverse line difficult. Make a transverse incision in the lower segment.
before your incision and align the points later. Choose its level carefully. If it is too high, delivery will be
Open the parietal peritoneum beyond the end of the previous difficult; if it is too low, you may have technical difficulties
scar. If you find a plane of loose connective tissue, closing the vagina or you may even incise the vagina.
free it with a finger. Cut fibrous bands. If dissecting the
adhesions is very difficult (unusual), give up and make an If delivering the head is difficult, do not panic.
upper segment incision. Everyone finds this a problem, especially when the uterus is
CAUTION! tight around it. Take time to push the uterine wall back
(1) Stay close to the uterus to avoid the bladder. from around the head, by inserting 2 fingers all round.
(2);If you find it helpful, open the uterus between stay If you still have difficulty, enlarge the wound curving
sutures. upwards laterally.
CAUTION!
If she has had a previous classical Caesarean Section, (1) Do not lever the head out with your whole hand, because
you would probably be wiser to perform a lower segment this can cause vertical downward tears in the lower segment.
operation this time. (2) If the liquor was purulent or infected, clean the abdomen
carefully, and wash out the pelvis with warm saline.
If the bladder has stuck to the lower segment, Administer antibiotics for at least 5days.
so you separate them with a finger, incise the peritoneum on
the uterus about 2cm above the bladder. Lift the lower edge If there is a breech presentation, feel for a leg, or better,
in forceps to stretch the adhesions between the bladder and both legs, and deliver the foetus breech-first as if you
the uterus. Cut them close to the uterus, keeping the points were delivering the head. Then deliver the head slowly,
of the scissors directed at it. If this is difficult, give up and or you may damage it.
make an incision c.3cm above the area where the bladder If, by mistake, you take hold of an arm, replace it.
and the uterus have stuck together. Then feel for a leg; recognize it by feeling for the heel.
If an arm comes out and will not go back, you are in trouble:
If the incision in the uterus tears as you extract the foetal you may have to make an inverted 'T' incision to get the
head, there will probably be a vertical tear in the corner foetus out.
which will run down behind the bladder, often with heavy When necessary, deliver the head (22.7) by a modified
bleeding. If you are alone with the scrub nurse, ask for an Mauriceau-Smellie-Veit manoeuvre, and the arms by
extra assistant. Exteriorize the uterus by drawing it out of the pressure on the upper arms which you feel by palpating the
abdomen. Identify the edges of the incision and the tear. back, or by a modified Løvset manoeuvre.
Mobilize the bladder further downwards if necessary.
If there is a transverse lie, the choice of incision is
If you cannot define the extent of the tear, carefully open important. (21.9).
the broad ligament by cutting the round ligament (21-18). (1).If the mother is in early labour, and the lower
This will let you feel the ureter, so that you can avoid it segment is poorly developed, with most of the baby in the
before you apply any clamps. Now apply Green-Armytage upper segment, make a transverse incision in the upper
forceps to the edges of the tear, and draw its angle into view. segment and deliver the foetus by breech extraction (22.7).
Apply direct pressure with a dry pack, find the bleeding (2).If early labour has begun, the lower segment is
vessels, and tie them. Use interrupted sutures in the area of well developed, and the membranes are still intact,
the tear. These will be easier to unpick if you find you have make a transverse incision in the lower segment, and deliver
caught the bladder or the ureter by mistake. the foetus by breech extraction.
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(3) If labour is obstructed, and most of the foetus is in the If there is severe vaginal bleeding 8-14days after delivery
overdistended lower segment, simple delivery through a (SECONDARY PPH), the operation site is infected
transverse incision in the lower segment will cause large (common after an obstructed labour with sloughing of the
tears. So, if the foetus is alive, make a vertical incision in the tissues) or a piece of placenta was left behind,
lower segment, and extend the incision into the upper under peri-operative antibiotic cover, take the patient back to
segment until it is big enough to effect delivery. theatre, and examine her under GA. Put a gloved finger into
(4).If the foetus is dead, try to avoid opening the uterus. the uterus through the external os and feel for a piece of
Only make a transverse incision in the lower segment as a retained placenta, and for the inner wall of the uterine scar.
last resort and decapitate or eviscerate the dead foetus in If this feels weak, or has broken down, reopen the
order to deliver it in any convenient way (21.8). abdominal incision. You may find, especially in the
CAUTION! Do not try to deliver a dead impacted foetus presence of HIV infection, a soft necrotic bleeding uterus,
intact, because this will tear the lower segment severely. with blood and spreading infection in the peritoneal cavity.
Do not make a classical or inverted 'T' incision for a dead What was the scar may now be an infected hole in the
foetus. uterus. Under such circumstances perform a subtotal
hysterectomy (21.17). If you do not attempt this, she will die.
DIFFICULTIES WITH THE PLACENTA Expect to find that the parametrium is acutely infected and
If you anticipate placenta praevia, expect difficulty, swollen, so that it feels like cheese. In this situation treat the
and get help if you can. You can usually use the ordinary patient for septic shock with much IV fluids and broad-
transverse lower segment incision. This is, however, spectrum antibiotics.
contraindicated if:
(1);there is a poorly developed lower segment, which would DIFFICULTIES WITH THE URINARY TRACT
not allow a transverse incision of adequate length. If you notice that you have opened the bladder,
(2);there is a very vascular lower segment with large veins which is not often detected during the operation, identify the
on it: this might be a placenta accreta. hole carefully, hold its edges with Allis forceps, mobilize the
(3);the presenting part is high, and the foetus is lying surrounding tissues if necessary, and bring its edges together
transversely, indicating that the placenta praevia is probably with continuous inverting sutures of 2/0 or 3/0 long-acting
central. If so, mobilize the utero-vesical fold, as for a lower absorbable. Drain the bladder continuously with an
segment operation. Make a low vertical midline or a indwelling catheter for 14days.
transverse incision in the upper segment.
If you have injured the ureter at operation, first check that
If you find placenta in the incision: the other ureter is intact. Either, repair the damage if you can
(1).Peel it away from the uterine wall and enter the uterus with 4/0 interrupted long-acting absorbable. Or, insert a fine
from above it. T-shaped tube into the ureter, bringing out the ‘leg of the T’
(2).When the edge of the placenta is too far away to allow to the abdominal wall, and close the abdomen. Later, refer
this, push your finger through it quickly, and deliver the the patient for expert help. Do not fashion an external
foetus without delay through the hole that you have just ureterostomy, as this will stenose.
made. If you meet the cord, clamp it before you deliver the
foetus, but do not waste time looking for it: you can clamp it If there is anuria:
immediately afterwards. Remember that a baby can easily (1) This may be the result of severe hypotension,
bleed from an injured placenta. The mother can also bleed, while the patient was in obstructed labour (not uncommon)
so if you see a large bleeding vessel in the placental bed, or the result of pre-eclampsia. Hydrate the patient well and
control it with a figure-of-8 suture. add IV furosemide 40mg.
Beware of a placenta praevia after a previous Caesarean (2) Both ureters may have been tied or damaged.
Section: it might very well be a placenta accreta, increta or This you will find out usually the day after the operation.
percreta. If you can’t get the placenta off the uterine wall in Perform an ultrasound to look for hydronephrosis.
this situation, you have confirmed the diagnosis and should If you think you have tied one ureter or both, re-open the
proceed directly to a hysterectomy. abdomen. For each side, check if the ureters are patent by
N.B. If, beforehand, a referral is possible to specialists injecting blue dye proximally. If no dye comes out in a
where there is a reliable blood bank, that would be best. urinary catheter, remove the uterine sutures one by one.
Then close the uterus again. Otherwise refer the patient for
If there is postoperative bleeding (not uncommon with the reconstruction; if you cannot, except after considerable
common type of placenta praevia), bleeding is probably delay, fashion bilateral temporary nephrostomies (27.14).
arising from the lower segment at the site of the attachment
of the placenta. Administer oxytocin, and if necessary If there is a severe dull pain in one loin postoperatively,
transfuse blood. In desperation, pack the uterus (22.11) you may have tied one of the ureters. Proceed as above.
using a condom in the uterus, attached to an infusion to fill it Otherwise refer the patient as before.
as a balloon. N.B. Sometimes, when the ureter is damaged, neither the
patient nor you are aware of it: the kidney merely stops
functioning.
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If urine discharges from the vagina after 2-5days, After removal of the catheter, instruct the patient to continue
there might be: drinking and to pass urine frequently. She has to refrain
(1).Overflow incontinence. Check if the bladder is from sexual intercourse for 4-6months. She must attend
distended. This can happen if there is bladder atony due to antenatal care at subsequent pregnancies and to deliver in a
stretching of the detrusor muscle fibres. Keep in an hospital at all subsequent deliveries.
indwelling (not a condom) catheter for 4wks.
Expect complete recovery. If after 6wks of catheterization, the urine still leaks all
(2).Bladder or urethral stress incontinence. Ask the patient the time (i.e. not dry at night), and upon vaginal
to cough: you will see urine spurting out of the urethra. examination the fistula is too big or the balloon is inside the
If it is disabling, refer her for a colpo-suspension. fistula, remove the catheter and try to refer the patient to a
(3).A fistula. Pass a Foley catheter and perform a dye-test by hospital, where fistula-repair is done regularly: the first
instilling methylene blue in the bladder. attempt gives the best result. If referral is impossible, you
N.B. Not all urinary leakage postpartum is due to a may be justified to attempt repair of simple fistulae (21.18)
fistula!
(B) If the dye-test is -ve, there might be a leak from a
(A) If the test is +ve, the dye comes out from the anterior uretero-vaginal fistula. To confirm this, do the 3 swab test:
vaginal wall (juxta-urethral, 21-20A or mid-vaginal VVF, put 3 pieces of cotton wool in the vagina, instil methylene
21-20C) or the cervix (juxta- or intra-cervical VVF, blue through the catheter and let the patient walk around for
21-20E,F). The first is due to pressure from the foetal head 20mins. After that remove the cotton swabs one by one.
during prolonged obstructed labour. The last is the result of (1) If the first swab is blue, there is urethral incompetence or
cutting the bladder or stitching the bladder together with the a urethro-vaginal fistula.
lower uterine segment during a Caesarean Section. (2).If the middle gauze is blue there is a vesico-vaginal
Do not prescribe antibiotics (they are of no use) and do not fistula
send the patient away for evaluation in 3months’ time! (3).If the last gauze is blue there is a vesico-cervical or
Contrary to general belief, a great deal can be and should be vesico-uterine fistula.
done immediately by very simple measures under any (4).If the last gauze is wet but not blue, there is a ureteric
conditions, however deprived of resources, by whoever is fistula. This type of fistula is probably caused by damage to
involved in postpartum care. The principle is to decompress the ureter at Caesarean Section or hysterectomy by:
the bladder totally for a sufficiently long time to give it the (a) clamping it in error, not recognizing this, and leaving
opportunity to heal spontaneously as the fresh wound edges the clamp on for more than a few minutes, or
lie against each other. The earlier you do this the better the (b) by including the ureter in a suture whilst closing the
chance. Some 25-30% of fistulae will heal spontaneously in uterine opening. An IVU will tell you which side is
this way and larger fistulae will reduce to half the size. involved.
It is still worthwhile trying with fistula presenting up to The kidney on the affected side will show some degree of
3months postpartum. Open drainage of the catheter into a hydronephrosis. The left side is almost twice as often
pot or a plastic bowl is often better than closed drainage into damaged as the right side. There may or may not be pain in
a urine bag, which is often carried on the head or shoulder! the loin. A uretero-vaginal fistula has a better prognosis and
Therefore it is good to fix an IV giving set to the catheter to is less urgent than tied ureters, because it means that the
allow the patient free mobility. kidneys will not stop functioning. Try to refer for elective
There should be free drainage at all times: instruct the repair: the ureter may need reimplanting into the bladder,
patient to take care not to block the catheter or to lie upon it or repair end to end. To maintain good kidney function, refer
when she sleeps. without delay.
In all cases keep a sufficiently large (Ch18) indwelling
catheter in situ for at least 4-6wks, filling its balloon with a If there is a contraction (Bandl’s) ring in the lower
maximum of 10ml water. Encourage the patient to drink at segment, or between the lower and the upper segments,
least 5l fluids daily in order to produce a minimum of deal with it like this: If the foetus is entirely above the ring,
4l urine/day: the urine should be completely colourless and make a transverse incision entirely above it. If it is round the
odourless like clear water. If she does not drink enough and neck, make a vertical incision across it.
the catheter gets blocked, flush it or change it for another.
Do not allow it to get blocked or infected! If there are uterine fibroids, leave them unless they are
Early on, sitz baths bd are useful, to prevent leaking urine pedunculated and removal is very easy. In this case, make a
irritating the skin. Remove any necrotic tissue from the V-shaped incision, not a straight transection, so that closing
vagina. the uterine surface is possible without tension. Otherwise,
Support the patient with haematinics, and a high-protein leave them: they may settle and atrophy. Removing a
diet. Insist on immediate mobilization: it is a catastrophe to fibroid, at delivery, from within the wall of the uterus,
develop contractures and bedsores because of a fistula. causes severe bleeding.
For the first few days the patient should stay in the hospital
under close supervision to monitor her and to instruct her If there are ovarian cysts or tumours, remove them if they
properly in catheter care and drinking. Then when her are >5cm diameter. Ovarian cystectomy is possible, but
general condition is satisfactory she can be treated as an removing the ovary and tube will be quicker and safer.
outpatient. She should come every week to report on the Smaller functional luteal cysts will have usually disappeared
leak and to be instructed again to drink as much as 5l/day. spontaneously by the end of pregnancy.
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If there are dense adhesions, you will have to separate DE LEE (KRONIG/CORNELL) VERTICAL
them sufficiently to get good access to the uterus. Do not try IN ⅔ OF THE LOWER & ⅓ OF THE UPPER SEGMENT.
to remove them from around the tubes and ovaries; they will To make a de Lee incision, incise the visceral peritoneum
ooze and form again. transversely, as described below but high on the lower
segment. Mobilize the peritoneum and the bladder well
down. Find the midline of the uterus. Insert a small
21.12 Alternative methods of transverse suture where the bottom end of your incision is
going to be, to prevent it extending downwards behind the
Caesarean Section
bladder. Make a longitudinal incision, two-thirds of it in the
lower segment, and one-third in the upper segment.
TRANSVERSE CLASSICAL IN THE UPPER SEGMENT.
Check that the uterus is wide enough. Incise the peritoneum Later, repair a de Lee incision with two layers of continuous
over the lower part of its upper segment with a scalpel. #1 or #2 absorbable. Do not catch the full thickness of the
Mobilize it away from the incision with scissors, and incise uterine wall in the first layer: it is often too thick.
the uterus transversely in the midline. Enlarge the incision to Make sure you include the uterine fascia in the second layer,
the right and left, by stretching it with your fingers or it will continue to bleed. Repair the peritoneum and pull it
(it is usually too thick to be cut with scissors), and deliver up high, so that the top of the incision is covered, preferably
the baby by breech extraction. with a locking suture (4-8G).
MIDLINE CLASSICAL IN THE UPPER SEGMENT. If you have made a long cut in the upper segment, tie the
The midline classical Caesarean Section is seldom done by tubes on the same indications as in a classical Caesarean
experienced obstetricians. Because rupture of the uterus is Section.
such a danger with subsequent pregnancies, perhaps as early
as 28wks, you must close the uterus with particular care, and MODIFIED EXTRAPERITONEAL CAESAREAN SECTION
do all you can to persuade the patient to consent to a
simultaneous tubal ligation. Many steps are similar to those
for a lower segment operation. However, the uterus is much
thicker in the upper than in the lower segment, so you will
have difficulty opening it using your fingers only.
Make a 12cm vertical midline incision: check carefully that
the uterus is not rotated, before cutting!
MODIFIED EXTRAPERITONEAL
This method has undergone a renaissance, being
recommended not so much where antibiotics are absent,
but where infection is rife. The idea is that the foetus,
on its way out of the uterus, does not pass through, and
so does not contaminate the peritoneal cavity (21-14).
Fig. 21-13 MIDLINE CLASSICAL CAESAREAN SECTION.
A, packing gauze round the uterus. B, incising the uterus. C, extending Separate the parietal peritoneum from the rectus muscle
the incision downwards. D, delivering the baby. E, emptying the uterus. down to the level of the dome of the bladder, and cut it open
F, removing the placenta and membranes. G, an anchor stitch has been transversely to its lateral limits. Similarly cut open
inserted, and the wound is being closed by an inverting suture, which transversely the utero-vesical fold.
pierces each wound edge from within outwards. H, This buries the
peritoneal surface of the wound, and minimizes the formation of Then suture the superior leaves of the parietal peritoneum
adhesions. After Bonney V. Gynaecological Surgery. Baillière, 1971 Figs and of the utero-vesical fold together, thus sealing off the
331-7 with kind permission. peritoneal cavity from the lower uterine segment, before you
actually open this. Do not exteriorize the uterus!
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430
21.13 Infection following Caesarean Section She can have as many trials (TOS or VBAC) as she likes,
provided the previous one was successful,
but she must have only had 1 previous Caesarean Section.
Peritonitis (10.1) may follow any obstructed labour, Sometimes, however, after several TOS there is only a very
or an infected Caesarean Section, and is common after thin membrane, the peritoneum, separating the uterine and
rupture of the uterus. Death is a real risk when: the abdominal cavity. A subsequent TOS is more likely to
(1);labour is abnormally long: the longer, the greater the end in disaster in this case.
risk,
(2) the foetus is dead, If a woman has had ≥2 Caesarean Sections, you should
(3) membranes rupture early and liquor becomes infected, nearly always repeat the Caesarean Section.
(4) HIV infection, is present N.B. It is a good idea with any multipara to discuss during
(5) sterile procedures are poor. the antenatal period whether, if she needs a Caesarean
Use pre-operative antibiotics and proper sterile practice to Section in any case, she would also like a sterilisation.
try to prevent sepsis (2.7). Note it on her medical card that it has been discussed and
what the result of the discussion was.
INFECTION may take the following forms: This is even more important where women have one scar
(1);Wound infection (11.13) may discharge through the scar from a Caesarean Section.
into the cavity of the uterus. Infection may resolve, or you
may need to drain pus suprapubically. If fever recurs with TWO CAESARS OR MORE;
signs of more pus collecting, do another drainage operation. ALWAYS A CAESAR AGAIN
(2);Pelvic abscess (10.3), which will need draining
suprapubically or via a grid-iron incision When you try a trial of scar, admit the patient to hospital and
(3);Peritonitis (10.1): You will probably find that the uterus monitor her closely. If the scar shows signs of rupturing,
is totally disrupted, so it is hopeless to try to repair it. perform a Caesarean Section immediately. These warning
A subtotal hysterectomy (21.17) will usually be enough, signs only last 1-2hrs, before the uterus ruptures,
commonly with the removal of both adnexa, but retain one if so you must monitor her with the greatest care.
you can.
(4);Subphrenic abscess (10.10), which is a common late If CPD was the reason for the Caesarean Section,
complication, and is likely to kill the patient if you do not it reduces the chances of a successful trial of scar in the
drain it; as may multiple abscesses between loops of the current pregnancy, but does not exclude it, because:
bowel (10.3). (1);the pelvis continues to grow up to the age of 19yrs,
(5);Secondary postpartum haemorrhage (22.11,12) may (2) uterine action is often poor in the under-16s.
occur with a retained segment of placenta, needing
evacuation, or an infected uterine scar which will mean a NO TRIAL OF SCAR
hysterectomy (21.17). IF THE PREVIOUS CAESAREAN SECTION
(6);Burst abdomen (11.14) occurs especially after several WAS MIDLINE CLASSICAL !
Caesarean Sections, and needs repair.
(7) Infertility (19.3) is a late complication of infection. You can assume that no progress after 6cm cervical dilation
(8);Bowel obstruction and low-grade peritonitis will occur if in the 2nd stage of labour after a Caesarean Section,
packs or swabs have been left behind in the abdomen. with a vertex presentation and good (oxytocin-induced)
contractions means CPD. Caesarean Section for foetal
distress in developing countries is most often related to
21.14 Elective Caesarean Section, 'trial of scar', CPD.
or Caesarean Section early in labour?
ONE VERTICAL SCAR, ALWAYS ANOTHER
If a woman has had one Caesarean Section, Good care during a trial of scar means that monitoring must
the alternatives for the next pregnancy are: be reliable, and you must be able to perform a Caesarean
(1) an elective Caesarean Section, before labour ensues. Section within 1hr, even if it is 3am at night.
(2) a Caesarean Section in early labour.
(3);an attempt at vaginal delivery (a ‘trial of scar’ (TOS), If the organization and discipline of your hospital are not
or ‘vaginal birth after Caesar’ (VBAC)). such that it can provide care of this quality, elective
Caesarean Section will give the mother a better chance of
A lower segment Caesarean Section is sometimes done for saving her foetus, as well as her own uterus, and perhaps her
such conditions as foetal distress, placenta praevia, or the life.
prolapse of the cord or an arm, which are unlikely to happen
again in a later pregnancy. When a woman like this becomes If it takes several hours to find a driver, to fetch you, and to
pregnant again, there is every reason to expect that the prepare the theatre, a trial of scar will be dangerous.
labour will be normal, except for the scar that she now has in Ideally, uterine rupture should never occur during a trial of
the uterus. This will almost always give some warning scar.
before it ruptures, so, with good supervision, you can safely
let her have further attempts at delivering vaginally.
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Even when conditions are not ideal, a trial of scar may be CONDITIONS.
justified, because the immediate and future risks of a further (1) Only ≤1 previous Caesarean Section.
Caesarean Section can be considerable. If a woman knows (2) In hospital.
that she cannot have a trial of scar in hospital, she may try to (3) Caesarean Section must be available within 1hr any time
have a dangerous trial by herself at home. A woman will of the day or night.
usually understand if you say, “We will give you a try, (4) Estimated foetal weight <4kg.
and if you have any difficulty, we will perform another (5) A vertex presentation in the occipito-anterior position.
Caesarean Section”.
Ask the clinics to refer all women who have had a previous CONTRAINDICATIONS.
Caesarean Section, and who are sure of their dates, at (1) ≥2 previous lower segment Caesarean Sections.
34wks, so that you can assess. If a trial of scar is not (2) 1 previous classical midline Caesarean Section.
indicated, plan an elective Caesarean Section at 38wks, or in (3) Any degree of CPD, or suspected CPD in this pregnancy.
early labour, if a woman is not sure of her dates. (4) An occipito-posterior presentation.
(5).Any other form of malpresentation, (except perhaps a
Elective Caesarean Sections are a way to avoid a trial of breech, if you are experienced) or obstetric complication.
scar, but they are not the complete answer: you may perform (6) Foetal or maternal distress.
a Caesarean Section too early because the dates may be
uncertain, but even if they are certain, they need to be METHOD. Assess all pregnant women with a uterine scar
confirmed by early ultrasound, and risk prematurity. in the antenatal clinic at 36wks. Take a careful history.
Furthermore, you may become unpopular, so find out what Assess the pelvis clinically and assess the size of the foetus
the local women think. by measuring the height of the fundus; if it is >40cm, do not
do a trial of scar. A previous successful vaginal delivery at
The best indication that a uterine scar is going to rupture is a term is a good omen.
tachycardia, or foetal distress. Make observations ½hrly.
If the foetal pulse rises >160/min, or drops persistently Ask the patient to avoid heavy work during the last month of
<100/min, or there is pain between contractions, the scar is pregnancy, or to come in for rest. If possible, admit her to a
probably rupturing, so proceed to Caesarean Section. waiting area at 36wks for rest and observation.
Other signs are described below. When labour starts, restrict oral intake to fluids only.
Do not as a rule induce labour. Unless your blood bank can
HARBANS KAUR (38yrs, gravida 4 para 3) was admitted at 9am on a
be relied upon to have blood available within 1hr,
Saturday, for a trial of scar, having had one previous Caesarean Section
with the first pregnancy. She was 7cm dilated and had good contractions. have it cross-matched, and ready to use if necessary.
At noon she was fully dilated and the foetal head was 3/5 above the brim. Record the pulse and the foetal heart rate carefully.
During the next half-hour it remained there. The doctor on duty was called You may sometimes be able to feel the scar in the lower
for another emergency Caesarean Section, so the intern was advised to
segment at vaginal examination. This will be easier if you
attempt vacuum extraction. He failed, but in doing so, he included the
cervix under the cup, and tore it. At 3pm she developed pain, shock, are using epidural anaesthesia. If it bulges or feels weak,
and abdominal tenderness, and the foetal heartbeat disappeared. perform a Caesarean Section immediately: you may be able
She was rushed to the theatre. The uterus had ruptured, and the tear had to assess weakness of the scar on ultrasound. The tenderness
extended into the bladder. The superintendent was called. He found that the
of a scar is difficult to assess in labour, and is not on its own,
ureter had been caught in a hastily applied suture. The following day she
was found to be leaking urine vaginally. LESSONS. These are many, they an indication for Caesarean Section. Assist delivery with
include: (1) In multiparas the second stage should not last longer than 20 vacuum extraction, if necessary.
minutes. (2) A vacuum extractor was applied when the head was 3/5 above Abandon the trial if:
the brim. It should be only 1/5 above or less (except for a trial of vacuum or
(1) The alert line is crossed on the partograph!
symphysiotomy). (3) When you apply the cup of a vacuum extractor,
you should make sure that you do not include the cervix. (4) When a trial of (2) The foetal pulse rises to 160.
scar is done, it must be possible to perform an immediate Caesarean Section (3) There is pain between contractions.
if the trial fails. (4) Pain is generalized.
(5) There is unexplained vaginal bleeding or haematuria,
WARNING SIGNS MAY ONLY LAST 1-2HRS though this may be caused by the balloon of a Foley catheter
BEFORE RUPTURE being inflated in the urethra when the foetal head is low.
(6) Uterine contractions cease.
TRIAL OF SCAR (7) There is rectal or vaginal tenesmus.
INDICATIONS. (8) Restlessness ensues.
(1) A woman who has had only one previous lower segment (9) Palpation of the uterine scar causes the patient to hit you
Caesarean Section, and the indication for it is absent in the on the hand!
current pregnancy. Stay with the patient during labour so that you can examine
(2) A scar from a myomectomy (provided the uterine cavity the lower uterine segment vaginally immediately after
was not opened during the operation), hysterotomy (21.5), delivery of the placenta, so as to be sure that it has not
or uterine perforation during a D&C. ruptured. This is uncomfortable, but does not need
N.B. A request for tubal ligation may induce you to anaesthesia if you do it just after the placenta is delivered.
perform an elective Caesarean Section. On its own, it is not Do not delay because vaginal examination is an insufficient
a reason to avoid vaginal delivery, because this followed by indication for a GA! If you find a rupture, which may
tubal ligation will still be safer for the patient whether she present as postpartum haemorrhage, do not delay but
arrives in labour or not. proceed to laparotomy (21.17).
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21.16 Old 3rd degree tears Hold each one until the next is in position, and then cut it.
When you have closed the vagina, close the perineal skin.
Delay in anatomical repair of a 3rd degree tear will result in The last 2-3 sutures should complete the formation of the
scarring, distortion and stenosis. Make sure any woman with anus, so that anal skin folds (rugae, 21-15T) radiate from it
a deep perineal wound gets sitz baths at least bd. Do not be like the spokes of a wheel. If they do not, you have not done
tempted to rush in to repair before you can identify all the the operation as you should.
structures. This may mean considerable difficult, intricate Manage the patient post-operatively as above (21.15).
dissection, and it will mean a good understanding of the
normal anatomy. Sometimes patients have minimal 21.17 Uterine rupture
symptoms; remember >20% of patients still have some
incontinence after a successful repair. Operate if your means The uterus can rupture before or during delivery, especially
for effective referral are very limited. If there is a minor tear (1) in multipara,
in the levator ani the patient may only have mild (2),after previous Caesarean Section, especially with a
incontinence with loose stools: do not make a tolerable vertical incision, and
situation worse! Consider that this region is always (3) when oxytocin is used, or
primarily infected. Reconstruction is hazardous in untreated (4) when version has been performed.
HIV+ve patients. Make sure the rectum is cleaned out with In only c.⅔ of cases do you make the diagnosis before
laxatives and enemas 2-3days pre-operatively. delivery. In the rest you make it afterwards, usually after
some difficult obstetric manoeuvre, such as a retained
REPAIR OF AN OLD 3RD DEGREE TEAR (GRADE 2.4) placenta (22.11), a destructive operation (21.8), or after a
trial of scar (21.14). Here we are mostly concerned with
METHOD. rupture of the uterus before delivery, as a complication of
Position the patient as before (21.15). Cut round the exposed obstructed labour.
mucous membrane for the full thickness of the vaginal skin.
Apply tissue forceps, and use scissors to separate the vaginal If a woman, particularly a multipara, arrives late in
wall from the rectum gently (21-15C). While you exert obstructed labour, or you do not make this diagnosis,
gentle tension on the vaginal wall, dissect laterally and free the uterus is likely to rupture. This is a great obstetric
the rectum anteriorly and on both sides (21-15D). disaster. If primary care is really poor in your district, 50%
Apply clamps to the cut edges of the vaginal skin, and hold of the women referred to you may need an operative
them downwards. Extend the dissection upwards in the delivery, and of these 5% may end up with a uterine rupture.
plane of cleavage between the rectum and the vagina, The usual story (21.11) is that a woman is brought from a
holding your scissors against the posterior vaginal wall rural setting in obstructed labour, having waited a long time
(21-15E). for transport to hospital. She is often sufficiently
Incise the vaginal wall in the midline (21-15F), to expose the clear-headed to be able to tell you that she had strong
rectum (21-15G). Hold the rectum medially, and use the frequent pains which stopped suddenly.
handle of your scalpel to extend the plane of cleavage When the uterus ruptures, it may do so intra-peritoneally
between the vaginal flap and the rectal wall (21-15H). (complete rupture), or extra-peritoneally (incomplete
If you are able to mobilize the rectum, you will be able to rupture, less common) when the foetus remains out of direct
close it without tension. Trim the remaining scar tissue from contact with the intestines.
the edge of the rectal mucosa (21-15I). Hold the upper edge
of the torn rectum in tissue forceps, and invert its mucosa If the membranes have ruptured some time before
with a row of fine atraumatic long-acting absorbable sutures delivery, the contents of the uterus will become infected,
(21-15J). Continue these until you reach the muco-cutaneous and the uterine muscle bruised and in poor condition for
margin of the anal opening, so as to refashion a normal anus. repair.
Reinforce and bury the 1st layer of sutures with a 2nd layer N.B. Never try to deliver a woman with a ruptured uterus
(21-15K). This will reduce the size of the rectum, vaginally. Your aim is to:
but only temporarily. (1) Resuscitate the patient and operate soon.
Search for the retracted ends of the sphincter ani muscles, (2) Remove the baby and the placenta.
which you will find buried in dimples at either side of the (3) Control bleeding.
anus. This is essential, because if you only freshen up (4) Repair or remove the uterus on the indications given
the margins, you will not achieve continence. below. Unless the rupture is extensive, and the tissues are
Use hooks (21-15L), or baby Babcock forceps. Bring the particularly bruised and oedematous, repairing the uterus is
hooks together to see if you have secured the sphincter likely to be easier than removing it, because distortion of the
(21-15M,N) and approximate them with at least anatomy makes hysterectomy difficult. But even repair is
3 long-acting absorbable sutures. not easy, because the edges of the tear will be ragged and
Close the levator ani muscles with long-acting absorbable not easy to bring together.
(21-15O,P) starting distally. Excise any excess tissue on the Hysterectomy takes longer than repair, and causes more
flaps of the vagina (21-15Q), taking care not to remove too bleeding. A subtotal, which leaves the cervix and perhaps
much. Bring the raw edges of the vaginal wall together with part of the lower segment, is easier than a total
interrupted absorbable sutures (21-15R,S). hysterectomy; it causes less bleeding, and there is less
danger to the ureters. If you have to remove the uterus, try to
leave at least one ovary behind.
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Speed is critical. Most time is lost getting the patient to SIGNS OF ACTUAL RUPTURE:
theatre, and in getting it ready, so make sure that it is always (1);Uterine contractions stop suddenly and are replaced
ready. If you are not familiar with the anatomy, study 21-18, commonly by no pain, less pain, or else, more rarely by
23-20,21! severe continuous pain.
Be aware of impending rupture when labour is obstructed, (2);Shock and pallor without immediate response to blood
especially in multipara, and try to prevent it by rapid transfusion (especially if the placenta is retained).
intervention. (3);Vaginal bleeding, usually quite severe, but not
necessarily so.
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N.B. If the presenting part is jammed in the pelvis, If the presenting part is not easy to dislodge, try pushing
no blood can escape from the vagina. Perform an immediate it up a little vaginally. If this fails, stop for fear of damaging
ultrasound to see if the patient has a haemoperitoneum, the urethra. Pass your fingers anterior to the presenting part,
or aspirate at the sides of the uterus. into the uterus and feel for a rupture. If there is one,
(4);A tender uterus to palpation (it may feel soft, or be you will feel the inner surface of the abdominal wall.
permanently tense), especially vaginally. Later, the entire If you are convinced there is no rupture, proceed to vaginal
abdomen may be tender. delivery if the foetus has died (21.8).
(5);The foetus is usually abnormally difficult to feel,
but may be abnormally easy to palpate! Sometimes, If the patient is sufficiently conscious to understand,
the shape of the uterus changes, and you may be able to feel explain that you would like to tie the tubes. If she is not fit
the foetus outside it (usually the limbs are close under the enough to understand, speak to the relatives. It is seldom
abdominal wall, a certain sign of rupture). necessary to tie tubes without permission. As a general rule,
(6);The foetal head which was previously low in the pelvis, no woman who has had a ruptured uterus should ever
has now risen higher and may now no longer be palpable become pregnant again. The only exception is an
vaginally. extraperitoneal (partial) rupture through a lower segment
(7) Bloodstained urine. scar.
(8);An absent foetal heart-beat usually, unless the rupture is CAUTION! Do not try to deliver the foetus before
early and small. starting resuscitation, and beware of using any relaxational
(9);Rarely, the appearance of the placenta at the vulva anaesthetic because this will remove the tamponading effect
before delivery of the abdominal wall muscles, increase shock, and perhaps
(10);Rarely, prolapse of loops of bowel into the vagina. extend the uterine tear.
N.B. Shock or severe vaginal bleeding may dominate the
picture. The patient is usually lucid, and may even be EXPLORATION
talkative, which may delude you into thinking she is less Make a low midline incision (11.2), and insert a
critical than she really is. Dramatic symptoms of rupture are self-retaining retractor. You may find a lot of bleeding, and
uncommon but death within a very short time is not. an obvious uterine rupture with, commonly, a dead foetus.
The placenta may be lying free in the abdomen, but if it is
DIFFERENTIAL DIAGNOSIS. still attached to the uterus, the foetus may still, albeit rarely,
Suggesting placental abruption: the cervix is closed or be alive, even if lying free in the abdominal cavity.
nearly so. A detached placenta means foetal death, wherever it is.
N.B. Beware making this diagnosis in a patient with a
previous Caesarean Section scar. The cervix may still be If the foetus is lying free in the peritoneal cavity, uterine
closed in rupture of a vertical Caesarean scar, or a corneal rupture is complete. Extract the foetus and check if it is still
ectopic gestation. alive.
Suggesting septicaemia: purulent discharge or other signs If the foetus is in the broad ligament, divide it and extract
of infection, which may be subtle in the presence of HIV. the foetus.
Suggesting severe dehydration: reduced skin elasticity, If the foetus is still in the uterus, as with a posterior
extreme thirst, dry mouth, no urine output. rupture, deliver it through a transverse incision in the lower
segment, as for a standard Caesarean Section.
MANAGEMENT
Resuscitate the patient vigorously in theatre or the labour At delivery, administer oxytocin. Suck out blood, meconium
ward. Instil at least 1l normal saline or Ringer’s lactate and liquor from the abdomen. Lower the head of the table
before anaesthesia starts. Do not delay; adequate and pack off the bowels. Deliver the empty uterus into the
resuscitation is impossible if bleeding continues internally. wound and inspect it, especially its posterior wall: there may
Continue the resuscitation while you operate. be another tear. Find the edges of the tear along its whole
Start 2 IV infusions: one for saline or Ringer's lactate run length. Divide the round ligament (21-18) if this makes the
fast, and the other for blood. Prepare for an emergency tear easier to see. The rupture may:
laparotomy (11.1). Administer IV antibiotics. (1) be in the anterior wall of the uterus, often with a vertical
Use the lithotomy position. Wash the abdomen, extension at one end, making it L-shaped (21-17B).
and introduce a urinary catheter: this will prevent you (2) extend into the bladder (21-17C).
mistakenly opening a high full bladder. (3) extend longitudinally, along the lateral wall of the lower
segment, from the fundus to the vagina, opening up the
If there is obstructed labour, and you are still not sure if broad ligament and involving a uterine artery (21-17D),
there is uterine rupture or not, perform a vaginal especially on the left.
examination. The presenting part may have disengaged, (4) extend, rarely, transversely across the posterior wall of
so that your hand passes through the rupture into the the uterus (21-17E).
abdominal cavity, allowing you to feel the inner surface of (5) detach the uterus almost completely (21-17F).
the abdominal wall. You may find that the presenting part is (6).keep to the upper segment through the scar of an old
unexpectedly easy to dislodge from the vagina, and there is classical vertical Caesarean Section (21-17G).
then a gush of blood flowing out. (7) have torn one of the uterine pedicles right across.
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Feel for the placenta and detach it from the uterus with your If the rupture is lateral and has extended into the broad
fingers. Try to get a tourniquet (a taut Foley catheter is the ligament, open its peritoneal roof, and ligate the
most readily available) around the base of the uterus, bleeding vessels. Control any oozing not stopped by
close to the cervix (22.11). Control bleeding from the uterus compression with under-running sutures. Avoid the ureter.
with #2 long-acting absorbable. Or, clamp the edges of the With one finger inside the broad ligament and another
tear with several pairs of Green-Armytage forceps. behind it, feel for the ureter; if necessary, pass a cloth tape
Control bleeding from the broad ligament temporarily with under it to keep it out of the way. Start at the apex of the
pressure from a pack. If there is an extensive haematoma rupture and work downwards. Exert traction on the running
tracking up from the torn vessels on one side towards the suture to expose the depths of the tear. Stop before you
kidney, evacuate the haematoma and ligate the vessels. reach the lower edge, so as to leave room for a drain from
the broad ligament into the vagina. If there is much oozing,
REPAIR OF A RUPTURED UTERUS (GRADE 3.1) pack the broad ligament with a gauze bandage, bring it out
of the vagina, and close the visceral peritoneum over it.
INDICATIONS. Remove the pack 12hrs later.
(1) A rupture which is not too large. N.B. Do not forget to perform a tubal ligation (unless you
(2) A rupture with clean edges which are easy to see and are have repaired a lower segment rupture, and the patient
not too oedematous. wishes for more children).
(3) Little or no infection.
(4) Relative inexperience. PARTIAL HYSTERECTOMY FOR A RUPTURED UTERUS
(GRADE 3.4)
CONTRA-INDICATIONS. Hysterectomy may be surprisingly easy when the tear is
(1) Extensive or multiple tears. extensive and transverse, and the uterus almost completely
(2).Edges which are very bruised and oedematous and not detached.
easy to define, especially a posterior rupture, or rupture
extending down into the vagina. INDICATIONS.
(3) Gross uterine infection. (1) Complicated rupture of the uterus.
(4).Uncontrollable haemorrhage. In these circumstances, (2);Postpartum haemorrhage, which is not responding to
a hysterectomy is preferable. treatment, and when a B-Lynch suture or tying uterine
arteries has failed to control bleeding.
Start by defining the position of the uterine pedicles,
the ovarian pedicles, and the round ligaments (21-18). METHOD.
This is modified somewhat from elective hysterectomy (23.15).
If the tear extends into the cervix or lower segment, Having delivered the uterus from the abdomen, maintain
reflect the bladder as for a lower segment Caesarean traction on it with one hand, or insert a traction suture.
Section. Avoid the ureters. Ask your assistant to pull the Start by identifying: (1) the uterus and round ligaments,
uterus forwards and to the opposite side. Lift the tube and (2) the tubes and ovaries on both sides, (3) the infundibulo-
ovary, to make the infundibulo-pelvic ligament, pelvic ligaments (21-18), (4) the avascular area in each of
which carries the ovarian vessels, taut. Put your thumb and the broad ligaments, (5) the lower segment, (6) the rectum,
index finger on either side of this ligament, and slide them and especially (7) the ureters (23-21). You will find this
down. difficult, because of the size of the uterus, and the
Feel for the ureter as a hard round cord near the pelvic brim. disturbance to the normal anatomy caused by bruising and
From there trace it down to the injured area (23-20). oedema, both near the tear, and far from it.
Remove all clot. If there is a little bleeding, disregard it. Deflect the bladder, and trace the ureters over the whole
If there is much, apply haemostats or transfixion sutures. length of the operative field (23-22G). Find where they are
in relation to the tear, in the distal part of their course.
CAUTION! Find the tear and clamp the obvious bleeding points.
(1) Be sure to keep the bladder well away from the edges of Pull the uterus to the left, and divide the right round
the tear. ligament between clamps about 2cm from it. This will open
(2) Do not excise any tissue unless it is obviously dead. the anterior peritoneal leaf of the broad ligament.
Enlarge this opening down towards the bladder.
Start at the apex of the rupture; if convenient hold it with a Lift the right tube and ovary with one hand, and push a
stay suture. Suture it as for Caesarean Section, using 2 layers finger of your other hand from behind through the avascular
of continuous long-acting absorbable in a large (#2 or #3) area in the broad ligament.
half-circle round-bodied needle. You can suture a vertical CAUTION! Leave the ovary and tube in place on one or
tear going down to the cervix from below upwards, but both sides.
sometimes the other way round is easier. Traction on the On the side on which you will remove the ovary, clamp the
suture will help to bring the lower end into view. infundibulo-pelvic ligament between two artery forceps and
Do not worry if the inner layer has to be placed inside the divide it. On the other side, to retain the tube and ovary,
uterus. Make the second layer an inverting continuous clamp and divide the tube and the ovarian ligament near the
suture. If necessary, use extra sutures to close off the uterus. If they are very thick and vascular, you may have to
corners, or repair the vagina, usually anteriorly. clamp and divide them in two steps.
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Transfix the pedicles of the round ligaments and Pull the uterus to the right and clamp the uterine vessels with
infundibulo-pelvic ligaments with #2 multifilament or strong Kocher forceps, just above the level where the
absorbable. bladder is still attached to the lower segment.
CAUTION! Make sure the points of the forceps are close
to the uterus or even a little in its wall.
Place a 2nd clamp inside the 1st, and cut the uterine vessels
between them. Tie and transfix the pedicle.
Use a double transfixion ligature because of its width,
and then do the same thing on the other side.
Excise the uterus through its lower segment, just above the
level of the cut uterine vessels. Have artery forceps ready to
pick up the cut edge of the lower segment, before it
disappears in the depth of the pelvis. Clamp any bleeding
vessels.
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Use the 2nd layer to invert the 1st one. Insert an indwelling Fistulae result as the unrelieved obstructed foetal head
catheter and maintain open drainage for 10-14days. impacts against the back of the pubis, especially in very
Unfortunately, complete closure of the bladder is often young girls (<16yrs). The head cannot move further,
impossible; its edges are usually thin and necrotic, so that a resulting in pressure necrosis of the vaginal and adjacent
fistula often follows. In this case, re-insert the catheter and bladder wall (21-19A). If the pressure of the head is exerted
wait 3months. posteriorly (21-19B), the result may be a rectovaginal fistula
(RVF, 21.19).
If complete closure of the torn bladder is impossible,
because there is much pressure necrosis, or the opening A vesico-vaginal fistula (VVF) means uncontrollable
extends far down into the urethra, you may have to close the urinary incontinence for the young woman, usually stillbirth,
bladder over a wide-bore suprapubic tube. If a vesico-uterine and often also infertility subsequently. After the catastrophe
fistula develops, arrange for its repair later. of losing her baby in childbirth, the young mother is often
thrown out of the home because she cannot have sexual
If you think that you have caught the ureter in a suture, intercourse, is incontinent and smelly. She is rarely able to
unpick it; usually there is no permanent harm. find a job, becomes depressed, lies curled up in the corner of
It is better to be safe than sorry! A dye test (21.11) may a house where she can find lodging, develops contractures
help. Otherwise a nephrostomy will bale you out. and pressure sores, and dies neglected.
If there is anaemia after delivery with a boggy pelvic
swelling and deviation of the uterus, there is probably a There are estimated to be 3 million untreated VVF patients
PELVIC HAEMATOMA. This is really a rupture of the in Africa alone. In Ethiopia there are just under 10,000 new
cases per year, and the Fistula Hospital in that country has
uterus which has bled into the broad ligament instead of into
gained a well-deserved world-wide reputation for the
the peritoneal cavity (21-16A,C). If the patient presents
treatment of such fistulae. If you can get training there
<24hrs after delivery, perform a laparotomy and explore and
repair the tear. (or at another special centre) you will not regret it, but do
not think that all VVF must be handled at a specialist centre:
there are too many fistula victims for this to be feasible.
They have a reputation of being impossibly difficult to
21.18 Vesico-vaginal fistula (VVF)
repair, but this is not so for at least 25% of cases.
Certainly, though, your best chance of success is in the first
Fistulae are usually the result of: attempt; so, do not perform this operation unless you are
(1);obstructed labour in a young primigravida (21.4). reasonably experienced, or have gone to a special training
(2);unskilled Caesarean Section. centre, preferably several times in between increasing your
(3);rupture of the uterus into the bladder, especially through own experience. The important thing is to be able to
the scar of a previous Caesarean Section. recognize which is the easier fistula, and which the
(4);traumatic vaginal delivery (especially with Kielland's complicated. You are advised to leave the latter, and the
forceps). second or subsequent repairs, to experts.
MECHANISM OF VESICO-VAGINAL FISTULA FORMATION
Even then, experts who tackle every type of case will only
achieve 75% success, meaning total continence (i.e. absence
of stress incontinence, which is often severe). Anyone who
claims a 100% success rate either has not done many,
has selected easier cases, or has not done a proper follow-up.
N.B. A gracilis flap is easy to learn and can help out in
many difficulties: try to get an expert to show you how to do
this!
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PROPHYLAXIS
At Caesarean Section, take care to dissect the bladder well
down off the lower segment prior to incising the uterus.
If the head is deeply impacted in the pelvis, get an assistant
to push from below, rather than inserting your hand between
the foetal head and the lower segment.
HISTORY
Age and parity: (some patients still achieve pregnancy after
developing a fistula after a Caesarean Section).
Fig. 21-20 SITES OF VESICO-VAGINAL FISTULAE. Incontinence. Check if the patient is wet all the time:
A, simple juxta-urethral. B, extensive juxta-urethral with a gap
between (stenosed) urethra and bladder. C, mid-vaginal. D, simple if she is dry at night, a fistula is unlikely. Ask about faecal as
juxta-cervical. E, complex juxta-cervical involving the anterior cervix. well as urinary incontinence. They may be separate or
F, intra-cervical. (x) is the site of the ureteric orifice. combined.
After Hancock B, First Steps in Vesico-Vaginal Fistula Repair, RSM,
London 2005, Figs 2-7 p.4-6.
Amenorrhoea. Ask about menstruation: it often stops after
The first is the most common: if ischaemia is mild, a small traumatic childbirth, but may suggest a hysterectomy about
hole is produced (21-20A), if ischaemia is prolonged, which the patient was never informed.
the defect may be circumferential and result in separation of
the urethra, which becomes closed off, from the bladder Delivery. Ask if labour was prolonged, delivery difficult
itself (21-20B). The mid-vaginal fistulae are less common and traumatic. Ask if it was at home, in a clinic or at
but easy to repair, unless they extend to the cervix (21-20C). hospital. Note whether a Caesarean Section was performed,
The juxta-cervical fistula (21-20D) usually follows a vertical and if so, how many times.
tear in the lower segment at Caesarean Section (21.10):
the defect may include the anterior cervix, and encroach Previous Surgery. Ask sympathetically if previous attempts
onto the ureteric orifice (21-20E). The intra-cervical fistula at repair have been made: remember patients may try to hide
may be due to prolonged pushing against an incompletely this fearing they may be turned away.
dilated cervix, or due to iatrogenic injury at Caesarean
Section (21-20F). Neurological deficit. Look especially for a foot drop, even
if partially recovered.
FEATURES OF THE FISTULA
Apart from their position, take note of their size: EXAMINATION
tiny (admitting only a probe) to large (>3cm, usually General. Note malnutrition, state of hydration
involving most of the anterior vaginal wall and the complete (many patients drink little in order to reduce their wetness),
vesico-urethral junction). Occasionally the fistula may be anaemia and the psychological state.
truly extensive extending to the anterior bladder wall,
and exposing the bare bone of the back of the pubis. Dermatitis & pressure sores. Look for an obvious urinary
The ureters may even be draining freely outside the bladder! leak and signs of dermatitis (discoloured darkened or
reddened skin around the perineum) and examine pressure
Take note of the amount of scar tissue: if you find extensive points. If you cannot see any wetness, ask the patient to
scarring, leave the case to an experienced surgeon. drink plenty of water and re-examine her after 1hr. Get the
Note the remaining length of the urethra: the shorter it is patient to cough if you still cannot visualise any wetness.
and the more scar tissue that needs to be removed, the bigger
the risk of stress incontinence. Urethral orifice. Is it destroyed or stenosed?
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If you do not see any swab stained blue, repeat the test METHOD OF VVF REPAIR (GRADE 3.3)
with 200ml after leaving the dye 20mins in the bladder. Place the patient, with the buttocks well over the end of the
If this 2nd test is -ve, suspect a uretero-vaginal fistula table, in the exaggerated lithotomy position with legs flexed
(see above). If the 3rd gauze is wet but not blue, suspect a and slightly abducted. Make sure your position is
ureteric fistula (21.11). comfortable, that your seat is not too high or the operating
table too low.
If after you have removed the catheter, leaving the dye
inside, the colour dribbles out, especially on coughing, Suture the labia to the thighs, and cover the anus with a
this indicates stress incontinence which you should treat swab (21-21A), or insert a temporary purse-string suture to
with pelvic floor exercises, or 12wks of continuous catheter close it if faecal leakage is troublesome.
draining if there is an atonic bladder with overflow after
delivery. Record the size and position of the fistula.
Estimate the distance from the external urethral orifice to the
SELECTION OF CASES distal fistula margin (ideally 3-4cm), and that from the
Select a straightforward case for your first attempts at repair; proximal fistula margin to the cervix (ideally >4cm)
you will get a good reputation through success, (21-21B). The nearer the fistula is to the cervix, the greater
so do not attempt any difficult cases until you have is the danger to the ureters.
considerable experience. You will do your patients and your
reputation no good by attempting difficult cases and failing. Only operate juxta-cervical fistulae in multiparous women
Do not waste time with futile investigations and treatment: with where you can easily pull the cervix downwards.
if you cannot treat a patient, refer her early.
Pass artery forceps or a metal catheter through the urethra,
CONTRA-INDICATIONS holding it to point forwards to expose the fistula clearly
Do not attempt: (21-21C). Check if the urethra is detached from the bladder:
(1);Complex fistulae, including those you have difficulty in this case, leave it for an expert.
visualising, and rectovaginal fistulae, except in special
circumstances (21.19). Administer gentamicin 160mg IV plus metronidazole
(2);Where the urethra is completely detached. 500mg if there has been faecal contamination.
(3) Cases where there is considerable scarring
(4);Surgery in grossly malnourished, anaemic or untreated Check with ultrasound if there are stones within the bladder,
HIV+ve patients. and estimate its size.
(5) A case where you are uncertain how to proceed.
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Infiltrate the tissues between the vagina and bladder with If your operation is taking >1hr, you are either tackling
dilute (1:200,000) adrenaline solution (21-21D). too complex a fistula, or there is some difficulty with your
technique. Consult this manual and get help.
Whilst steadying the anterior vaginal wall with the forceps
passed through the urethral orifice, lift up the mucosa over POST-OPERATIVE CARE
the urethra with an Allis forceps and incise in the posterior You may have performed marvellous surgery, only for it to
margin of the fistula through the vagina (21-21E). be ruined by poor nursing care; so make sure before you
embark on VVF repairs that you involve all your nursing
Identify the correct plane between vagina and bladder and staff and explain what is needed and why. Keep a simple
continue to dissect round to the sides so that you record of patients on their beds: measuring urine output is
mobilize at least 1cm beyond the fistula hole (21-21F). unnecessary.
Start the anterior dissection with a little extension vertically
towards the urethra and complete it right round; then tie the (1) The aim is that the patient is drinking freely, draining
right and left antero-lateral flaps to the labia to urine freely and free to mobilize without being wet.
improve the exposure of the fistula. Do not use diathermy. The catheter must never block: if this happens, urine will
Trim away with scissors any vaginal mucosa and scar tissue emerge alongside the tube or even leak through your
(this should be minimal) at the fistula margin (21-21G). well-sutured repair and re-create the fistula. The problem
Now you have freshened up and exposed the margins of the about drainage bags is that they can fill up (quickly if the
fistula, you can start closure from the corners (21-21H). patient is drinking well) and fall on the floor, or cause
Insert 2 sutures and complete the repair with interrupted traction on the catheter when the patient turns in bed,
big bites taking in the full thickness of the or overfill and cause back-pressure, or twist and become
bladder muscle, but not the bladder mucosa (21-21I,J). blocked.
Remove the forceps in the urethra and insert a catheter, The easiest solution is connecting the catheter to a straight
and perform a dye test (21-21K) with 50ml of dilute plastic tube that drains freely into a basin or bucket: this has
solution. Press over the abdomen or ask the patient to cough the advantage that you can readily see if urine is dripping
to see if there is any discolouration. If there is a leak through freely from the tube.
the suture line, inset another one or two sutures, and re-test.
Exclude the presence of a second, unsuspected, fistula If the catheter blocks, i.e. you no longer see urine dripping
higher up. from the tube, and the patient is wet or has a full bladder,
act immediately: untwist the catheter, unkink the tubing
Finally, close the vagina with interrupted everting mattress (or replace it, if it is full of débris), gently irrigate the
sutures, and fix the catheter in situ with a suture to the catheter with a bladder syringe. If this does not make urine
labium. Place a betadinized pack gently in the vagina. flow, replace the catheter.
Urine will not flow if the patient is not drinking!
DIFFICULTIES WITH SIMPLE VVF REPAIR So make sure she drinks 5l/day, because concentrated
urine flows poorly and is susceptible to become infected.
If exposure is poor, perform an episiotomy, on both sides, The urine should be almost colourless.
if necessary (and remember to repair them at the end of the
operation). If the patient is wet, exclude a blocked catheter. Check if
urine is leaking alongside the tube during bladder irrigation:
If there is necrotic sloughy tissue, debride this adequately this may suggest urethral dysfunction. Perform a dye test to
and review the situation when all the tissues are clean and check your repair or look for a second (missed) fistula.
fresh. This is likely, however, to become a complex fistula,
however. (2).Wash the perineum twice daily, especially where the
catheter emerges from the urethra.
If the urethra is stenosed, try to dilate it with sounds.
Remember you will need more generous exposure of the (3) Remove the vaginal pack after 48hrs.
fistula, and need to excise scar tissue. You may find the
stenosis recurs and needs regular dilation, so keep a careful (4).Mobilize the patient, carrying a bucket to drain her
follow-up. urine.
If you find bladder stones, unless the stone is small, (5).Remove the catheter after 12-14days after you have
or comes out easily through the fistula, abandon the VVF confirmed that a dye test shows no leak. Encourage the
repair, and proceed to cystolithotomy (27.16). Schedule the patient to pass urine every 2hrs and then increase the
VVF repair at least 2wks later. interval gradually as bladder tone recovers. Do not clamp
and unclamp the catheter: this all too frequently leads to
If you suspect the ureter to be damaged, you are likely to disaster!
be dealing with a juxta-cervical fistula, which is a matter for
an expert.
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Fistulae between the rectum and the vagina (RVF) are less
common than those between the bladder and the vagina
(VVF). If there is a large VVF, there may also be an RVF
also when there is pressure exerted posteriorly (21-19B) on
account of unrelieved obstructed labour. An RVF may
occur, rarely, without a VVF.
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Remember also that the commonest complication is 22.2 Inducing labour at term
rupture of the membranes due to inserting the needle too
low, too close to the cervix. If labour does not start when you would like it to, you may
Alternatively, aspirate at the level of the umbilicus on the be able to get it going. If it is progressing, but too slowly,
side of the foetal limbs. You need to be able to feel the you can speed it up. Distinguish between:
position clearly. There is usually a good pool of liquor (1).Priming the cervix which might also result in labour
there. Injuring the foetus is very unusual. without further interference,
Withdraw 5-10ml of fluid. Record it as being clear, (2).The attempt to start labour when the cervix is ripe
or blood-stained (indicating a traumatic tap), and the (induction),
vernix, the white cheesy substance that covers a neonate’s (3).The acceleration of labour (augmentation of
skin, as being absent, scanty, or plentiful. If you see vernix contractions), in the active phase with the cervix
easily, this is in itself more or less proof of foetal maturity. >3cm dilated.
If, at an ultrasound scan (38.3), you see vernix floating Here we are concerned with (1) and (2).
clearly, a shake test is not needed because the foetus is
mature enough. Do not try the procedure more than twice. If the continuation of pregnancy would be harmful to a
mother or to her foetus, and especially if either of them
EQUIPMENT. You need: is in danger of death, the logical solution might seem to be
(1);1ml of clear liquor, uncontaminated by meconium or to start labour and deliver the foetus. Unfortunately,
blood. Only the faintest blood-staining is acceptable. this action has its own risks for both, so there are very few
If you cannot avoid blood contamination, centrifuge the indications for doing it in a district hospital.
liquor hard for 5mins and test the supernatant. The commonest one is probably proven rupture of the
(2) 95% alcohol. membranes (22.4) lasting >24hrs, when the mother is near
(3) Some completely clean glass test-tubes with an internal term (>37wks). This indication is pressing if there are
diameter 8-14mm. signs of infection (elevated temperature, tachycardia in the
(4) 'Parafilm' to cover the tubes. Otherwise, use new corks foetus).
or rubber stoppers. If you do not have these either, a very
carefully washed, and even more carefully rinsed, gloved The effects of induction/priming with prostaglandin can be
finger is probably better than a used cork or stopper. more powerful than anticipated. Whilst you can
easily reduce the speed of an IV oxytocin infusion,
METHOD. Take exactly 0∙5ml of liquor, 0∙5ml of saline, and immediately reduce its action, you cannot so
and 0∙5ml of alcohol. Shake the mixture vigorously for easily stop the effects of administered prostaglandins.
exactly 15secs. Then do not move the tube. Wait 15mins Nonetheless, poorly supervised or inappropriate use of
before examining it in a good light against a dark oxytocin might also cause foetal death and uterine rupture.
background (22-1). In general the main disadvantage of the use of oxytocin is
that it works best when the membranes have ruptured
0 No foam
1 An incomplete ring of bubbles peripherally round the meniscus. (artificially or spontaneously) and then you are committed:
2 A complete ring of bubbles round the meniscus. if it does not work in a reasonable time you will have to
3 As above, but foam just covering the whole meniscus perform a Caesarean Section. Apart from that,
4 Plentiful foam covering the whole meniscus thickly. oxytocin does not work well with an unripe cervix and
A score of 1 means that the lungs are mature. early in pregnancy, even if the membranes have ruptured.
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(3) if you try to induce labour too soon: BISHOP'S INDUCIBILITY SCORE. Assess the dilatation
(a) the foetus will be immature and have less chance of of the cervix, its length, its consistency, its position in
surviving. relation to the axis of the vagina, and the height of the
(b);labour is unlikely to start, and if it does start, foetal head. Add up each individual item: the higher the
it may be so slow that you have to perform a Caesarean total score is, the more likely that induction will succeed.
Section. So only induce labour, when the balance of risks The highest score is 13; a score of ≥7 is favourable for
favours it, and Bishop's inducibility test (see table below) induction.
shows that the cervix is ripe, and ready for labour.
(4) inducing labour increases your Caesarean Section rate, SCORE 0 1 2 3
Dilation (cm) 0 1-2 2-3 3-4
with all the disadvantages this has (21.1). Length (cm) 0 3 2 1
(5).rupturing the membranes may cause the cord to Station 5/5 4/5 3/5 2/5
prolapse. of the head
(6) the placenta may separate (abruption). Consistency Firm Medium Soft
Position of cervix Posterior Middle Anterior
So never induce labour to suit your convenience or the
Do not confuse the position of the cervix with the position
mother’s, but only for the soundest of obstetric reasons.
of the presenting part (occipito-anterior OA, occipito-
If the cervix is unfavourable, you can also try ripening it,
posterior OP, etc.).
but only of course if the membranes are intact,
Make a poster of this score system and keep it on the
with inserting the balloon of a Foley catheter into the
Maternity wall.
extra-amniotic space.
RIPENING THE CERVIX
INDICATIONS FOR STARTING LABOUR.
(1);Proven rupture of the membranes lasting >24hrs when
INDICATIONS.
the foetus is near term (>37wks), or when associated with
When the cervix is not sufficiently ripe to enable you to
a fever, which cannot be explained otherwise (malaria,
rupture the membranes to induce labour. After ripening,
HIV/TB) even <36wks.
labour will often start without any need to rupture the
(2);Severe pre-eclampsia or the HELLP syndrome (severe
membranes (22.4).
liver pain associated with haemolysis, elevated liver
enzymes & low platelets). Of course the nearer the
METHODS. There are several ways of ripening a cervix:
gestation approaches 40wks, the less can be
(1) A dinoprostone vaginal tablet (3mg) in the posterior
gained by potential further growth of the foetus.
fornix on the evening before you induce labour.
Therefore, continuing the pregnancy while the mother is at
Follow this by another 3mg 6-8hrs later if labour is not
some risk from the pre-eclampsia has less merit the further
established, and then, if necessary, a further one,
the pregnancy is advanced. On the other hand an induction
to a maximum of 3.
which involves ARM increases the chance of Caesarean
CAUTION!
Section which also is quite a risk then and in future
(a) The tablet must be close to the cervix in the posterior
pregnancies.
fornix; merely slipping one into the introitus does not
Low dose misoprostol (half a tablet, i.e. 100µg, dissolved
work.
in 20ml water) giving 4ml (= 20g/ml) orally 3hrly, might
(b) Avoid prostaglandins in multipara ≥5.
be the solution. No ARM is needed. The dose/frequency
N.B. There may be hyperstimulation, so:
can be increased if the urgency is high and decreased if the
(c) Insist on close overnight observation of mother and
parity is high.
foetus.
(3) Diabetes.
(2).A dinoprostone 05mg (prostaglandin PGE2) oral
(4) Abruption (20.12).
tablet in the cervical canal. Repeat this 6hrly up to
(5);Postmaturity (22.5) is an uncertain indication, because
4 doses.
the diagnosis is rarely made in district hospital practice.
There should be, apart from the gestation of >42wks, (3) A misoprostol tablet (200g) in the posterior fornix.
very little liquor or a sudden decrease in foetal movements This is cheap and effective and does not need refrigeration.
In many countries it is not registered for induction of
or a bad obstetric history before you try to induce labour
labour but is used anyway extensively. It is certainly the
for this indication.
drug of choice if the indication is intra-uterine death or
severe foetal abnormalities (e.g. anencephaly).
If the indication for induction is rupture of
membranes, then ARM is of course not needed provided The dose depends on the parity, gestation, ripeness of the
you are sure. Try to abstain from entering the cervix cervix, urgency and level of monitoring available.
After the 2nd trimester a scarred uterus is a
during examinations.
If there is a lot of liquor pouring out, placing 200µg contraindication.
misoprostol in the posterior fornix will probably not help The maximum dose, if the aim is for a viable foetus,
because the active ingredient will be washed out. is 200g in the posterior fornix for a nullipara with severe
Use oral, sublingual, or buccal misoprostol or oxytocin IV pre-eclampsia at about 35wks (introduce it very early in
instead. the morning). You can repeat this dose (if absolutely
nothing has happened) at the earliest in 6hrs. If this is not
the first delivery, 100g is better.
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N.B. Misoprostol 100g (½ tablet) dissolved in 20ml N.B. Do not use oxytocin for induction/augmentation of
water provides 5μg/ml. The 200μg tablets cannot reliably labour without rupturing the membranes first.
be broken in pieces smaller than a half. Occasionally in a HIV+ve patient there might be an
A multipara 4, 42wk pregnant woman, for example, indication not to rupture during induction till late in the
with very little liquor would need only 20g orally, to be 1st stage of labour.
repeated if nothing happens 3hrly. By contrast, if there is
an intra uterine death or severe foetal abnormality at METHOD.
22wks and there is no scar in the uterus, put 600μg Use only low dose oxytocin as mentioned below under
vaginally starting very early in the morning and repeating ‘protocols on the wall’. Also as soon as labour is
4hrly till labour starts. With a scar, in the 2nd trimester, established try without oxytocin.
use only 100μg. Check the foetal lie and presentation, and try to make sure
that one nurse stays with the patient all the time.
(4).A Foley catheter in the extra-amniotic space Start early in the morning with a dose of 10mIU/min
is useful if you have no prostaglandins. 12-18hrs before (10drops/min of 5IU (usually one vial) in 500ml saline
induction, with careful aseptic precautions, and under where the system gives 10drops/ml.) Monitor her closely
direct vision, use a Cusco's speculum to insert a Ch16-24 and increase the IV rate every 30min like this:
catheter, with a 30-45ml balloon, into the extra-amniotic 10 drops/min, 20 drops/min, 40 drops/min, and
space. 60 drops/min. Have a poster with the detailed protocol on
Inflate this with 30-45ml of sterile water, and leave it in the wall. Increase the infusion until the uterus is
place. This is generally 4hrs faster than using contracting 3-4 times every 10mins. If vaginal
prostaglandins. examination shows that the cervix is not dilating, increase
CAUTION! Whenever you induce labour, monitor the the infusion to 60 drops/min as long as she has not
foetus carefully. >5 contractions in 10mins and there are no foetal cardiac
N.B. Do not waste time trying to induce labour if the decelerations. If this does not work and the foetal heart
Bishop’s score is <7 and there is an overwhelming rate is fine it is possible in nullipara to increase the
indication to deliver: perform an immediate Caesarean concentration to 10IU in 500ml and start again at
Section! 40 drops/min. Do not go above 60 drops/min
(=120mIU/min) with this concentration.
OXYTOCIN TO INDUCE LABOUR AT TERM N.B. It is not the oxytocin itself which is dangerous but
(Other uses: 21.5) the strength or frequency of the contractions.
Therefore high doses without strong, frequent,
INDICATIONS. or continuous contractions are not dangerous in theory,
A high risk-factor, particularly for the foetus, such as: but lack of close supervision to detect these contractions
(1) Diabetes. can still damage the foetus or kill mother and/or child.
(2).Gestational hypertension, especially if there is When the cervix is >5cm, and contractions are good,
proteinuria. you may be able to reduce the rate of the infusion.
(3) An unstable lie (22.8). Do this gradually.
(4) A confirmed dead foetus (20.4). If they contractions diminish, increase it again.
(5) Postmaturity (22.5). If the membranes have not ruptured, and labour has not
(6) Twin or triplet pregnancy. started by 7pm, stop the infusion and try again in the
CAUTION! For all these indications, ripen the cervix morning. If the membranes have ruptured, induction must
first, according to the score given above. not stop; add antibiotics after 12hrs with membranes
(7).Placental abruption with intra-uterine death (20.12): ruptured.
here there is a vital urgency, so do not wait! CAUTION!
(1);Higher doses than the above increase the uterine tone
CONTRAINDICATIONS. between contractions, and thus impair the placental
(1) Cephalo-pelvic disproportion (CPD). This diagnosis is circulation. Palpation does not detect this increased tone,
difficult to make before labour, however. Do not give a unless it is gross. Too much oxytocin will cause prolonged
multipara oxytocin: there is too great a risk of uterine tetanic contractions, and may rupture the uterus
rupture and artificial rupture of membranes will usually (especially in a multipara).
suffice to induce labour. (2);In a multipara, reduce the starting dose to 1IU,
(2) A previous Caesarean Section, unless close round-the- and reduce or stop the infusion as soon as there are regular
clock supervision is possible, and the previous Caesarean contractions.
Section was certainly not for a CPD nor for ‘failure to (3);Assess the uterine contractions carefully. If there is no
progress’. relaxation between contractions, stop the infusion.
(3) Previous myomectomy, uterine perforation or cornual If there are >5 contractions per 10mins, reduce the dose.
ectopic gestation. (4).Oxytocin in high doses (>60mIU/min) has an
(4) Foetal distress. antidiuretic effect. So beware of 'water intoxication' (20.4),
(5) Malpresentation. especially if 5% dextrose was used instead of saline or
(6) Grand multiparity. Ringer’s lactate.
(7) Placenta praevia.
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(5).If delivery has not occurred but contractions are If you use 5IU oxytocin/l saline, halve the above figures;
satisfactory and progress is good, you can use up to 2l of a If you use 10IU oxytocin/500ml, double them.
solution of 10IU in 500ml. Greater than this volume there N.B. Never use >20mIU/min with a scarred uterus or
is a risk of water intoxication, as above. If delivery is not Para ≥4, and >40mIU/min with Para 2-3. An IV system
about to happen, consider Caesarean Section. with 20 drops/ml has to run half as fast to deliver the same
(6) Do not infuse >3l in 24hrs without careful review. dose as one running at 40 drops/ml.
All sorts of different protocols exist for the use of Try to have a nationally agreed schedule, adapted to the IV
oxytocin: ideally, of course, an infusion pump will give a systems you normally have available, as your basic
controlled dosage with limited fluid. You should protocol, displayed on the wall.
remember that the sensitivity to oxytocin differs from
person to person. By increasing the dose in steps of ½hr, RUPTURING THE MEMBRANES TO INDUCE LABOUR
you can find the right dose for a particular woman without
losing too much time, remembering that the longer CONTRAINDICATIONS.
membranes are ruptured, the greater the risk of infection. (1) A high mobile head: the cord may prolapse.
Excess oxytocin is characterized by: (2);A dead foetus (except in abruption): labour will be
(1) foetal distress, quick.
(2) too frequent contraction, (3);Maternal polyhydramnios: start by withdrawing some
(3) pain between contractions, amniotic fluid via the abdomen with a needle or cannula,
(4) restlessness, so as to reduce the uterus to a normal size. A sudden
(5).vaginal haemorrhage suggesting threatened rupture. release of much fluid can precipitate abruption, and make
As oxytocin is metabolized fast in the body, you can slow malpresentations, such as a shoulder presentation,
down or stop the infusion (and put the woman on her left more likely.
side): the tissue concentration of oxytocin will quickly (4) Postmaturity.
decrease and the situation will normalise. (5);A (potentially) HIV+ve patient: prolonged rupture of
Occasionally, the right dose for a particular uterus to dilate membranes is a risk factor for vertical transmission.
is too high a dose for the foetus to endure. At the peak of If the patient is not receiving ARV therapy, then rupture
contraction there is generally no new oxygen available for the membranes as late as possible; you may, however,
the foetus. Most foetuses can cope, but not if their oxygen be forced to do so earlier in order to make labour progress.
supply was already marginal. (Compare this with N.B. She might be a candidate for Caesarean Section
somebody with severe asthma who is pushed under water (instead of induction, to prevent vertical transmission)
for 30sec.) In that case a Caesarean Section is mandatory. combined with a tubal ligation, to prevent future vertical
However, a foetus with normal reserve oxygen can still get transmission, if her family will thus be complete.)
into trouble if the maternal contractions persist too long or
are too frequent. This happens more often if labour has not METHOD. (GRADE 1.1)
started spontaneously (unripe cervix/uterus) but was Make sure the bladder is empty. Check the foetal heart,
induced. put the patient into the lithotomy position, and use careful
aseptic precautions. Flood the vulva with antiseptic
PROTOCOLS ON THE WALL. solution. Wearing sterile gloves, do a careful vaginal
In the absence of an infusion pump, the dose needed in examination and measure Bishop's score (see above).
terms of drops/min is inaccurate. There are paediatric IV Spread the labia widely, put 2 fingers into the vagina and
systems which form such small drops that it takes 60 drops then into the cervix. If necessary, stretch it to admit your
to constitute 1ml but there are also systems (blood giving 2 fingers. Gently sweep the membranes away from the
sets) with 10 drops/ml. This should be indicated on the lower segment without rupturing them. Feel carefully for
wrapping of the IV system. It is best to express the the placenta, or the cord.
oxytocin dose in mIU (1/1000 of an IU)/min. Not all of your
staff will be able to do the calculations correctly and If you can feel the placenta (which is unlikely if the head
perhaps also yourself at 3am! Because of this, put a poster is low), it is a placenta praevia and you have a large risk of
on the wall of your maternity to give simple instructions ante-partum haemorrhage. Perform a Caesarean Section if
for the use of infusion pumps if available, or for the it is type III or IV (20.11, 20-9)
different IV systems available in your unit.
Using 5IU oxytocin/500ml saline, the dose is, in If you can feel the cord presenting through the
mIU/min: membranes, leave them intact, turn the lady on her side
and repeat the examination in 2hrs. With luck, the cord
System (drops/ml) 10 15 20 25 30 35 40 will have floated away. If it has not, perform a Caesarean
Flow rate Section, but feel again just before you start the operation.
(drops/min)
10 10 6·5 5 4 3·5 2·5 1·5 CAUTION! If labour has started, rupture the
20 20 13 10 8 7 5 3 membranes during a contraction, to minimize the risk of
40 40 26 20 16 14 10 6 prolapse of the cord and let the liquor come out slowly.
60 60 39 30 24 21 15 9
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If you cannot feel either the placenta or the cord On the other hand, failed induction with ruptured
presenting through the membranes, rupture them with membranes soon forces you to perform a Caesarean
Kocher's forceps. Hold these in your left hand, and guide Section especially if an intra-uterine infection develops.
them through the cervix with your right hand. Unless the indication for induction is vital, start with a low
As you prepare to tear the membranes, ask an assistant to dose of misoprostol to prevent complications in case of
push the presenting part into the pelvis. This will allow the extra sensitivity to this drug. With a low dose there is of
fluid to escape in a controlled way, and will minimize the course the risk that you have to repeat the induction
risk of the cord prolapsing. Grip the membranes and tear (if the cervix has not changed perhaps with a somewhat
them. If fluid flows, or there is foetal hair in your forceps, higher dose) the next day.
you have succeeded. Note the amount and colour of the N.B. If you perform a Caesarean Section for prolapsed
amniotic fluid, make sure the cord has not prolapsed, cord (or nearly every other indication) check the foetal
and check the foetal heart. heart just beforehand with the best instrument you have:
prefereably, ultrasound (38.3) or handheld Doppler tool
N.B. Finding meconium-stained liquor at this stage is (doptone). Do not open the abdomen for a dead foetus
not an indication for a Caesarean Section; it just means, (21.8)!
especially if it is fresh thick meconium, that supervision
should be even closer if at all possible.
If the cord has prolapsed, put the mother in the The management of preterm labour is not a success story.
knee-elbow position, push up the head and prepare for an Avoid IV tocolytics: they are dangerous if not well
urgent Caesarean Section. If there is a delay, filling the supervised especially if there might be a hidden maternal
bladder via a catheter with the help of an infusion bag of cardiac abnormality. There may be a place for steroids.
500ml fluid will often prevent fatal cord compression. However, using medication may divert you from the
Alternatively, separate the amniotic sac membrane from treatment of the cause of the premature labour, which may
the cervix (a membrane sweep) at vaginal examination be antepartum haemorrhage, urinary tract infection,
(this releases the prostaglandins) only, and do not rupture or intrauterine growth retardation (IUGR), etc. In practice,
the membranes until she is well advanced in labour. when a mother does start preterm labour there is little you
This can be effective, and there is less risk of infection can do about it. It often stops spontaneously, and 70% of
than when the membranes are ruptured some time before mothers do not deliver within 48hrs, and start labour
delivery. normally nearer term. You can try to postpone delivery for
at least 48hrs in order to ripen the foetal lungs with 12mg
N.B. As mentioned above, prolonged rupture of betamethasone IM od for 2days. You can also try 20mg
membranes increases the chance of vertical HIV nifedipine PO in the 1st hr followed by a maximum
transmission. Still there are indications to perform an of 90mg/day in divided doses. Between 24-30wks,
ARM. If you use a Kocher’s and you push the membranes indomethacin 50-100mg (preferably as a suppository)
against the presenting part and then rupture the membranes followed by 25mg 4hrly for a maximum of 3days might
you will often catch some hair but also scratch the foetus, help.
increasing the chance of mother-to-child transmission.
If labour starts before 34 completed weeks, and the
N.B. Using misoprostol to prime the cervix/induce membranes have not ruptured, assess as follows:-
labour has as disadvantage that the medication cannot be (1) In the active phase of labour (the cervix is >3cm),
controlled as easily as an oxytocin infusion. On the other try to delay delivery with nifedipine (or indomethacin if at
hand with misoprostol, the membranes do not need to be <30wks) in order to gain time to ripen the foetal lungs with
ruptured till (very) late in labour making mother-to-child steroids.
transmission less likely and making it possible to try again (2) In the latent phase of labour (the cervix is <3cm) with
the next day. regular contractions, look for a possible cause, although
you are unlikely to find one. Insist on bed rest, and try to
delay delivery as above.
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If the contractions are doubtful, consider other common Midwives often justify vaginal examinations by saying
or less common causes of pain: that they are necessary to exclude prolapse of the cord.
(1) urinary tract infection or partially kinked ureters (21.5), Teach that:
(2) constipation (12.15), sometimes the result of pica, (1).The risk of prolapse of the cord is small, but the risk of
(3) abruption (20.12), infection is great.
(4) appendicitis (14.1), (2).Cord prolapse will only physically harm the foetus,
(5) bowel obstruction (12.2), but infection will endanger the mother also.
(6) red degeneration of a fibroid (3).If the cervix is sill closed, as it often is,
(7) an extra-uterine gestation (rare, 20.9) vaginal examination certainly does not help because there
If you have the slightest suspicion, treat with antibiotics; cannot be a cord prolapse. Teach that premature rupture of
in the next pregnancy use them in the 2nd trimester for the membranes means there needs to be a very good
1wk. indication for vaginal examination!
At delivery, the foetus is at high risk, so control the Ideally use abdominal ULTRASOUND (38.3):
delivery of the head very carefully. Handle the foetus occasionally you might detect a cord prolapse: you can
gently and keep him warm, using the kangaroo method usually rule it out confidently; you may also deduce a
(i.e. carrying the preterm infant skin-to-skin next the simple high tear in the membranes if there is still a lot of
mother). liquor.
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If gestation is 28-35wks, treat prophylactically with A foetus >2wks postmature is at increased risk of stillbirth,
antibiotics, preferably erythromycin. but there is little evidence that inducing labour before
N.B. If you use antibiotics before there are signs of 42wks significantly reduces the perinatal mortality.
infection, they might prevent infection and labour.
Once an obvious infection is established, induction is The risks of accidental premature induction are
needed as well as antibiotics as before to prevent spread of considerable:
this infection. As long as the foetus is in the uterus, it is too (1);A mother's dates may be wrong, because she has had
late to expect infection to be cured without evacuating the no menstrual period since the previous pregnancy, or
uterus. simply because of breast-feeding, which causes a longer
If the liquor stops draining, do not intervene. menstrual cycle. Thus, if periods occur every 2months,
If it continues to drain at 48hrs, induce labour, if the risk conception will occur 6wks after the last period, instead of
of infection is high. Otherwise, wait until the foetus is 2wks. This means that pregnancy is usually less advanced
more mature at 36wks. Culture the amniotic fluid at than mothers think.
delivery. (2);Many mothers present so late for their first antenatal
visit, that the size of the uterus or foetus cannot be reliably
If gestation is at >36wks, induce labour with oxytocin, used to confirm gestational age.
if labour does not start spontaneously in 24-48hrs. Even ultrasound is of little help in the last trimester and
CAUTION! Be sure to induce labour if: cannot reliably differentiate between 38 and 42wks.
(1) The foetus is dead at any stage of pregnancy.
(2) There are signs of intra-uterine infection at any stage of If gestation is >42wks, and the dates are certain, admit
pregnancy. the patient and ask her to keep a foetal movement chart.
(3);Gestation is >36wks, and labour has not started If there are any of the risk factors below, induce labour
spontaneously in 24-48hrs. Remember the precautions for with low dose misoprostol (22.2) or oxytocin, if the cervix
the use of oxytocin (21.5, 22.2) and use it with extreme is ripe:
caution in the presence of infection. Consider a Caesarean (1) Nulliparity >30yrs.
Section if the patient wants a tubal ligation. (2) Twin pregnancy: this is postmature at 40wks so should
certainly not be allowed to progress to 42wks.
DIAGNOSIS OF INTRA-UTERINE INFECTION: (3) A bad obstetric history.
(1) Foetal tachycardia. (4) Gestational hypertension.
(2) Maternal pyrexia and tachycardia. (5) Markedly reduced foetal movements.
(3) Uterine tenderness. (6) A cardiotocograph, if available, that is not reassuring.
(4) Offensive, blood-stained liquor. (7) No liquor as measured by ultrasound or palpation.
(8) Gestational diabetes.
TREATMENT. There is a high risk of septicaemia with (9) A dead foetus: do not rupture the membranes.
development of septic shock. Resuscitate with IV fluids. N.B. Repeatedly failed induction is sometimes a clue
Treat with broad-spectrum IV antibiotics; that there is a large extra-uterine gestation (20.9).
e.g. chloramphenicol and metronidazole (2.8,9) plus Other clues are that at a gloved finger pushed through the
benzylpenicillin against β-haemolytic streptococcal cervix does not palpate membranes or a foetus: a fibroid is
infection in the foetus. Empty the uterus as soon as assumed to be present, but is in fact the whole uterus!
possible, whatever the duration of pregnancy: it will often N.B. Ultrasound often misses the diagnosis of advanced
empty spontaneously. extra-uterine gestation.
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22.6 The malformed foetus If you make the diagnosis when labour with a cephalic
presentation has been in progress for some time, and
the foetal head is more than minimally enlarged, you will
With most congenital malformations, a foetus is not large have to make it smaller before you can deliver it.
or misshapen enough to cause difficulty during labour. Drain the CSF with a lumbar puncture needle:
The important exceptions are anencephaly and (draining the CSF does not kill the foetus!).
hydrocephalus. If you have the misfortune to find a grossly This is simplest under ultrasound guidance. If you are not
abnormal conjoined twin, Caesarean Section is the method sure of the diagnosis, or do not feel you can risk
of choice. Omphalocoele (33.4) and gastroschisis are, sacrificing the foetus, you may be forced to perform a
on the other hand, not in themselves indications for Caesarean Section. However, even then the head may be
Caesarean Section. too large for a routine lower segment Caesarean Section.
Anencephaly is complicated in 90% of cases by The alternatives are:
polyhydramnios; so when you diagnose this, (1);The best, to drain the head before making the uterine
do an ultrasound on the mother to see if the foetus has a incision;
brain (38.3). If not, it is usually stillborn, and even when it (2);2nd best, to make a transverse, curved incision 4cm
is born alive, it does not survive >6hrs. When you have higher than normal with the ends near the attachments of
explained the diagnosis to the mother, she may insist that the round ligaments;
the pregnancy is terminated. (3);3rd best, to make a vertical incision starting in the
midline in the lower segment at the level (2cm lower than
Hydrocephalus is not always easy to diagnose clinically, the bladder reflection) where you would normally do a
and is often missed during pregnancy. A common mistake lower segment transverse incision.
is to misdiagnose a brow presentation (when the head feels N.B. Take care that it does not tear further distally
big) for hydrocephalus. If you suspect it, confirm the because you made the incision in the direction of the
diagnosis by ultrasound (38.3). Even during labour the fundus too short.
diagnosis is easily missed, if you can’t feel the widely
distended sutures and fontanelles. If the diagnosis is In order to avoid a Caesarean Section when there is no
doubtful, wait. If it is obvious, proceed as follows: cervical dilatation or the foetal head is still very high,
it is very easy to drain CSF from the head through the
ANENCEPHALY. mother’s abdominal wall (with an empty bladder) with a
If this is accompanied by (painful) polyhydramnios, thick needle or cannula. The head then collapses, engages
drain the mother's amniotic sac with a needle or cannula and delivers vaginally if the mother is in labour. If she is
through the abdominal wall. Sometimes you have to not, and the membranes are intact, there is no hurry
manipulate the foetus through the abdominal wall in anyway.
longitudinal position while the water is draining. To perforate the foetal head vaginally, wait until the cervix
A breech presentation is no problem. Use low doses of is >3cm dilated, then drain the cerebrospinal fluid with a
misoprostol erring on the side of too little because there is large needle or artery forceps between the widely
no medical hurry. separated skull bones. The collapsed head will slowly
settle into the mother's pelvis, and delivery will be simple.
If anencephaly is not accompanied by polyhydramnios In this situation, however, you are committed because the
(10%), pregnancy may rarely be prolonged up to 1yr or membranes are ruptured and if labour has not started or
more, and make delivery difficult. Misoprostol is the drug stops, you might have to perform a Caesarean Section on a
of choice also, the dose depending on the parity and dead or non-viable foetus. So be sure labour has started
possible uterine scarring. If the membranes are ruptured, a before you rupture the membranes.
higher dose is acceptable because there is now the risk of CAUTION! If possible, perforate the foetal head before
infection. the cervix is 5cm dilated, because an over-distended lower
segment may rupture if you do not.
HYDROCEPHALUS.
If you make the diagnosis during pregnancy, If you make the diagnosis during a breech
try to measure the size of the foetal head and determine if presentation, (22.7), the foetus will probably deliver
there is also a spinal deformity. Discuss the problem with spontaneously as far as the umbilicus. Often you are
parents, explaining the need for a ventriculo-peritoneal alerted to the hydrocephalus by seeing clubfeet (32.10)
shunt or third ventriculostomy and the problems the child and/or a spina bifida (33.11). Progress will then be arrested
may encounter (33.12). Do not endanger the life of the as the hydrocephalic head fails to enter the pelvic brim.
mother trying to save the foetus! Try hard to avoid a Trying to save the foetus is not now your priority!
Caesarean Section if you think the chances are that the Draining the CSF is less messy than a craniotomy.
foetus will die anyway or be severely handicapped. If, at this stage you see the commonly associated
In this case, induce labour without artificial rupture of meningomyelocoele, pass a steel or gum elastic male
membranes. If you wish to be sure of saving the foetus and catheter through the spinal defect into the ventricles, to
the mother understands that a future pregnancy will almost drain off the CSF.
certainly mean another Caesarean Section, prepare for this
option.
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If there is no spina bifida, you can easily perforate the The risks of ECV include:
head at the back very near the neck with a Kocher’s or (1) Knotting of the cord.
artery forceps. Alternatively, make sure that the bladder is (2) Placental abruption.
empty, and then tap the aftercoming head abdominally (3) Uterine rupture.
with a large spinal needle. (4) Vertical transmission of HIV.
LINDA (17yrs) started labour normally, but it not progress. The district These risks must be compared not only with the risks of
doctor failed to notice that this was because there was a hydrocephalus: breech delivery but also of Caesarean Section.
she had not seen such a case before. She decided to perform a Caesarean
Section, but noticed that she could not deliver the foetal head through the Unfortunately, ECV is not often done by doctors or by
lower segment incision. She did not panic but drained the head with the
help of the scalpel. The foetus was put on the resuscitation table but not experienced midwives as often as it should be; it should
attended to because everybody thought it was dead. Then it started not be done by inexperienced practitioners. If your excess
crying. It survived for 6months, paralysed from the waist down because perinatal mortality with breech deliveries is >2%, after
of a spina bifida. It dribbled urine continuously and probably died of an correcting for prematurity and foetal abnormality
urinary tract infection. The mother became psychotic and needed a long
period of rehabilitation. LESSON Remember hydrocephalus as a cause of (see below), the risks of ECV are worth taking.
failure to progress, and consider draining the liquor. Do not attempt it under GA!
N.B. Beware of performing a symphysiotomy to deliver THE CORRECTED PERINATAL MORTALITY FOR
a hydrocephalic baby: the symphysis may separate so BREECH DELIVERIES.
much that severe urinary stress incontinence may result. This should be fairly easy to calculate from your labour
ward record books, which should routinely record
presentation, birth weight, obvious abnormalities, and live
22.7 Breech presentation and still births.
(1).Work out your perinatal mortality for all babies
If a foetus presents with his buttocks (breech) or his (10-80/1000) excluding breeches, babies <25kg, twins,
foot, he is about four times more likely to die than if he and babies with obvious malformations. The perinatal
presents by his vertex. This is so, even if you exclude the period lasts (in this case) from the 28th week to the end of
excess mortality due to the higher rate of prematurity, the 1st week of life.
multiple pregnancy and foetal abnormality that is (2).Do the same for breech deliveries only. In many
associated with breech deliveries. district hospitals, it will be 50-200/1000.
This increased mortality is due to: Subtract (1) from (2). If the difference is >20/1000,
(1).Late diagnosis, in the case of CPD, unless you can perform ECV.
perform a swift, skilled symphysiotomy (21.7). The problem is of course that the higher the breech related
(2).Lack of time for the head to mould so that there is mortality is, the higher the Caesarean Section related
effectively CPD though this would not have been the case mortality is likely to be. The reasons for high breech
in a cephalic presentation. related mortality usually include absence of permanently
(3).An incompletely dilated cervix (especially with available skilled personnel and/or patients arriving too
straining before full dilatation, or prematurity). late. These are exactly the same factors which make it very
(4) The increased risk of cord prolapse. dangerous for women to have a scar on the uterus.
(5).Nobody being present able to solve the problem of the
arms being extended. If ECV or the knee-chest position fail, you can deliver a
breech:
These are methods which may help prevent breech (1) Vaginally, by assisted breech delivery.
delivery if you find a breech presentation after 36wks: (2) Vaginally, by breech extraction.
THE KNEE-CHEST POSITION (as if praying like a (3) Vaginally, adding a symphysiotomy if there is CPD.
Muslim, 22-2C) is an alternative to manipulation that (4) Abdominally, by Caesarean Section.
might succeed. It is also safer. Ask the mother to spend
10min tds in this position. This may allow the foetal In breech extraction you, rather than the mother, provide
breech to disimpact from the pelvis, so that it can turn the power for expulsion. You exert traction on the legs,
spontaneously. groins and pelvis, so it is more dangerous for the foetus
than an assisted breech delivery, which is the usual way of
EXTERNAL CEPHALIC VERSION (ECV) delivering a breech. Only do this extraction if there is no
If you can reduce the number of breeches you deliver, you alternative (foetal distress) or with the 2nd of twins.
will reduce the perinatal mortality associated with them. Otherwise IV oxytocin will probably help especially if the
Turning a breech presentation in the 3rd trimester will do foetus is smaller than average. If the foetus is large or
this, but it is of little value <34wks in a primipara, or normal in size lack of progress of the buttocks in the
<36wks in a multipara, because many breech presentations second stage might predict subsequent CPD (see below).
spontaneously correct themselves before this. Perhaps an acceptable approach in nullipara would
After 36wks, a foetus gradually becomes less mobile, be to prepare for a Caesarean Section at 36-37wks.
which makes version more difficult. On the other hand, Administer spinal anaesthesia. Try to turn the foetus.
if version does succeed, it is more likely to be permanent. There is then a success rate of 2/3 as opposed to 1/3
without spinal anaesthesia.
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If you succeed, cancel surgery. This is without danger in a CORRECTING A BREECH PRESENTATION
nullipara, but at higher parity where there is a risk of
rupture, the mother will not be able to warn you by
indicating pain. However, a mother who has previously
delivered spontaneously vaginally around term has
certainly no indication for an elective Caesarean Section
for a simple breech presentation.
Judgement is difficult nonetheless, if for example a
primipara delivered by vacuum extraction the last time.
There could have been borderline CPD, or was it just a
tired mother or an impatient doctor, occiput posterior
position, or foetal distress? Probably the best would be to
try ECV but without spinal anaesthesia.
N.B. Performing an elective Caesarean Section for
breech presentation without very good reasons is
irresponsible, if you cannot guarantee good supervision
for trial of scar and access to a Caesarean Section for the
next delivery.
A liberal Caesarean Section rate will reduce your perinatal
mortality, but you will have to weigh this against the
increased maternal morbidity and mortality that will
follow. If the difficulties of vaginal breech delivery worry
you, and you are tempted to perform a Caesarean Section
for all breech presentations, remember the dangers of
anaesthesia, bleeding, sepsis, and a scarred uterus.
However, if your hospital has not the skill available
continuously to perform a vaginal breech delivery and Fig. 22-2 CORRECTING A BREECH PRESENTATION.
there is no guarantee of a swift referral to a place with A-C, external cephalic version. Flex the foetus between your hands so
these skills, then you might be forced to perform an that you make him do a forward somersault. D, the knee-chest
position. Ask the mother to spend 10mins tid like this.
elective Caesarean Section on a breech presentation at
37wks.
Symphysiotomy (21.7) is useful in breech delivery for the
If there is any question of CPD before or during the unbooked patient, who is admitted in the 2nd stage of
2nd stage of labour, have everything ready (including labour, and when there is no time for a Caesarean Section.
infiltrating the symphysis with LA) for a possible However, it is not a good idea to make your 1st
symphysiotomy (21.7), or proceed to Caesarean Section. unsupervised symphysiotomy in these circumstances,
In communities where the contracted pelvis is common, because if the head is stuck and you have tried everything
the risks of a breech delivery are great, so that to be sure else, there is then very little time left to deliver an
all these babies survive, you may have to perform a undamaged foetus.
Caesarean Section on all mothers without a proven
adequately sized pelvis; and this you can only know if they If a breech delivery might end in a symphysiotomy
have delivered vaginally at term successfully beforehand. (21.7), it is good practice to infiltrate the symphysis and
N.B. Do not allow a mother with a true conjugate (21.4) the skin over it already before it is needed, so as to shorten
of <9cm to deliver a full term breech vaginally unless you the time required for the probably necessary subsequent
can perform a symphysiotomy! procedure. Have a catheter and a large size scalpel ready!
A foetus with IUGR or prematurity presenting by as a Epidural anaesthesia will prevent a mother bearing down
breech is a problem. Much depends on the foetal age: before she is fully dilated, and it will make any
(1) <28wks gestation (<1kg): the chances of life are small, manipulations that you have to do in the second stage of a
the lower segment is poorly formed, and it is questionable vaginal delivery much easier. An occasional 'stuck breech',
if Caesarean Section will be any less traumatic than and a dead foetus, are more acceptable than a maternal
vaginal delivery. death in most cultures. As your skill and experience and
(2) From 28-32wks (1-1·5kg) the foetus may have a better that of your staff improve, so will your successful vaginal
chance with Caesarean Section, especially if it is a footling deliveries.
presentation. However, about 20% have severe
abnormalities, and if you do not have ventilators, even the
normal ones have a poor chance of surviving. So, in an
area of high parity and high perinatal mortality, you should
rarely perform a Caesarean Section for a premature breech
presentation. It is important to dissuade the mother from
pushing before full dilatation: do not leave her alone!
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CAUTION! This is a method for getting a grip directly EARLY DIFFICULTIES DELIVERING A BREECH
on the head. NEVER pull on the shoulders: you can too CAUTION!
easily distract the cervical vertebrae and damage the cord. (1);Perform an episiotomy (except in a multipara with a
lax outlet) before you do any manipulations, because there
is a high risk of a perineal laceration, but lacerations tend
to bleed less than early episiotomies, so consider the risk
of HIV transmission.
(2) Do not squeeze the abdomen!
(3) If the head fails to descend, do not pull on the neck.
(4);If the head becomes impacted and the foetus dies,
do not sever the neck, nor be tempted to open the uterus
from above.
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The shoulder which was above the sacrum will now be If the head has entered the pelvis and the Mauriceau-
above the pubis. A hand in the posterior vaginal space may Smellie-Veit manoeuvre fails to deliver it, rotating the
ease the arm down. Two further 'unscrewing' half-turns head in the pelvis may help. Stop struggling and think.
like this, each bringing the shoulders progressively below What is the cause? If it is CPD, a quick symphysiotomy
these obstructions will deliver the foetus. (21.7) may save the foetus. Do this only if you are
experienced.
Grasp the thighs and pelvis with both hands (if the baby is
slippery use a gauze swab or small towel), your thumbs If there is hydrocephalus, see 22.6.
along the foetal sacrum, your forefingers on the foetal
symphysis, and your remaining fingers round the foetal If CPD is the cause or the cervix is not fully dilated,
thighs. and you cannot deliver the foetus, apply gentle traction,
and try to slip the cervix over his head. If this fails, avoid
If, in the extreme case, the foetus obstructs transversely harming the mother and allow the foetus to die.
(22-5A), start by turning the body through 90º, so that the While she is still in the lithotomy position, sedate the
back faces to the left. The left shoulder will then be above mother with pethidine 50mg and let the foetus hang for a
the symphysis, and the right shoulder above the sacrum while. The head will usually mould, or the cervix dilate, so
(22-5B). With your first 180º turn (22-5C), bring the left that the foetus delivers in <1hr. If this does not happen,
shoulder under the sacrum. With your second turn traction with a bandage around the foetal legs and 1-3kg
(22-5D) bring the right shoulder under the sacrum. infusion bags as weights over the foot of the bed will
The left arm will now be low enough for you to sweep it succeed after some time.
gently down. With your third turn (22-5DE) bring the right
shoulder under the pubis; it will now be low enough for If the above measures fail and CPD is severe,
you to bring the right arm down. you may have to perform a CRANIOTOMY through the
foramen magnum (unpleasant but effective: 21.8).
CAUTION! Ask an assistant to pull down the body. Retract the anterior
(1).These three 180º turns are in opposite directions, so vaginal wall with a Sims' speculum and expose the back of
that the back always passes under the clitoris, and the arm the neck. Pick up a fold of the skin over the cervical
which started posterior always drags across the face. spine with toothed forceps, and incise it transversely.
The belly should never pass under the clitoris. Use curved Mayo's scissors to cut a tunnel under the skin
(2).In the worst case you start in 22-5A with both arms up to the occipital bone, and push scissors into the head.
extended, so you have to begin with a 90º turn, followed Open the scissors and rotate them a few times to break up
by three 180º turns. If the foetus arrests at a later stage, the brain compartments, withdrawing the scissors in an
with only one arm extended, you may only need 2 turns, open position to enlarge the hole. Pull gently on the neck
or perhaps only one. while the brain gradually escapes. Apply traction if
(3).The first 2 turns release the shoulder which was delivery does not occur immediately.
arrested above the symphysis when you started it.
The 3rd turn enables you to bring down the right arm. If the dead foetus protrudes from the vulva,
(4) Do not squeeze the belly, or back: you may rupture the examine to feel if the cervix is fully dilated or not.
liver, kidneys, spleen, or adrenals (huge in the newborn). If it is fully dilated, proceed directly to decompress the
If you hold the chest, take care not to compress the head with a craniotomy. If it is not fully dilated,
abdomen. apply traction. If this fails, perform a craniotomy.
(5).Remember that the upper part of the birth canal, CAUTION! Do not try to pull the head forcefully
in which the foetus is stuck, is directed backwards, so start through the undilated cervix: you may cause tears which
by pulling the foetus dorsally relative to the mother. extend into the lower segment.
If Løvset's manoeuvre fails to deliver the shoulders, If the neck has been severed, but the head has retracted
it is usually a failure of technique. You may have to be a into the uterus, it will be difficult to find and remove.
little firmer, or reach up a little higher to get the arm down. Use ultrasound and craniotomy equipment.
A broken arm will soon heal, so it is no disaster, and is
better than letting the foetus die. If the cord prolapses, manage as you would with a
cephalic presentation: perform a Caesarean Section,
LATER DIFFICULTIES DELIVERING A BREECH unless the cervix is fully dilated, and delivery is imminent.
CPD is the most important cause. Cord prolapse is more common with breech deliveries,
especially with a footling, but the foetal parts surrounding
If the head is stuck above the brim, you are really in the cord are softer so that the cord is often not compressed
trouble. You may be able to draw it into the pelvis with the completely.
Mauriceau-Smellie-Veit manoeuvre. If this fails, the foetus
will probably be dead, and the best treatment will be
craniotomy (see below).
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OTHER METHODS FOR BREECH DELIVERY N.B. FORCEPS FOR THE AFTERCOMING HEAD.
Standard obstetric forceps, e.g. Neville Barnes type:
BREECH EXTRACTION uses your pulling forces, rather (1).are not easy to use on the aftercoming head,
than the mother’s pushing forces. It is a quick way of (2).are liable to be misused if they are in the labour ward
delivering a small breech, usually a 2nd twin. It may be at all,
indicated for: (3).create the impression for midwifery students that a
(1) Delay with the second twin. breech delivery is something that only doctors can do.
(2) Foetal distress with the second twin. Outlet forceps (Wrigley's) are not long enough when you
(3) Cord prolapse at full dilatation with a breech. really need them. If they will reach the head they are
(4).A transverse lie in a second twin, following internal hardly necessary in a breech delivery.
version.
(5) A dead foetus.
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If the foetus is alive and the active phase of labour has If the 2nd stage is prolonged and the foetus is in the
begun with intact or ruptured membranes, and the mento-anterior position, with <2/5 of his head above the
cervix is <8cm, perform a Caesarean Section. pelvic brim, you can make a symphysiotomy (21.7) if CPD
If the membranes are still intact, and you can feel a leg is mild, or perform a Caesarean Section depending on your
through the lower segment, you can deliver the foetus experience. Remember that the head moulds less in a face
through a lower segment transverse incision. But if the presentation. If CPD is significant, perform a Caesarean
membranes have ruptured, and especially if an arm has Section in any case.
prolapsed, a de Lee incision (21.9) is better, because you
can extend this into the upper segment as necessary. CAUTION!
(1).Remember the possibility of anencephaly.
If the foetus is alive and the cervix is fully dilated or An anencephalic foetus often presents by the face,
nearly so, perform a Caesarean Section. but usually delivers easily. You should be able to
distinguish anencephaly, a face and a breech presentation
If the foetus is dead, and the cervix is not yet 8cm vaginally, once the cervix is 8cm dilated; feel for the foetal
dilated, perform a lower segment Caesarean Section. brow and mouth. An ultrasound is useful.
(2) Use oxytocin with the greatest caution.
If the foetus is dead, with an impacted shoulder, and (3) Never use a vacuum extractor!
the cervix is >8cm dilated, and the uterus is not
ruptured, perform a destructive operation (21.8).
BROW PRESENTATION
22.9 Prolapse & presentation of the cord
You will feel:
(1) the foetal anterior fontanelle,
(2) the supra-orbital ridges, and If the cervix is not well applied to the presenting part,
(3) the base of the nose. the umbilical cord can prolapse when the membranes
rupture, especially if the head is high, there is a transverse
Brow presentation is often missed: lie, a breech, a face presentation, or twins. The cord is said
(1).during labour. The head is high, but by the time it to be presenting when it lies below the presenting part,
descends, the sutures and fontanelles by which it might inside intact membranes. Both prolapse and, to a lesser
have been diagnosed, have become obscured by caput; degree, presentation can obstruct the circulation in the
(2) at Caesarean Section until the typical moulding makes cord, and so endanger foetal life. Other presenting parts
the diagnosis obvious. press less firmly on the cord than does the head,
Unless the foetus is premature, or the mother's pelvis is but do not let this delay you.
enormous, the foetus will not deliver vaginally.
FACE PRESENTATION
You will feel (1) the foetal eyes, (2) mouth and gums,
(3) nose, and (4) chin. Fig. 22-6 TREATING PROLAPSE OF THE CORD BY FILLING
THE BLADDER. A, the head pressing on the cord. B, to free the
cord, fill the mother’s bladder via a catheter, and clamp it.
Varieties are (‘mento’ refers to the chin):
(1).mento-anterior,
PROLAPSE.
(2).mento-transverse,
A routine vaginal examination immediately the
(3).mento-posterior.
membranes rupture spontaneously may diagnose a cord
prolapse, but this is not indicated if:
If the pelvis is large and there are no signs of CPD,
(1) the gestation is <36wks and there are no contractions,
allow labour to progress. The foetal position is most likely
(2) the foetal head is well down (not >2/5 above the brim),
to be mento-lateral, and will probably rotate anteriorly and
(3) the cervix is closed,
deliver spontaneously. You may be able to help by turning
(4) you have not followed the advice in 22.4 on premature
the foetus with your hand. If the position remains
membrane rupture.
mento-posterior, perform a Caesarean Section.
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If you find a prolapsed cord, do not take your hand out 22.10 Multiple pregnancies
of the vagina! Instead, push the foetal head (or breech)
off the cord.
While you are holding the head, ask an assistant to insert a You can deliver most twins vaginally, and only perform a
Foley catheter and fill the bladder with 500ml of saline, Caesarean Section on the same indications as for a
and clamp the catheter (22-6B). A full bladder will keep singleton pregnancy (21.5).
the head away from the cord and may inhibit the Twins do however have problems:
contractions of the uterus. (1).Labour is more often premature, which puts the
foetuses at risk.
Listen to the foetal heart. It may still be beating, (2).Uterine inertia is more common; this prolongs the
even if you can’t feel the cord pulsating. Assess the foetal 1st & 2nd stages of labour, and makes postpartum
size, and try to exclude gross congenital abnormalities, haemorrhage more likely.
particularly hydrocephalus. (3) Malpresentations are more common, especially with
the second twin (22-7).
N.B. A completely compressed cord, a complete (4) Prolapse of the cord is also more common.
abruption, a uterine rupture or the sudden death of the (5) When the 1st twin has been born, the 2nd may suffer as
mother can still be compatible with an undamaged the uterus retracts and constricts the placental site.
surviving foetus if delivery occurs within 15mins,
As soon as you diagnose twins plan for:
provided the foetus was in excellent condition initially. (1) Hospital delivery.
(2).Rest from 32-37wks at the shelters of a hospital.
Remove your fingers, and apply a pad to the perineum,
Rest in itself has no proven benefit but being near a
so that the cord remains in the vagina. Place mother in the
hospital has. You will in any case have to admit a mother
knee-chest position (22-2C), and cover her embarrassing
at 34-35wks to the mothers’ waiting area.
position with a sheet during transport to theatre. Perform a
Caesarean Section as soon as possible. The patient is more likely to become anaemic, so be sure
she is taking iron and folic acid. Watch for gestational
There is probably no time for a spinal and sitting up and
hypertension. She should not labour for longer with twins
curving the back will probably endanger the cord
than she would with a single pregnancy.
circulation. The best option is probably to use ketamine.
Do not empty the bladder until you are ready to open the
parietal peritoneum. Then simply remove the clamp on the
catheter
PRESENTATION OF THE CORD. Fig. 22-7 HOW TWINS PRESENT: in 40% of cases both twins are
If you feel the cord vaginally when the membranes are cephalic; in 21% the 2nd twin is a breech; in 14% the 1st twin is a
breech; in 10% of cases both twins are breeches. In all remaining
intact, observe carefully for foetal heart changes which cases one or the other twin, or occasionally both, are transverse.
indicate cord compression. Put the patient into the head-
down or knee-chest position, with the foot of the bed Use oxytocin in the 1st stage with the greatest care.
raised for 24hrs. This will nearly always allow the cord to Oxytocin IV to restart the contractions after the delivery of
rise above the head. Alternatively, <37wks, try ECV. the first twin is prudent and also later to prevent (or treat)
Turning the foetus may draw the cord from under the post-partum haemorrhage. Deliver triplets (or quadruplets)
presenting part. Otherwise perform a Caesarean Section, as you would twins. Expect the same problems as with
unless the foetus is dead or too small to survive. twins, but expect them more often.
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1ST STAGE. If the head stays high, increase the speed of the oxytocin
As soon as a woman is admitted in labour, determine the infusion and encourage the mother to push. A breech is
lie and presentation of the 1st twin by abdominal palpation. better than a cephalic presentation if the preventing part
Confirm this by vaginal examination and ultrasound stays high. A breech extraction is usually easy.
(38.3), and at the same time assess the pelvis. Manage as If you fear the cervix is closing and there is a high head
for a singleton pregnancy and use a partogram. (or a transverse lie) effect an internal version and
If there is delay during the active stage, apply the same extraction. It is much easier than you may think.
criteria for the use of oxytocin and performing a Caesarean (Have long gloves ready somewhere for this eventuality)
Section. Remember the rare possibility of locked twins. N.B. A vacuum extraction with a floppy cervix may be
If the 1st twin is cephalic, or a fully-flexed hip-breech, difficult especially if the 1st twin’s umbilical cord gets in
manage the 1st stage as an ordinary trial of labour, unless the way of the cup.
the foetus is very big, or the pelvis is very contracted.
If the 1st twin has a transverse lie, or is a footling If the cervix closes, the diagnosis is then a retained
(one or both thighs flexed and one extended at the hip), 2nd twin. Active management with an oxytocin infusion,
perform a Caesarean Section, unless the foetus is very aiming at rupturing the membranes 3mins after delivery of
small (<1½). In this case, it may slip through an undilated the 1st twin, will almost always prevent this problem.
cervix, and there is an increased risk of cord prolapse. N.B. Many Caesarean Sections are wrongly performed
for retained (originally sometimes unrecognised) twins,
2ND STAGE. often after the 2nd twin has already died. It is too late to
Find an assistant who will be ready to look after the refer a mother for intervention at this stage!
1st twin, while you deliver the 2nd. Be prepared for an CAUTION!
operative delivery of the 2nd twin, and for a postpartum (1) Try to know what the presenting part is before you
haemorrhage. Insert an IV line, and have oxytocin, rupture the membranes, although this is not always easy
misoprostol or ergometrine within easy reach. without ultrasound (38.3).
Deliver the 1st twin as usual for a cephalic or breech (2) The 2nd twin may be larger than the 1st. If you are
presentation. This is usually no problem although the motivated, a vaginal delivery will always be quicker than
distended abdomen might interfere with the strength of the organizing a Caesarean Section.
forces of expulsion. Oxytocin or a vacuum extraction may N.B. CPD is unusual with twins.
help. Nearly immediately after delivery, divide the cord
between clamps, and then replace the maternal clamp by a If ECV fails, do not delay! Rupture the membranes in the
ligature (22.11). labour ward and immediately effect an internal version,
CAUTION! As soon as the 1st twin is born, look at the (see below) and deliver the foetus. Otherwise proceed
clock. Deliver the 2nd twin as soon as possible, but without immediately to a Caesarean Section
undue hurry: 15mins is a reasonable time. N.B. Internal version is dangerous if the membranes
have been ruptured for some time.
Feel, or ultrasound (38.3), the abdomen to find the lie,
which you can make longitudinal if it is transverse or 3RD STAGE.
oblique. Version of a 2nd twin is usually easy, provided Manage this actively to minimize blood loss. Speed up the
you do it without delay, immediately after the 1 st twin has IV oxytocin infusion with the birth of the anterior shoulder
been delivered, while the membranes remain intact, and of the 2nd twin, and then deliver the placentas by controlled
before uterine contractions restart. Then do a vaginal traction on both cords. If bleeding continues or the uterus
examination to feel how it fits the pelvis. Use 4 fingers or is lax, put 800µg misoprostol rectally, massage the uterus
even your whole hand, instead of the usual 2; there will and express clots if it rises, till the tablets start working.
always be room for them immediately after delivery of the
1st twin. The presenting part of the 2nd twin is likely to be INTERNAL VERSION (GRADE 2.2) is often possible
high: you may not be able to reach it with 2 fingers or you without GA. It is kinder however under sedation.
might just feel small parts through the membranes not Put the woman into the lithotomy position. Make sure the
being sure what they are. If you have a skilled assistant, bladder is empty. Prepare the vulva with antiseptic as
ask her to do the abdominal palpation and keep the foetus usual, and the abdominal wall also. Wait until she is
in a longitudinal lie, while you rupture the membranes. relaxed between contractions, and then put your
At this stage it is good to have an IV oxytocin infusion long-gloved right hand through the fully dilated cervix into
running because otherwise it may take long for the the uterus, until you can feel the intact membranes.
contractions to resume. Be pro-active in rupturing the Rupture them so you can get a grip on a foot. Palpate the
membranes because you do not want the cervix to close; abdomen with your left hand. Search for a foot, which you
the presenting part will come down after the stimulus of will recognize by its heel.
rupturing the membranes.
If you find this difficult, work out which way round the
If the presenting part comes down, this is a sign of foetus is lying, and then feel in the direction of the
impending success. Sometimes this success has to be buttocks. Find a leg and follow this down. Use your other
clinched by fundal pressure, a vacuum extraction or a hand if this seems easier. When you have found a foot,
breech/delivery extraction but this is bound to be easy. bring this down. Hold the ankle between your index and
middle finger, with your thumb on the dorsum of the foot.
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Gently pull the foot, so as to bring one of the legs over the CAUTION!
pelvic brim, and down the vagina as far as you can, (1).Internal version is only for the 2nd twin with intact or
if possible as far as the vulva. The buttocks and other leg recently ruptured membranes, during a delivery which you
will follow. have been supervising. It is not suitable for a retained 2nd
At the same time push the head upwards towards the twin.
fundus. Keep pulling on the leg in the direction of the (2).Make quite sure you bring down a foot, and not a hand!
floor. If necessary, squat to do this. Do not, in exasperation, bring down any limb! It is not
As more of the leg appears, hold it higher along its length. possible for the foetus to hide its feet so well that a
When the anterior buttock appears on the perineum, committed doctor can’t find them.
pull horizontally, and then upwards (breech extraction). (3).If you still do not know what is presenting, do not
When the buttocks are out, deliver the shoulders by waste time waiting for the presenting part to come down.
Løvset's manoeuvre and the head by the Mauriceau- While you wait, the membranes will probably rupture
Smellie-Veit manoeuvre (22.7). spontaneously, and the presenting part may be an arm!
Once the membranes rupture, labour will commence,
and if the head remains high, especially with a transverse
lie, the uterus is likely to rupture.
If, after the delivery of the 1st twin, you feel the head or
breech of the 2nd twin, but the cervix is only 7-8cm
dilated, assistance with manual fundal pressure will help
very well. Rupture the membranes and make the patient
push. The cervix will dilate again, as soon as the
presenting part of the second twin comes down.
Contraction of the cervix will not at first delay delivery of
the 2nd twin, and is no reason for delaying rupture of the
membranes.
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Occasionally, the husband has the same blood group or has 5IU oxytocin IM. (Ergometrine 0∙5mg IM is not such a
group O Rh-ve. (If the mother is HIV+ve and he also, good option because it can cause retention of the placenta
this added problem would also be removed!) (see below) but it is better than nothing.) Oxytocin will
N.B. Make sure you have access to collection bags with work quicker if you use it IV, but there may be nobody
citrate day and night. around to monitor the patient.
Routinely use oxytocin IM as soon as the foetus is born,
PREVENTING PPH BEFORE LABOUR and you are sure there is no twin still in the uterus.
The following are RISK FACTORS which make it more Then (unless the mother is HIV+ve), after 3mins delay,
likely that a woman will have a PPH and so should deliver clamp the cord to increase the foetal iron stores and deliver
in hospital. the placenta by controlled cord traction.
A. IDENTIFIABLE DURING PREGNANCY: If there is a risk factor for PPH, set up a perfusion of IV
(1) APH in this pregnancy. saline with a large bore cannula before the patient reaches
(2) PPH, or a retained placenta, in a previous pregnancy. the 2nd stage. When the foetus and the placenta have been
(3) Multiple pregnancy or other cause of extremely delivered, add 20IU oxytocin IV in 500ml at 30drops/min
distended uterus. for at least 3hrs. Also, for patients seriously at risk, insert
(4).Combination of previous Caesarean Sections and a 800µg misoprostol rectally as soon as the placenta is
placenta low on the anterior wall. delivered and massage the uterus for a contraction.
(5) Placenta accreta, percreta or increta This is likely to help because it works via different
N.B. Grand multiparity (>4 children) is not really a risk pathways. If misoprostol is not available, use ergometrine
factor for PPH, but the consequences of haemorrhage in an 0·5 mg IM and massage the uterus.
older multipara are much worse than with a 1st pregnancy.
CONTROLLED CORD TRACTION.
B. IDENTIFIABLE DURING LABOUR.
(1) Prolonged, especially infected, labour. Unless the mother is HIV+ve, clamp the cord after a delay
(2) Anaesthesia, using ether, halothane or spinal. of 3mins. Then, as soon as the uterus is contracting firmly
(3) A full bladder. from the action of oxytocin (or ergometrine), put your left
(4) Placenta praevia. hand on the abdomen, above the pubic symphysis, and turn
(5).Placental abruption, mainly because this causes a your palm towards the head. Grasp the uterus.
clotting defect, but also because there is already much As soon as it feels hard from the effect of the oxytocic,
blood lost in the uterus (concealed bleeding) and there are push it upwards towards the umbilicus (deliver the
few clotting factors left to prevent even more loss. placenta more by pushing the uterus up than by pulling on
(6) A clotting defect, especially DIC (3.5). the cord).
(7) Incomplete expulsion of the placenta. Wind 2-3 loops of cord round your index finger and gently
CAUTION! PPH may occur without there being any pull on the cord, first downwards and backwards, and then
risk factors: it is best to have an oxytocin infusion running more anteriorly as the cord comes out. Very, very rarely
routinely after Caesarean Section. you might feel an inversion of the uterus originating at this
PREVENTING PPH DURING LABOUR stage if you pull without a contraction.
Treat every mother, especially those with risk factors, with As soon as the placenta is delivered check to make sure
that:
(1).it is complete and that no lobes have
been left behind (see below) and,
(2).that there are no obvious large
lacerations in the birth canal. Keep the
mother in the labour ward, and monitor her
for at least 1hr, before returning her to the
ward. Check that the uterus is well
contracted and note any bleeding.
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Ideally, you should never apply controlled cord traction It seems that the placenta becomes separated by
before the uterus has hardened under the effect of an contractions at the place of the placental insertion.
oxytocic drug; so, if you do not have any oxytocics, Using ultrasound (38.3), you can see that the uterus is thin
you should not do it. In practice, little harm results if there behind an adherent placenta but thick everywhere when
are already signs of placental separation (lengthening of the placenta is merely trapped.
the cord and hardness of the uterus).
If the placenta is retained for <1hr, try to make the
Although it is a very valuable procedure, there is a risk, uterus contract.
particularly if you do it incorrectly, that you may invert the (1).If you have not used oxytocin, use it now.
uterus. (2).If this fails to stimulate a contraction, gently massage
CAUTION! Do not squeeze the uterus to try to get the the uterus for a contraction.
placenta out. This is very painful. (3).Remove the placenta by controlled cord traction,
as soon as the uterus is contracting firmly. It should deliver
RESUSCITATION FOR PPH immediately.
As soon as you are called to a patient with PPH, (4).You can reduce the need for manual removal by c.20%
quickly call an assistant: at least 2 people are needed. by the use of intra-umbilical vein oxytocin (50IU in 30ml
saline). This will stimulate exactly only that uterine area
Start vigorous resuscitation. What is the state of the where a massive contraction is wanted. An even more
peripheral circulation? How much blood has been lost? effective alternative is 30ml saline with 4 misoprostol
Is it clotting normally in the receiver used to collect it? tablets (800μg) dissolved in it. Cut the cord 5cm in front of
It may clot to start with, and then stop clotting later. the vagina or open a vein in the cord near the introitus with
What has been done so far? a scalpel and thread a Ch10 gastric tube in the direction of
the placenta till you feel resistance. Withdraw it 5cm to
Monitor the volume of blood loss, the warmth of the allow for branching of the vein and inject the 30ml with
peripheries, pulse and blood pressure, and the urine output. either oxytocin or misoprostol (Pipingas technique) while
preventing back flow by clamping the cord.
If she is still bleeding: is the uterus still contracted?
Is the placenta out and complete? Is the bladder empty? If the placenta is retained for >1hr, this is an indication
Does she have any obvious lacerations of the vulva, for manual removal. Of course, if there is bleeding
vagina or perineum? Could the uterus be ruptured? (placenta partly separated or incarcerated), something
should be done fast, such as manual removal with IV
If she has stopped bleeding, is the uterus well contracted? pethidine with diazepam or ketamine in the labour ward.
CAUTION! Make sure that one nurse is allocated Before doing a formal manual removal, perform a vaginal
solely to observe and monitor this patient, until bleeding examination, and see if the placenta is stuck in the cervix,
has stopped, and her condition is stable. Poor supervision from which you can remove it quite easily.
is an important cause of death in PPH. While preparing to do a manual removal concentrate on:
(1) continuing resuscitation,
PPH WITH A RETAINED PLACENTA (2).keeping the uterus contracted with 20-40IU oxytocin
In low-income countries, retained placenta affects c. 0·1% IV, and
of all deliveries, but has a case fatality rate up to 10%. (3).if the oxytocin or misoprostol does not work against
There are large regional differences: for example, bleeding, gently massage the uterus for a contraction.
the incidence is very high in Papua New Guinea.
MANUAL REMOVAL OF THE PLACENTA (GRADE 1.5)
Some placentas are simply trapped (the incarcerated or can either be fairly easy when it is merely trapped behind a
trapped placenta) behind a closed cervix; the use of closed cervix; rather difficult, needing removal because it
ergometrine promotes this situation. Some are adherent to is adherent or locally invading the uterus; or impossible
the uterine wall but usually easily separated manually (the clinical definition of placenta accreta), when most or
(placenta adherens), and some have grown into the wall in the entire placenta has grown in the uterus.
a small area, needing manual or instrumental removal
usually in piecemeal fashion though blood loss is It is usually best done in the labour ward (which must be
controllable. Others are pathologically invading the equipped for anaesthetic resuscitation) 30-60mins post
myometrium (placenta accreta, increta, percreta) over a partum rather than in the theatre, which usually requires
large area, needing ligation of uterine blood vessels, or moving the patient and will cause delay. You will need
even hysterectomy. These last cases are quite rare and stirrups to maintain a lithotomy position, and a good light.
mostly seen during Caesarean Section because they are Before you start, set up IV saline or Ringer's lactate,
often related to more than one previous Caesarean Section if necessary with 2 IV lines. If an infusion of oxytocin IV
combined with placenta praevia. is already running, stop this just before manual removal to
allow the cervix to relax, so that you can get your fingers
Active management of the 3rd stage limits blood loss and inside the uterus.
shortens this stage but after 1hr the number of retained Ketamine is safest; do not use sedation in a hypotensive
placentas is similar whether there was active management patient. Use aseptic procedures.
or not; the same applies to the use of misoprostol.
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Hold the cord in your right hand. Put the tips of the fingers
of your left hand together, and introduce it into the upper
part of the vagina. If the placenta has stuck in the cervix,
grasp it and slowly remove it. Now let go of the cord, and
place your right hand on the fundus (over the towel).
Prevent the fundus from being pushed up, as you gradually
work your way into the uterus with your left hand.
Feel for the part of the placenta which has already
separated, and push your fingers between it and the wall of
the uterus. Gently separate the placenta from the wall of
the uterus with a slow sawing movement, with the side of
your hand.
CAUTION! All this time keep your right hand pressing
on the fundus, so as to bring the uterus as close to your left
hand, as you can. If you do not do this there is a danger
you may lacerate the placenta.
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METHOD. Use sterile precautions. Catheterize the If there are multiple small lacerations rather than one
bladder. Use ketamine. Use the lithotomy position, large one which you can easily suture, or there is a
get a good light, and find a Sims' speculum or one which is steady ooze, pack the vagina.
wider, and an assistant to help hold it. Wipe out the blood
in the vagina with gauze swabs. Look at its walls. If there is a retained piece of placenta, use suction.
Check that the vaginal wall, and the perineal and vulval If this fails, scrape it off with your fingers. Do not persist
skin are intact. if you cannot get it all off, as this will be due to an
abnormally adherent placenta.
To inspect the cervix, use 2 swab-holding forceps.
Grasp the front lip of the cervix with one of them. If you find a rupture of the uterus and bleeding is
Pull the cervix gently down, and look for lacerations on it. severe, apply bimanual compression or compress the aorta
If there are none, use the 2nd forceps to pull down the next against the spinal column just above the uterus,
portion of cervix, and look at that. Continue round the until you can get someone to organize for an immediate
cervix in this way, looking at every part (22-11). laparotomy (21.17). Do not then leave the patient without
Then put your hand into the uterus and carefully feel its continuing the compression!
front, sides, back, and fundus. Feel for a rupture of the
uterus (21.17), and for any pieces of adherent placenta.
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If bleeding persists despite all other measures when you If you cannot get your whole hand through the cervix
have used oxytocics properly, sometimes the only way to to perform a manual removal (not uncommon if a lot of
keep the uterus contracted is to massage it for hours. ergometrine is used shortly before the manual removal is
This can be quite painful for the woman. done, or there has been a long delay), you are in difficulty.
Avoid this problem, if you can, by using IV oxytocin,
BALLOON TAMPONADE OF THE UTERUS AND rather than ergometrine, and by discontinuing it just before
VAGINA (GRADE 1.2) Packing is messy and time- manual removal. Try to get one or two fingers through the
consuming. If there is a steady ooze, blood is scarce, and cervix, and push the fundus well down with your other
HIV common, packing may save a mother's life. hand. Usually, the cervix relaxes gradually so that,
In practice it is very useful as a near-last resort, before if you are slow and gentle, you can put your whole hand
tying the uterine arteries or removing the uterus. It is much into the uterus. Long forceps to remove the placenta
less effective in controlling bleeding from the uterus, piecemeal are an option; keep your non-dominant hand on
than from the cervix. Much the best way to do this is to the fundus to prevent perforation: you will feel the forceps.
use oxytocin and misoprostol to make the uterus contract. This method can be combined with suction via a large
(12mm) Karman cannula.
METHOD. Use sterile precautions. Use the lithotomy
position. Pack the uterus and vagina with a condom, If the placenta seems abnormally adherent to the
attached to tubing or a Foley catheter and filled with 1l uterus (placenta accreta), remove what you safely can
water (22-10), or occasionally 2 such condoms. piecemeal, without perforating the uterus, and leave the
You can use another such condom in the vagina to rest. This is not a problem as long as the uterus contracts
compress the cervix. This is far more effective and cheaper sufficiently afterwards to obstruct the blood flow to the
than using sterile gauze, which you may have difficulty relevant areas. Avoid sharp curettage: the myometrium
getting through the cervix. might be very thin at the point of adherence and there is a
CAUTION! high risk of perforation.
(1) Be sure to compress the whole genital tract from the The placenta which you have to leave will be slowly
fundus to the introitus. absorbed. There is serious risk from sepsis and secondary
(2) Do not only compress the vagina, because bleeding postpartum haemorrhage. Continue IV oxytocin for 48hrs,
will continue invisibly in the uterus, the only sign of which then stop if all is satisfactory. Treat with prophylactic
may be increasing hypovolaemic shock. chloramphenicol and metronidazole. Monitor carefully in
(3) If you do use gauze, tie it in one long piece to prevent hospital.
bits getting lost. N.B. Placenta accreta over a large area will often need
a hysterectomy; suspect this if there have been several
With a balloon inflated in the uterus, it will be difficult to previous Caesarean Sections.
pass urine, so catheterize the bladder.
Continue monitoring and infuse IV fluid or blood as If bleeding continues from an empty uterus, despite all
necessary. Remove the compression after 24hrs. the above measures, try infusing oxytocin 40IU in 500ml
saline fast IV with repeated doses of ergometrine 0∙5mg
DIFFICULTIES WITH PPH IV. Try prostaglandins if you have them.
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Certainly it will make a hysterectomy later a much less If bleeding is mild, observation may be all the patient
bloody and dangerous procedure. needs. It is not rare anyway for a woman to have a
N.B. A tourniquet, put on in this way, stops blood bloody discharge continuing 2months after delivery.
supply to both the uterine and the ovarian arteries. If she continues to bleed, or has signs of infection, treat her
This means that the uterus and ovaries will necrose if the with chloramphenicol and metronidazole, and supply iron
tourniquet is left on for >3-6hrs. supplements.
If you place the tourniquet so it only stops blood supply in
the uterine arteries, sparing the ovarian vessels, this might If bleeding is severe, the patient needs antibiotics,
still control the bleeding without causing the ovaries to resuscitation, and an ultrasound examination for retained
necrose. To do this, you have to push your tourniquet pieces of placenta (38.3). Alert your anaesthetist. Make
through the broad ligament just lateral to the uterus near sure you monitor your patient carefully! Be sure she is
the cervix from front to back then go round behind the well resuscitated before you start evacuating the uterus!
uterus and do the same on the other side from back to front
and tie. EXPLORING AND EVACUATING A SEPTIC
BEWARE: do it bluntly with a small artery forceps UTERUS IS DIFFICULT.
first, and then pull the catheter through, avoiding many
distended veins in this area. EQUIPMENT Sterilize 2 ring forceps (or swab holders), a Sims'
speculum, and a big, blunt curette. If available a large (12mm) suction
Alternatively, control the haemorrhage with the tourniquet,
curette is best. Add them to the vaginal examination tray.
and then formally ligate both uterine arteries:
Start an oxytocin infusion and place 800µg misoprostol
rectally, so that you have the best chance of a well
contracted uterus which will also help you avoid a
perforation because it is easily felt when hard.
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The babies at greatest risk of some major handicap Usually there is a rapid thready pulse and a low blood
associated with IUGR, particularly cerebral palsy, are: pressure. The abdomen is uniformly distended, tympanitic,
(1) The badly asphyxiated foetus with severe IUGR born silent, and acutely tender.
at or post-term.
(2) The foetus with IUGR delivered <34wks. There may be a visible mass extending up to the
Try to diagnose and deliver babies in the 'window' umbilicus; you may have to pass a catheter to make sure
between 34-36wks if you can. Delivering a foetus whose that it is not merely a distended bladder.
mother has diabetes presents similar problems in judging
the best time for delivery, the main difference being that MANAGEMENT:
he is too big rather than too small. Resuscitate the patient (10.1). Treat her with
chloramphenicol, ampicillin or gentamicin, and
Much of the effort of modern obstetrics is devoted to metronidazole. Monitor her 4-6hrly for signs of spread of
detecting babies with IUGR, monitoring them, and getting infection.
them out into the world at just the right moment, when the
risks outside the uterus are less than those inside it.
If you can judge the moment of induction successfully,
you may increase a child's chance of survival.
Because of the enormous progress made in neonatal
intensive care in high technology surroundings, survival
without handicap has improved dramatically. In your case
delivering a foetus too soon might be much more risky.
Despite a massive investment in resources, a foetus
suspected of having IUGR is often found to be normal,
or simply premature and vice versa.
However, treat the more manageable causes of perinatal
mortality, some of which express themselves as IUGR:
malaria, gestational hypertension, syphilis, obstructed
labour, and poorly managed breech and twin deliveries.
HIV however remains a huge challenge.
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Infection may also spread through the uterine wall into the Fig. 23-1 PELVIC SEPSIS. A, infection spreading from the uterus to
cause peritonitis. Infection can also spread as an infected thrombus
broad ligaments to cause metritis, pelvic cellulitis (thrombophlebitis). B, infection of the connective tissue beside the
(parametritis), a broad ligament abscess, or septic uterus (parametritis). Infection may spread into the broad ligament,
thrombophlebitis of the ovarian or the uterine veins. round the vagina or uterus, or up into the loin. C, collection of pelvic
This is very serious and causes septicaemia with few local pus. D, salpingitis. After Garrey MM. Obstetrics Illustrated Churchill
Livingstone 1974, p.319-20 with kind permission.
signs. This occurs mostly after a pregnancy and is then
called either puerperal sepsis (22.14) or post-abortal
A patient with 'postmenstrual PID' is not pregnant; she has
sepsis. This is by definition not called PID although the
suffered no birth trauma and there are no infected products
first-line treatment is the same.
of conception. She may however have an intra-uterine
device (IUD) in the uterus, which increases the risk of
If antibiotics do not help in an infection related to
infection, but not as seriously as was previously supposed.
pregnancy, a hysterectomy may be necessary to save a
PID is seldom fatal, and never causes septic
patient’s life. Hysterectomy is not helpful in severe PID,
thrombophlebitis. The pregnancy-related infections are all
but of course if both tubes are blocked or need removal
dangerous, and can kill. Post-abortal peritonitis is
because of pus, the result is just the same: infertility.
particularly deadly and has a mortality of 50%.
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The organisms (gonococci, mycoplasma, chlamydia) You can usually treat PID non-operatively, but remove an
responsible for PID may be sexually transmitted. IUD if present. Make sure she can then get an alternative
These can pave the way for other organisms, especially contraceptive. Condoms provide some protection against
anaerobes, and through tubal damage allow infestation by sexually-transmitted infections (STI) and hence PID;
other organisms which may normally live in the vagina; depo-provera, implants and the contraceptive pill do not
viz. coliforms, various anaerobes, especially bacteroides, prevent STI but often prevent PID, which is a complication
and rarely actinomyces. The latter organisms of STI and hence reduce infertility.
(and sometimes even the former) live harmlessly in the Occasionally, you will need to drain pus. Unfortunately,
vagina and cervix, and only cause disease when the once PID has become chronic, there may be recurrent pain.
barriers to spread are removed by: The pain threshold is likely to be low if there is also
(1) Miscarriage or delivery. infertility. Don't operate on chronic PID, because once it
(2) Menstruation. has been present for >4wks, the pelvic organs will be so
(3) After D&C, IUD insertion, or hysterosalpingogram. densely stuck to one another that freeing them will be
(4) HIV disease. difficult and dangerous: you can easily injure the bowel.
Many gonococci, and typically all chlamydia and If surgery is indicated, be conservative. Leave the pelvic
mycoplasma are sensitive to tetracycline. But when organs intact unless there is a tubo-ovarian abscess.
infection follows pregnancy or a miscarriage, a mixture of Removing this can be difficult, so open it and drain it.
organisms is responsible, including anaerobes, for which If you leave the uterus and some ovarian tissue intact,
the patient needs metronidazole with chloramphenicol. menstruation will continue. Otherwise (if the ovaries have
By the time many patients present, secondary infection is to be removed) advise hormone supplements for younger
likely, whatever the primary cause of the infection. women (in the form of the contraceptive pill) till the age of
45yrs, but beware: oestrogen therapy increases the risk of
The clinical manifestations of pelvic sepsis are wide. breast and uterine cancer.
They range from an otherwise symptomless infertility
caused by blocked tubes, to generalized peritonitis,
septicaemia and septic shock, with everything between
these two extremes. Like a fire, PID can be of any degree
of severity, from smouldering to fulminating. Also, like a
fire, it can die down, only to light up again later.
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If you are not sure of the diagnosis, which may be There is usually no need to remove the tubes or ovaries,
beyond Stage II, perform a MINI-LAPAROTOMY to however diseased they may look. The tubes have a double
examine the pelvic organs, looking for red, sticky, blood supply which prevents them becoming gangrenous:
and oedematous tubes. This is safer than laparoscopy, anyway, you need consent for sterilization in order to
which may result in bowel perforation if there are dense remove both tubes!
adhesions, and the incision can be extended to a formal Even if there is a ruptured tubo-ovarian abscess,
laparotomy if required. leave the Fallopian tube.
LAPAROTOMY FOR ACUTE PID (GRADE 3.2) When you find the uterine fundus, push your fingers down
INDICATIONS. behind it, between the tubes, which will almost meet in the
(1) After 2wks of treatment with IV antibiotics for Stage middle. You need not fear perforating the bowel here.
II PID without resolution.
(2) Failure of 48hr IV antibiotic treatment for post-abortal Gradually work your fingers down below the tubes.
or post-partum sepsis. Of course if there is a hole in the Free them from the bowel from below upwards.
uterus with peritonitis present, the operation cannot be Remember the anatomy. Both tubes will be stuck down
postponed that long. Make sure the uterus is empty. behind the uterus, over the top of each ovary. The rectum
(3) Generalized peritonitis due to rupture of a tubo-ovarian and colon will be adherent from below upwards to the
abscess. This may be spontaneous or it may follow a back of the uterus, and then to both the tubes. Loops of
vaginal or rectal examination. small bowel and omentum will have stuck to them on top.
(4) Septic shock after adequate IV fluid resuscitation. If you can find the fundus, you will know where you are.
(5) The diagnosis is in doubt, and there is a possibility that
there might be an ectopic gestation or appendicitis, Don't panic when you find a mass of adherent bowel and
for example: start with a mini-laparotomy. omentum. It will always come clear in the end. First get
N.B. This is not an easy operation and has a significant down to the fundus by carefully easing off the bowel and
mortality. omentum. Do not use force! Divide all adhesions and
release all the pockets of pus.
PREPARATION. Resuscitate with IV fluids: you may Do not be tempted to remove a normal appendix.
need to infuse 3-4l saline or more during the first 24hrs.
There may be considerable bleeding from the raw surfaces CAUTION! Never pull the bowel. Avoid tearing it by
that will form when you free the adhesions between the going slowly, and squeezing and pinching the plane of
loops of the bowel, so have 2 units of blood cleavage between your fingers (12.6). Cut dense adhesions
cross-matched. If the patient is seriously ill, there is danger with scissors.
of renal failure, so insert an indwelling catheter and
monitor the urine output. Pass a nasogastric tube. If there is generalized peritonitis (10.1), suck away as
Start antibiotics before the operation, if this has not already much pus as you can, then suck out the paracolic gutters.
been done. Discuss the possibility of salpingectomy and/or Wash with copious amounts of warm fluid. Make sure you
hysterectomy, and get consent. release any collections of pus under the abdominal wall,
between the large bowel and the abdominal wall,
INCISION. Make a lower midline incision (11.2, 11-1) and under the diaphragm and the liver (subphrenic &
and extend it above the umbilicus if necessary. subhepatic spaces). Bring out the whole small bowel over
Be prepared on occasion to find some other quite its full length in stages. Break down adhesions between
unexpected condition. Do not use a Pfannenstiel incision. loops of bowel, by careful blunt dissection, to release the
many collections you will find there. Cover the bowel with
If the infection is limited to the pelvis, examine the upper moist warm cloths. Then go to the pelvis, and proceed as
abdominal cavity before you explore the pelvis and disturb above for a localized pelvic infection.
the adhesions, which are limiting the spread of infection.
Examine the subphrenic and subhepatic spaces, and the LAVAGE depends on the extent of the sepsis (10.1):
paracolic gutters; look for pus between the loops of the If the pus is localized to the pelvis, wash it out of the
small bowel as far as you can reach them. If you find pus, pelvis only, before you remove the packs protecting the
wash it out with warm fluid. If you find dense adhesions, rest of the abdominal cavity.
separate them very gently (12-8). If you don't find pus in If there is generalized peritonitis, wash out the whole
the upper abdomen, carefully protect the upper uninfected abdominal cavity with warm fluid.
part of the abdominal cavity with large abdominal packs.
Slowly and methodically divide the adhesions between the CLOSURE. Close the abdomen as a single layer,
bowel and the uterus, and look for pus. Divide the taking care to pick up the peritoneum and posterior rectus
adhesions round the tubes and ovaries, and release the pus sheath which may be retracted, and leave the skin open for
you find there. Try to get right down into the pouch of secondary closure if there is a great deal of pus (11.8).
Douglas. Do not insert tension sutures.
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DIFFICULTIES WITH ACUTE PID If you inadvertently tear the small bowel,
Be prepared for small bowel fistulae (11.15), and a burst repair the perforation transversely in two layers.
abdomen (11.14), especially if abdominal distension If there are several holes in the bowel, it is better to
persists for some time postoperatively. sacrifice a segment and perform one formal anastomosis
(11.3) than close several holes which may leak. Lavage the
If there is a septic miscarriage, you will have to make the abdomen thoroughly and be prepared to reopen the
difficult decision as to whether or not to perform a abdomen in 48hrs to inspect the bowel, and do a further
hysterectomy. Assess the state of the uterus and adnexa lavage.
perform a hysterectomy if:
(1) the uterus is perforated. If you accidentally tear the pelvic colon,
(2);the patient is no longer young and has had children what you should do depends on the size of the tear and
(though even if you leave the uterus she will probably be where it is. If it is small, oversew it in two layers.
infertile). If it is large, but there is minimal soiling, freshen the edges
(3);you are not so experienced (a subtotal hysterectomy and repair it formally, lavage the abdomen thoroughly and
will be enough). leave a drain. If there is considerable faecal spillage, close
Perform a salpingo-oophorectomy (avoid a hysterectomy) it as before and make a defunctioning colostomy (11.5,6)
if generalized peritonitis seems to originate in an abscess higher up. There is rarely a need to perform a Hartmann's
in one of the adnexa only. procedure (12.9).
If there is a mass and you are not sure if there is a If there is persistent sepsis in the abdominal cavity,
ruptured ectopic gestation or pelvic abscess, in spite of repeated attempts at drainage, leave the
and you have no reliable pregnancy test, perform a abdomen open (laparostomy) for daily irrigation (11.10).
culdocentesis (20-6) preferably with ultrasound guidance,
under GA. If you find pus, drain it through the vagina. B. CHRONIC PID
If you find blood which fails to clot, or liquor, perform a
laparotomy (20.6). DIFFERENTIAL DIAGNOSIS: urinary tract infection,
endometriosis, schistosomiasis and pelvic tuberculosis.
If there is an IUD in situ, and fever with great tenderness,
infuse IV antibiotics and remove the IUD. Otherwise, ANTIBIOTICS.
if the fever is not high and the response to IV antibiotics If there is recurrent or continuing infection suggested
good, you can leave the IUD in situ. by raised ESR counts, try doxycyline with ceftriaxone,
N.B. Sometimes PID is related to the insertion of an and maybe adding azithromycin for a maximum of 14days.
IUD while there is an existing chlamydia or gonococcal
infection. If there is no improvement, either your diagnosis is
wrong, or there is a collection of pus, perhaps a chronic
If you enter the abdomen, and find little or no pus and tubo-ovarian abscess or a pyosalpinx.
few signs of inflammation, examine the pelvic organs and Always consider TB.
particularly the infundibulo-pelvic ligaments (23-21).
One or both may be thickened and oedematous, Suggesting endometriosis: no children, >30yrs, chronic
and the thickening may extend under the ovaries to the menorrhalgia since puberty, getting worse.
uterus. This is SEPTIC THROMBOPHLEBITIS of the
ovarian veins. If you find nothing, the thrombophlebitis is DIFFICULTIES WITH CHRONIC PID
probably in a uterine vein which is not so easily seen.
Continue with antibiotics in high doses. If possible, If, on laparoscopy or laparotomy, you see bluish or
2hrs after the operation start SC or IV heparin brown nodules on the surface of the peritoneum and
1,000-10,000 units by bolus qid, controlled by estimating particularly on the utero-sacral ligaments, surrounded by
the clotting time and lengthening it to about 15mins serosal folding, suspect ENDOMETRIOSIS. You are most
(dosage varies depending on the type of heparin you use). likely to see such nodules on the utero-sacral ligaments, in
Continue this for 1wk. the pouch of Douglas, on the ovaries, on the posterior
Watch carefully for abnormal bleeding, particularly from surface of the broad ligament, or on the fimbrial ends of
the abdominal incision, the urinary or intestinal tracts. the tubes.
Improvement should be quick.
If there is pain use a non-cyclical progestagen to suppress
If you find disseminated yellowish-white nodules menstruation, such as norethisterone 10mg od starting on
throughout the pelvis, or a localized infection in the the 5th day of the cycle (increased if spotting occurs to
pelvis with nodules on the tubes and perhaps a 25mg od in divided doses to prevent break-through
CASEOUS ABSCESS or a shrunken thickened omentum, bleeding) for at least 6months. Or, use depo-provera
suspect TUBERCULOSIS (16.1). Take a biopsy and send 150mg monthly for 3months and then 3monthly: this will
this for histology. Start treatment early, and check for HIV probably cause amenorrhoea and hence also stop the
disease (5.7) bleeding in the ectopic endometrial mucosa.
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N.B. Norethisterone in the above formulation is, in most 23.2 Septic miscarriage
countries, far more expensive than a progestagen-only
contraceptive pill. The amount of norethisterone in the
progestagen-only pill is 0·35mg. It is financially far more If there is fever and pus discharging from the cervix after
feasible for women to use this instead of the special an incomplete miscarriage, the products of conception
norethisterone tablet: if used for endometriosis have almost certainly become infected. This can follow a
28 tablets (a whole monthly packet) are needed per day neglected spontaneous miscarriage, or it can follow
(in divided doses). unskilled interference. It is nearly impossible to prove
which of the two is the case unless you find a perforation
In a young woman who complains of infertility, or foreign body.
menstrual irregularity, and chronic pelvic discomfort,
TUBERCULOSIS (16.1) is a possibility. N.B. In some cultures it is dangerous for the woman if
you document ‘criminal abortion’ in the notes. If women
If there is chronic PID and the woman is worried about know that going to the hospital might result in prison, they
PAIN but is not worried about having any more will not come or arrive much too late. If a woman is
children, unilateral or bilateral salpingectomy without brought by the police or angry members of her family for
hysterectomy is usually possible but this is difficult, you to examine her, judge carefully where your
so don't attempt it unless you have considerable operative professional duties lie. Note that it is virtually impossible
experience, because the trouble with complications will be to collect water-tight proof of criminal interference as long
greater than the pain she had before! as she denies this. Remember you are not the judge!
Most of the time you can only state that a pregnancy was
there but is now lost.
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Repair the uterus with a single layer of interrupted sutures HISTORY. A careful history and examination will nearly
(21.17), and perform a tubal ligation if there is a complete always reveal some obvious cause.
family anyway. If the tissues do not hold, try to plug the
laceration with omentum, if there is minimal bleeding. ONSET “When did the bleeding start?” “For how many
Otherwise you may be forced to perform a hysterectomy days do you bleed and when?” “Are you bleeding now?”
(23.15). Look for any structures, especially small bowel, “Were you bleeding last week? Last month?”
which may have been damaged in the perforation.
N.B. The treatment of an accidental perforation of a Ask the woman to describe the bleeding pattern by giving
non-pregnant uterus or a small perforation in the midline approximate dates and amounts. Make sure the patient
of a uterus without infected products is different (23.4). distinguishes blood escaping vaginally, from blood in the
urine. If she sometimes does not bleed at all for a week or
If septicaemia develops, treat vigorously with IV fluids, so, a malignancy is unlikely.
broad-spectrum antibiotics, and oxygen. Correct the CAUTION!
acidosis and support the ventilation. (1);Avoid labels like 'polymenorrhoea', 'menorrhagia'
‘metrorrhagia’ etc. because they are too vague.
If you feel crepitations in the tissues, (2);Ask about post-coital bleeding.
suspect GAS GANGRENE (6.24).
EXAMINATION. Is there anaemia? Examine the pelvic
abdomen bimanually. Examine the cervix with a
speculum.
23.3 Abnormal and dysfunctional DIAGNOSE DUB by exclusion, and remember that a
uterine bleeding (DUB) D&C is not automatic treatment for all forms of uterine
bleeding. Exclude:
Abnormal uterine bleeding includes any bleeding which is (1) Chronic PID (23.1), vaginitis (due to foreign body,
abnormal in its degree and timing. Dysfunctional uterine chlamydia, trichomonas, or atrophic menopausal change),
bleeding (DUB) is irregular, heavy or long-lasting cervicitis & cervical ectopy
bleeding not related to infection, pregnancy, medication or (2) Miscarriage (20.2), ectopic gestation (20.6),
neoplasm. (3) Contraceptive medication, devices or hormone
In low-resource countries, abnormal uterine bleeding treatment,
usually has some obvious pathology. The list of its (4) Fibroids (23.7), cervical or intra-uterine prolapsing
possible causes is a long one and is given below. polyp (23-8),
Only diagnose DUB after you have excluded obvious (5) Ovarian cysts and tumours (23.9),
pathology. DUB occurs most commonly at the extremes of (6) Cervical or endometrial carcinoma (23.8),
reproductive life, in young girls not long after menarche, (7) Gestational trophoblastic disease (23.10).
and in older women nearing the menopause, (8) Tuberculosis (16.1)
before complete amenorrhoea sets in. DUB should be an
uncommon diagnosis in the prime of life; if you make it At age <10yrs, there is probably a foreign body in situ.
often, you are probably misdiagnosing miscarriages, At age <20yrs, this is probably truly DUB.
Chlamydia and Trichomonas infections, cervical cancer, At age 20-40yrs, there may be any of the pathology listed
submucosal fibroids, or chronic ectopic gestation. above. Don't miss carcinoma of the cervix. If there is
inter-menstrual or post-coital bleeding, be sure to take a
The commonest cause of DUB is the failure to ovulate. biopsy of any hard, friable, or ulcerated area on the cervix.
Because ovulation does not occur in the middle of a cycle NB. A D&C will not diagnose carcinoma of the cervix
as it should, the corpus luteum does not develop and nor will a Papanicolau (Pap) smear (23.8); you can almost
produce progesterone normally. The endometrium grows always diagnose carcinoma advanced enough to bleed by
abnormally thick under the influence of unopposed looking at the cervix with a speculum and taking a biopsy.
oestrogen, and eventually begins to shed unevenly. In early pre-malignant cases you need to inspect it with 4%
Courses of progestagen stop bleeding temporarily, acetic acid. However, if you need acetic acid to see if there
and when these are stopped normal periods usually follow. is something wrong with the cervix then the bleeding is not
caused by carcinoma in the visible part of the cervix, but
The important diseases not to miss are carcinoma of the there might coincidentally be a very early carcinoma, or
cervix (very common), and, usually in women >35yrs, one situated in the cervical canal or endometrium.
mostly post-menopausal, carcinoma of the endometrium. At age >40yrs, and especially if there is postmenopausal
The investigation of abnormal bleeding often requires bleeding (bleeding ≥1yr after the menopause),
intervention, but you may have to limit yourself to priority always inspect the cervix, and if normal, do a suction
cases. These are inter-menstrual bleeding, and especially curettage to exclude carcinoma of the endometrium.
post-coital bleeding, which does not have some more Other common causes include fibroids, especially
obvious cause. Heavy regular periods are a common prolapsed submucosal fibroids (23-7), and atrophic
complaint, and are usually benign but may result in severe vaginitis.
anaemia.
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If the uterus is retroverted (flexed backwards), it may be If you split the tight vagina of a post-menopausal
held in place by adhesions. If a bimanual examination woman with a speculum, suture it, especially if it bleeds.
shows that it is fixed, abandon the operation unless a D&C
is essential. Then put the vulsellum on the posterior lip of LATE DIFFICULTIES WITH A 'D&C’
the cervix and pull it well down; pass the dilators with
their points backwards. If, postoperatively, there is pain on one side and a
CAUTION! If you tear the adhesions that are holding swelling in the broad ligament, a haematoma has formed.
the uterus, she may bleed into the pouch of Douglas, Occasionally, it may be so severe as to raise the
or into the peritoneum. You may then have to open the peritoneum of the side wall of the pelvis, and extend even
abdomen to secure haemostasis. to the loin. If so, she will have the signs of a mass and of
hypovolaemia: hopefully volume replacement will suffice
If the cervix is so rigid that the larger dilators will not to stabilise her. Otherwise perform a laparotomy to secure
pass without the risk of causing tearing, leave one dilator haemostasis, which is very difficult in that area.
in place for several minutes, before introducing the next Try compression of the broad ligament for a full 15mins,
one. If a dilator is tightly gripped as you remove it, reinsert before you start looking for a bleeding point. If this fails,
it and leave it in a little longer before inserting the next put in packs of large gauzes to maintain the compression:
largest size. A nulliparous or old person’s cervix is often when you remove them the following day, bleeding has
stiff. Don't use excessive force. You can usually do an usually stopped or is readily controllable.
adequate suction or curettage with a small, sharp curette,
even if the cervical canal is only dilated to Hegar 6 (Ch20). If symptoms of low abdominal pain and fever ensue,
suspect salpingitis (23.1).
If larger dilators do not pass as far as smaller ones, you
are inserting successive dilators a progressively shorter If peritonitis develops: either
distance into the uterus. If you fail to realize what you are (1);there has probably been bleeding into the peritoneal
doing, you may only curette the cervical canal, and not the cavity after a perforation,
body of the uterus. Return to the smaller dilators, and start (2);you have missed an ectopic gestation and ruptured it
again. with your D&C,
(3) there is severe PID,
(4) there is iatrogenic bowel perforation, or
(5) there is a non-gynaecological cause.
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MARSUPIALIZING A BARTHOLIN’S
CYST. (GRADE 1.3)
Ask your assistant to immobilize the cyst
with sponges on forceps. Make a longitudinal
incision, with extensions at either end, in the
margin between the pink vaginal and vulval
skin, on the inside of the labium minus Fig. 23-5 MARSUPIALIZING A BARTHOLIN'S CYST.
(23-5). Let the fluid escape. Apply Allis forceps on the A, the cyst. B, the incision with its extensions. C, opening out the
edges of the labium minus, and retract them laterally. cyst. D, the first sutures. E, sutures almost complete.
If necessary, push the cyst forwards by putting a finger
behind it. Use interrupted absorbable sutures to tie the Place the balloon within the abscess cavity and inflate the
edges of the cyst wall to the skin, and to stop bleeding. balloon with a few ml of water. Tie a knot very tightly
round the catheter and cut excess tubing off so that the
DRAINING A BARTHOLIN’S ABSCESS. (GRADE 1.3) balloon, still inflated, remains in the cavity. Leave it there
Insert a small amount of LA subcutaneously; then open the for 7-10days; if it hasn’t fallen out on its own by then,
abscess with a stab incision to allow pus to drain. remove it after deflating the balloon.
Cut the end of the smallest Foley catheter available
carefully and introduce it (with the balloon deflated)
through the stab wound you have made.
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In some communities prolapse of the mucosa of the Fibroids, or myomata, are uncommon in young,
urethra is common in young black girls between 6months but common in older, particularly black, women.
and 8yrs. It usually causes no symptoms, but a child may There is also certainly a relation between low parity plus
have slight dysuria, or the mother may notice blood on the not having used hormonal contraception and fibroids;
clothes. While most of the urethra remains in its normal women with blocked tubes, women with infertile
place, its mucosa is gradually extruded at the external husbands, nuns, women sterilised at a young age, and
orifice to form a deep red or bluish tubular mass, which women postponing their first pregnancy till they are
swells and becomes oedematous, and occasionally even >35yrs have fibroids more often.
gangrenous. You cannot replace the prolapsed urethral
mucosa. Distinguish it from a schistosomal granuloma, a They present with: (1) Infertility or subfertility.
urethral caruncle (23.17), a wart, or a sarcoma. (2) Recurrent miscarriage.
Treat it with oestrogen creams. Only operate if this fails; (3) Abnormal bleeding.
don’t do so just to appease the mother. (4) An abdominal swelling.
(5).Lower abdominal pain, usually
pre-menstrual or more rarely, acute,
if a pedunculated fibroid twists.
(6).An intra-vaginal mass if a
pedunculated fibroid prolapses
(23-7). The cervix dilates to allow it
to pass, and remains partly dilated
around it.
(7).Chronic infection similar to PID
where the fibroid has degenerated
and itself becomes septic.
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INDICATIONS.
A woman with fibroids who wants children.
N.B. Fibroids may be the result of infertility rather than
its cause. Myomectomy is hazardous, and has more
complications than hysterectomy. Most patients are better
with a hysterectomy (subtotal if necessary), or with no
surgery at all.
If you are inexperienced, don't attempt it unless there is:
(1) A single fibroid <10cm in diameter.
(2);A fibroid which is subserous (pedunculated into the
peritoneal cavity), or submucous (pedunculated into the
uterine cavity, and coming through the cervix into the
Fig. 23-7 UTERINE FIBROIDS. A, sites of uterine fibroids: vagina: 23-7).
(1) intramural. (2) subserous, distorting the tube. (3) submucous.
(4) subserous and pedunculated. (5) intra-cavity (6) prolapsing
percervical. (7) parametrial. B, a submucous fibroid polyp has
CONTRAINDICATIONS.
brought the fundus of the uterus down with it. C, the correct site for (1) Active sepsis.
incision. First, incise the fibroid longitudinally (Y) to find the level of (2);Dense adhesions of both tubes which make pregnancy
its pseudo-capsule. Then cut or twist off and transfix the pedicle anyway impossible.
transversely just above (Z), with no danger of entering the peritoneal
cavity. N.B. Don't incise at level X!
(3);A large posterior fibroid in the pouch of Douglas.
Leave it unless you are an expert: removing this without
INDICATIONS FOR SURGERY. damaging the bowel or ureters is difficult, and can be
bloody.
The rate at which a fibroid grows varies greatly.
If it causes no symptoms, leave it alone unless it is the size METHOD FOR INTRAMURAL FIBROIDS.
of ≥12wk pregnancy. At this size it will probably cause
symptoms, so if the family is complete, recommend Bleeding is the great danger: cross-match 2 units of blood.
hysterectomy. Use tourniquets to prevent bleeding. Wind a rubber sling
The indications for removing a fibroid depend more on around the uterus, and push it down as far as you can in the
symptoms (bleeding, anaemia, and premenstrual pain) than direction of the bladder; do not encircle the Fallopian
on its size. Many patients don't need surgery, especially tubes and ovaries, making sure they stay above the
when menopause is a few years off because the fibroids tourniquet. Pull the rubber sling (or Foley catheter) tight
then stop growing or even reduce in size. and fix its tension by applying a clamp across both ends
If the woman is older and does not want children, just above the bladder.
consider performing a total hysterectomy (23.15). Make an incision over the fibroid which exceeds its
If the uterus and the mass seem fixed and tender, diameter by 2-3cm. The correct plane to remove it in may
and especially if there is fever, this is more likely to be not be easy to find. Cut into the fibroid and you should see
PID, with or without fibroids. Treat with antibiotics first, it. Shell it out. If necessary, remove some of the wall of the
and reassess in 3-4wks. uterus to reduce the size of the dead space.
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Be very careful not to remove too much normal uterus; If there is a large fibroid prolapsing through the
if you have to repair the outer layer of the uterus under dilated cervix, define it as well as you can with your
tension, the sutures will cut through. fingers first and then twist it by rotating it with 2 vulsellum
See if you can remove more fibroids through the same forceps in the same direction till it comes loose and then
incision; grasp a small fibroid with a towel clip or remove it vaginally. If it does not yet prolapse through the
vulsellum forceps to make it easier to remove and extract cervix, you can soften the cervix by inserting 600μg
from surrounding tissues. Try to prevent incisions in the misoprostol PV; wait ≥ 4hrs and then grasp the fibroid and
lower posterior wall of the uterus. Dense adhesions fixing twist it.
the adnexa and the uterus in the pouch of Douglas can N.B. Chronic bleeding may result in severe anaemia,
easily result: there is then little chance of pregnancy and so use iron medication but rarely blood transfusion
frequent dyspareunia pre-operatively. If there is post-operative bleeding, pack
the vagina. The alternative is a hysterectomy, but don’t do
Repair the uterus with at least 2 rows of #1 absorbable this till you have administered antibiotics.
mattress sutures Remove the catheter and sling. If the
uterine incisions bleed, insert more mattress or Z-sutures. DIFFICULTIES WITH FIBROIDS
N.B. Bleeding in the uterine wall will always stop once
the pressure within the wall becomes great enough. If the fibroid is painful, either spontaneously or on
palpation, with perhaps mild fever, this is due to aseptic
Close the abdomen without drainage. Make sure the necrosis (red degeneration), or associated torsion of a
patient knows what you have removed, and understands pedunculated fibroid.
that she must nearly always have an elective Caesarean
Section for a subsequent pregnancy: these are usually If you discover a small submucous fibroid when you are
elderly women and their last chance of pregnancy must not doing a D&C for abnormal vaginal bleeding, you may be
end in uterine rupture and foetal death! able to twist it off with the curette or ovum forceps.
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Some women are not able to conquer the initial DIFFERENTIAL DIAGNOSIS includes a simple cervical
infection of HPV which then becomes chronic, ectopy, a cervical or endometrial polyp, a submucous
changes her DNA and can cause cancer after many years. fibroid, various stages of miscarriage, irregular bleeding
Smoking, pregnancy, HIV infection, and probably near the menopause, carcinoma of the endometrium, senile
malnutrition inhibit the ability to overcome HPV. vaginitis, urethral caruncle (23.17), syphilis and a
There are now vaccines against the most common subtypes tuberculous or schistosomal granuloma.
of HPV which could have a dramatic impact on the N.B. this last may look exactly like cancer!
incidence of cervical carcinoma if given to girls (and boys,
so they don’t spread the virus) before they are sexually Suggesting carcinoma: the lesion feels hard, it is friable
active. Tragically this vaccine is too expensive for (bits break off easily), a raised edge, you can feel it
widespread use in many low-income settings. rectally extending into her parametrium.
The premalignant phases of cervical cancer can be If an acetic acid test is suspicious, freeze it with the help of
identified in a woman without symptoms by examining a liquid CO₂ (available via cool drink producers).
smear of cervical cells on a slide: a Pap smear. This will cure 80-90% of patients (with some innocent
N.B. Pap smears are nearly impossible in the presence over-treatment). Nurses can easily learn to do this.
of cervical bleeding! Otherwise you need to take an excisional cone biopsy,
but this is not feasible if your patient cannot return for
Unfortunately, a screening program needs good follow-up, pay for pathologist fees etc.
laboratories and a system to recall and monitor patients N.B. D&C is not necessary for investigating carcinoma
with abnormal cells. A cheap and effective screening of the cervix. This does occasionally reveal carcinoma of
method is to apply Lugol’s iodine or 4% acetic acid to the the body of the uterus or of the endocervix. Invasion of the
cervix and examine it after 1min. Look for the squamo- body of the uterus by a carcinoma of the cervix is not one
columnar junction, where the outer pink squamous and of the staging criteria for this tumour. Officially, staging
inner reddish columnar lining of the cervix meet. includes a cystoscopy but staging is usually quite possible
The presence of dense, opaque, well-defined ‘aceto-white’ without it.
lesions or growths here is highly suggestive of a pre-
malignant lesion (severe dysplasia). If this is present, STAGING AND MANAGEMENT
a cone biopsy would prevent this lesion becoming If you suspect the carcinoma is in one of the earlier stages,
malignant (see below). However, carcinoma is usually with some hope of cure or palliation, take care to stage the
recognized later by an irregular, ulcerative lesion of the disease under GA in the lithotomy position.
cervix, which bleeds easily. Cervical carcinoma is less Use a speculum to inspect the vagina for Stage IIA or III
common in those who use condoms, so encourage patients disease and for fistulae. Do a rectal examination to assess
with multiple sexual partners, or those with partners, spread beyond the uterus. Do a vaginal examination at the
who themselves have multiple partners, to use them. same time, and feel the rectovaginal septum between your
fingers.
DIAGNOSIS. Take a careful history and establish
the timing and appearance of the bleeding; If there is an advanced lesion, an examination under GA
a patient may confuse vaginal bleeding with haematuria. is unnecessary, and is possible as an outpatient if you are
Examine the abdomen, and the groins. Examine the vagina gentle, and remove a small piece of tissue for histology.
and cervix first digitally, then with a speculum using a You may however need to suggest admission on social
good light source. Perform a rectal examination and a grounds, especially if home is far away, but beware if you
bimanual examination of the pelvic organs. are dealing with terminal disease. Death in your hospital
Do all this as an outpatient procedure. You may see: might result in very steep transport costs for the family,
(1);An ulcer on the cervix, often extending into one or and no improvement to your reputation. Death caused by
more fornices. cervical carcinoma is usually not accompanied by pain.
(2);A cervical polyp (less common). It is mostly caused by uremia or blood loss. Arrange that
(3);An enlarged barrel-shaped cervix which may look there is access to analgesia/sedatives if needed.
relatively normal.
(4);Erosion into the bladder or rectum causing a Stage 0, carcinoma in situ. This is a histological
vesico-vaginal or recto-vaginal fistula. diagnosis, made from either a cone (or wedge) biopsy,
N.B. In all these situations, take a biopsy if you are or a +ve Pap smear. The cells look malignant, but have not
unsure of the diagnosis. A Pap smear is for lesions yet invaded the surrounding tissue, and may not do so for
invisible to the naked eye. many years, if ever. Freezing (cryosurgery, see above) or
cone biopsy (see below) is curative at this stage.
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Stage IIA. The tumour extends out from the cervix into
the upper vagina or uterus, but not into the parametrium.
Stage IIa is uncommon because progress to stage IIB is so
rapid. Manage as for stage I. There may be a 50% 5yr
survival. Radical, but not simple, hysterectomy is of some
value. Try to arrange radiotherapy for all cases of stages II
& III.
Stage IIB. The tumour extends into the parametrium but
not as far as the pelvic wall. Radical surgery is impossible,
but radiotherapy may be of benefit. Even if it fails, it is
nonetheless good palliation.
CAUTION!
(1);A Pap smear –ve does not exclude invasive carcinoma,
nor does a +ve smear prove it (there may be carcinoma in
situ, i.e. cells with cancerous changes only within the
surface layer of the cervix which with time can develop
into cancer).
(2);Carcinoma in situ does not cause abnormal bleeding
or other symptoms.
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Incise the normal epithelium c.5mm from the abnormal B. CARCINOMA OF THE ENDOMETRIUM
epithelium, and extend your incision all round the cervix. Endometrial carcinoma occurs mostly in post-menopausal
If you have cutting diathermy, cut (with your cold knife) in women, and presents with vaginal bleeding. The older the
small steps while in every stage of the procedure arresting woman, the larger the chance that vaginal blood loss is a
the haemorrhage. Apply Vulsellum forceps to the lips of sign of malignancy. When disease is advanced, abdominal
the cervix at 12 & 6o’clock positions. pain with or without bowel and bladder symptoms
Deepen the incision to remove a cone, with its apex at the dominate.
cervical canal, keeping its edge 3-5mm away from the
abnormal tissue. Use diathermy for haemostasis if STAGING
possible. Leave the raw surface open. Cut the cone open in Do this either after a hysterectomy or pre-operatively when
the 12o’clock position, (23-10E) and send it intact for the disease is very advanced and you note involvement of
histology. the bladder or bowel. If the cervix shows macroscopic
tumour of endometrial carcinoma, the stage is at least IIB.
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Alternatively, especially with a well-differentiated tumour Try to drain very large cysts through a small incision and
(grade 1) where operative cure is not an option, or there is then remove the cysts. The final diagnosis (pathology) will
recurrence, you can stabilize the cancer by high-dose only become clear after the operation.
progestogens, using 150mg medroxyprogesterone acetate
od for 3wks, then weekly for 12wks, then monthly. An ovarian cyst can be of any size, from 1-30cm or more
in diameter, and may:
SURVIVAL (1);Present as a mass, or as abdominal distension, which
The 5yr survival after surgery and radiotherapy worsens may be massive.
for each higher stage: Overall under the best circumstances (2) Cause abdominal pain due to torsion.
all stages combined, the survival is 75%. (3) Be confused with pregnancy.
Recurrences occur mostly in the vaginal vault and can be
temporarily controlled by radiotherapy. Very large cysts, the size of term pregnancies, are usually
benign and cause no pain. Cysts <5cm are usually benign.
Postmenopausal tumours are more often malignant.
Pre-pubertal tumours are usually germ cell malignancies.
23.9 Ovarian cysts & tumours
Before the operation make a malignancy risk assessment.
Many ovarian tumours are cystic, but many cysts are not The most useful diagnostic tool is ultrasound (38.2J).
malignant and some tumours are not cysts. If ascites is already obvious clinically, then most often the
Their classification is complex; this is a simplified scheme. disease has spread through the whole abdomen.
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If the other ovary is also cystic, and the patient is If you are in an endemic area and the patient is
relatively young, perform an ovarian cystectomy, 10-25yrs, remember Burkitt's lymphoma (17.6), which is
unless there is a suspicion of malignancy. Avoid removing often bilateral, or hydatid cyst (15.12).
both ovaries on a woman <40yrs for bilateral benign
tumours (usually dermoids containing hair or teeth).
Remember that operating on a pseudocyst, or a cyst in the
broad ligament, is particularly hazardous, because of
bleeding.
N.B. If you have to remove both ovaries, the cheapest
hormone replacement therapy is the contraceptive pill.
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POSITION.
Lay the patient with a sandbag under the
right buttock. This prevents the supine
hypotensive syndrome, if she lies on her
back.
INCISION.
Make a midline incision. If you hope to
remove the cyst intact, make it ≥5cm longer
than the diameter of the cyst.
If you are not sure if you can remove the
cyst intact with the ovary, or whether this is
really necessary, make the incision just
long enough to examine it properly,
separating such adhesions as you can see,
without too forceful traction on the wound.
If you cannot dissect further safely, enlarge
the incision to see the outline of the cyst and
any adhesions. Aspirating fluid may help
you to deliver it through the abdominal wall,
but seldom helps in dissecting adhesions.
A flabby cyst has an edge which is difficult
Fig. 23-13 REMOVING A LARGE OVARIAN CYST.
to define, so that vital structures, such as the ureter, A, explore the surface of the cyst. B, deliver the cyst without
are more easily cut. If you do decide to aspirate fluid, rupturing it. C, clamp and divide the pedicle. D, transfix the pedicle.
use a powerful sucker attached to some tubing you can E, tie the pedicle in halves. F, apply the encircling ligature.
secure to the cyst wall; don't contaminate the operation After Bonney V. Gynaecological Surgery, Baillière 1964 Figs 4.29-34
with kind permission.
site with the fluid you have aspirated!
OVARIAN CYSTECTOMY (GRADE 3.2): this removes
CAUTION: A wound which is too small is dangerous
the cyst but leaves behind the tissue of the ovary.
because you cannot dissect safely, and you are obliged to
exert excessive traction. A large wound is more likely to
INDICATIONS.
dehisce or give rise to other complications.
(1);The patient is <40yrs, and the other ovary is also
Remove the cyst by clamping its pedicle (23-13).
damaged.
Be careful not to pull it so hard that you tear this.
(2) The cyst is >5cm.
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(3);The cyst must be benign, a reasonable amount of CAUTION! It is safer to leave a little cyst wall on the
normal ovarian tissue should be present. bowel or the bladder, than to remove a little bowel or
N.B. If the cystic ovary is the only remaining one, bladder with the cyst wall. There may be many of these
it is not important if its tube is intact or not. cystic collections; just aspirate them rather than trying to
The patient needs its endocrine function, regardless of remove them all.
possible fertility. You may be able to shell out even quite If the cyst is not freely mobile, but seems to be embedded
large cysts, and retain some ovarian tissue. The cyst lies in in the broad ligament, it may be arising from the remains
the substance of the ovary and is covered by the ovarian of the Wolffian duct. Removing it may be difficult.
capsule. It may be stuck to the broad ligament, or inside it.
N.B. Don’t remove an ovarian cyst early in pregnancy: The distinction is usually unimportant. If it is inside the
the corpus luteum needed for its progesterone to prevent ligament:
miscarriage may be in that cyst or ovary! (1);Be sure to avoid the ureter, which may run anywhere
over the cyst.
INCISION. (2) Don't damage the venous plexuses in this region.
Make a midline or Pfannenstiel incision. Cut around the Study the anatomy carefully before you start.
edge of the cyst, well away from the remaining mass of the If the cyst does not shell out easily, and extends down
normal ovary. Using scissors or fingers, dissect between close to the ureter, you would be wise to remove as much
the cyst and the ovarian tissue. Control bleeding with 2/0 as you can, and leave the remains open to the peritoneal
absorbable, and close the outer layer of the ovary with cavity (marsupialization). Take a biopsy to exclude
continuous locking sutures. Cover any raw surfaces with malignancy.
omentum, to avoid adhesions. If you can define the cyst clearly by finger dissection,
and are able to push the ureter out of the way, you may be
SALPINGO-OOPHORECTOMY (ADNEXECTOMY) able to remove it completely. It is covered by peritoneum
(GRADE 3.3): this removes both Fallopian tube and ovary. which you need to dissect off. Divide the round ligament
on the same side, to open up the broad ligament.
INDICATIONS. Then dissect off the peritoneum posteriorly, until you
(1);Both tube & ovary have been affected by torsion, reach the ovarian vessels in the infundibulo-pelvic
bleeding, or infection. ligament. Tie them. Then dissect anteriorly and medially,
(2) A possibility of malignancy. and divide the tube and ovarian ligament close to the
(3) Extensive adhesions between tube and ovary. uterus. Finally, slowly and carefully dissect the cyst from
(4);Combined with a hysterectomy in a woman >50yrs the posterior leaf of the broad ligament, so as to avoid the
(usually means a bilateral adnexectomy). ureter.
N.B. The tube and ovary receive their blood from If the infundibulo-pelvic ligament is grossly thickened,
2 sources which anastomose with one another, the ovarian so that the ovarian vessels are difficult to distinguish from
vessels in the infundibulo-pelvic ligament and the the ureter, open up the peritoneal tissues lateral to them,
ascending branches of the uterine vessels (21-18, 22-14, and extend the incision towards the pelvic brim. Grasp the
23-20, 23-21). ovarian vessels and draw them medially. You will then see
. the ureter attached to the peritoneum, crossing the
INCISION. common iliac artery.
Make a midline or Pfannenstiel incision. Carefully divide
any adhesions between the ovary and broad ligament, DIFFICULTIES WITH GIANT OVARIAN CYSTS
approaching them from below and behind. Raise the tube If the patient develops cardiac failure, which may be
and ovary, find the infundibulo-pelvic ligament, and delayed for a day or two postoperatively, treat her with a
identify the ureter, so that you can avoid it. Clamp, divide, diuretic.
and tie the ovarian vessels in the infundibulo-pelvic
ligament. Clamp, divide, and tie the ovarian ligament. If the patient develops respiratory failure,
Clamp, divide, and tie the tube. due to the paradoxical movement of the diaphragm,
CAUTION! Be sure not to tie the ureter. This is not a which is lax and overstretched, now that the cyst has been
problem if the structures are mobile. But if there are removed, treat her with oxygen and sit her up.
adhesions, and especially if the ovary and tube have stuck
to the back of the broad ligament, be sure to identify and If the abdomen distends postoperatively, it is probably
mobilize them before you resect them. due to ileus. Mobilise the patient and if this fails, insert a
nasogastric tube for 1-2days and infuse IV fluids till bowel
DIFFICULTIES WITH OVARIAN CYSTS function returns.
If there are EXTENSIVE ADHESIONS, this may be a
post-inflammatory cyst. Don't try to deliver the tumour If the abdomen is abnormally lax, apply an efficient
until you have divided the adhesions, or you may lacerate binder postoperatively.
the bowel or tear large veins. Separate them using your CAUTION! Don't be tempted to resect any redundant
hands, swabs, or scissors (not a scalpel!). Gently pass your abdominal wall. This will make the operation much more
hand between the cyst wall and the floor of the pelvis. extensive and bloody. Abdominal compartment syndrome
Don't mistake the parietal peritoneum for the cyst wall. may result (11.10).
Don't tie off any colon when you tie off adhesions.
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PRESENTATION
Commonly <20 or >40yrs, usually presenting before
18wks gestation with:
(1).Rapid enlargement of the uterus, which feels
abnormally soft.
(2) Excessive nausea and vomiting.
(3) Vaginal bleeding which starts at the 6th-8th wk.
(4) Passage of vesicles though the cervix.
(5) Enlarged often palpable cystic ovaries (50%).
(6) Signs of gestational hypertension.
(7) Hyperthyroidism (occasionally).
or any combination of these signs.
If gestation exceeds 18wks, also the inability to palpate
fetal parts and the lack of perceived fetal movements
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You should be able to empty, change, and reconnect the A modern urine test is just +ve with 25mIU/ml
bottle fast or have 2 excellent suction machines in theatre. (check the leaflet in the box). This means that if the test is
N.B. This procedure can be done slickly (emptying the just +ve and you have collected 1½l of urine, there are
uterus in 30secs), but it can also become a disaster if you 37·5IU in a 24-hr collection. If x10 dilution is just +ve,
have not checked the equipment! there are 375IU present.
CAUTION! Take great care not to perforate the uterus.
You must insist on a reliable form of family planning
If you think that evacuation is incomplete, method for a year. If the husband cannot be relied on to
or if bleeding continues slightly, accept this, and repeat use a condom (unfortunately usual), either insert an IUD,
the curettage in 3days. Torrential bleeding can occur, even though its side effects may be confused with
so have 2 units of blood available, but don’t transfuse choriocarcinoma, or use depo-provera.
unless forced to do so. Suspect a trophoblastic neoplasm if during follow up:
After you have evacuated the uterus, you may feel cystic (1) dark vaginal bleeding continues,
ovaries: leave them alone. Repeat the evacuation if there is (2) the uterus remains large after evacuation or delivery,
still bleeding after 7-10days. (3);you see a haemorrhagic nodule near the urethral
meatus, vaginal vault or cervix,
If you still cannot control the bleeding, take the patient (4) amenorrhoea continues.
to theatre to apply a B-Lynch suture (22-3). This will stop Establish the diagnosis by ultrasound and by measuring
most bleeding and not interfere with a pregnancy later. serial β-HCG levels as above.
If even then, bleeding persists, tie a tourniquet round the B. INVASIVE TROPHOBLASTIC NEOPLASM
base of the uterus (as for a myomectomy: 23.7) and leave (INVASIVE MOLE)
it for 12-24hrs. Then re-open the abdomen to remove the
dead uterus; this transforms a horrendous procedure into DIAGNOSIS.
an easy one! A titre of β-HCG of >200IU in a 24hr specimen after
N.B. Avoid a hysterectomy without the tourniquet as the 2-3months, or a rising or unimproved titre after 2months is
GTD may have invaded the large vessels. During a abnormal.
hysterectomy clamps and sutures will cut through and you Look for absence of metastatic disease in the vagina,
might be unable to stop the haemorrhage. pelvis, liver, brain, and chest (23-14A).
The differential diagnosis includes the incomplete
FOLLOW UP is essential to identify those patients evacuation of a normal placenta, placenta accreta,
(up to 20%) who need cytotoxic drugs. However, >98% of or ectopic gestation.
women who become pregnant following a cured molar If you make the diagnosis within 4months of delivery you
conception will not have a further GTD and these have a 95% chance of cure.
pregnancies are at no increased risk of other obstetric Treat with oral methotrexate 15mg/m2 od in courses of
complications. You can follow the expected drop in 4days. Repeat the courses every 14days for 2 courses after
β-HCG by routine urinary pregnancy tests. If a routine the β-HCG is normal, to a maximum of 6 courses.
modern monoclonal sensitive pregnancy test is -ve If the β-HCG is still >2,000IU/24hrs, after 6 courses of
(can take 2-3months) then the trophoblastic disease has methotrexate, start actinomycin D 2mg/m2 (or 1mg on
most likely virtually disappeared. You should however days 1 & 3), one course every 3wks. Repeat this every
repeat it then 2wkly for 3months (while the patient is using 3wks for 2 courses after the β-HCG test is -ve.
proper contraception) and then monthly for 1yr. If it is still If the β-HCG test remains +ve, start therapy,
-ve you can consider her cured. She can stop contraception as for choriocarcinoma (see below).
if she wants, and become pregnant.
C. METASTASIZING TROPHOBLASTIC NEOPLASM
If the pregnancy test stays +ve then try a 2 suction nd (CHORIOCARCINOMA)
evacuation carefully (even if an ultrasound scan indicates a
normal empty uterus) and send the material for histology. PRESENTATION.
If after that, the pregnancy test stays +ve, it is then time for (1).A history of heavy irregular bleeding, sometimes
a work-up (chest radiograph, ultrasound of uterus, kidneys following a miscarriage, especially with the need for
liver, laboratory) and a quantitative β-HCG test because repeated evacuation, particularly if an embryo was never
the patient will probably need chemotherapy. seen by ultrasound or within the evacuated material.
You need a baseline β-HCG level to see later how (2) Persistent amenorrhoea following GTD.
successful the chemotherapy is. The β-HCG value should (3) A haemorrhagic nodule on the urethral meatus, vaginal
preferably be reduced by ≥90% after every course. vault or cervix.
Commercial kits measuring the quantity of β-HCG in (4) Cough, chest pain, ‘unresolved pneumonia’ or a bloody
serum are easiest but expensive. You could try pregnancy pleural effusion.
tests on serial dilutions of a 24hr-urine specimen (5).An acute haemoperitoneum like a ruptured ectopic
(keeping it cool during collection to detect the greatest gestation, due to perforation of the uterus by the tumour.
dilution showing a +ve result. This is an inexpensive way (6) Neurological symptoms.
of doing a quantitative test, and although it is not ideal, (7) Gastro-intestinal bleeding.
you have to do it carefully. (8) Haematuria.
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CHEST RADIOGRAPHS may show round metastases. Childbirth may so injure the pelvic organs that the uterus,
CAUTION! If the choriocarcinoma arose from a the bladder, or the rectum may prolapse, either singly, or
hydatidiform mole, you will already have evacuated it. in combination. In nullipara, it also occurs after the
menopause. There are large regional differences in the
If it presented in other ways, don’t do a diagnostic prevalence of prolapse, most likely related to the quality of
curettage, because: the ligaments.
(1) A ‘negative’ one does not exclude the diagnosis. In Southern Africa prolapse is rare but stress incontinence
(2) You can easily perforate the uterus, or cause even more so, possibly related to the ubiquitous use of the
catastrophic bleeding. squatting position, which strengthens pelvic floor muscles.
(3) You may spread the tumour. Women working on the land with long skirts can easily
squat frequently and keep their bladder content small.
PROGNOSIS. All untreated patients die from multiple Travelling long distances in buses or taxis might become
metastases. Try to diagnose this disease early. You may, embarrassing; this also applies to shopping in
if you cannot refer to a special centre, treat ‘low risk’ circumstances where there are few toilets for clients.
patients, but do not attempt to treat ‘high risk’ patients However absorbent ‘Makapads’ can be made from dried
who need different complicated expensive chemotherapy: crushed raw papyrus processed into a thick paste with
waste paper and water, cut to size and placed in absorbent
1. Index pregnancy was a mole or inserts.
(Makapads from t4tafrica.co, PO Box 21049, Kampala, Uganda)
Low risk, after miscarriage.
normalisation of 2. Metastases only in vagina or lungs.
β-HCG, 2 more 3. No previous chemotherapy.
courses 4. Interval between evacuation &
chemotherapy <12months.
1. Insufficient success with
previously administered
chemotherapy.
2. Metastases in >1 organ outside the
High risk, after
uterus.
normalisation of
3. Metastases in one of: liver, spleen,
β-HCG, 3 more
kidney, GI tract, brain, bones.
courses
4. Index pregnancy was a term
delivery.
5. Interval between evacuation &
chemotherapy >12months.
Repeat the courses every 14 days (i.e. start day 15) as long
as the β-HCG decreases by a factor of 10 by every course;
repeat 2 more courses after a sensitive β-HCG test is
negative.
If this is unsuccessful, and if β-HCG (in blood) is <100IU,
use:
Actinomycin D 0·5mg IV day 1,3,5,7
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If the bladder or urethra prolapse as a cystocoele, It will resume its ring shape and take up a position in the
perform an anterior colporrhaphy (23.13). coronal plane. If a 70mm pessary falls out, try a larger size
If the rectum prolapses as a rectocoele, perform a in 5-10mm intervals. If it feels very tight and
posterior colporrhaphy (23.14). uncomfortable, so that the patient cannot pass urine, try a
If the uterus prolapses arrange a Manchester repair smaller size. Let her walk around, drink a lot, go to the
(23.12) if it is to be left in situ, or a vaginal hysterectomy toilet and return in c.1hr to see if it is likely to be
if it is to be removed. A simpler alternative is a satisfactory. She should not feel it, and be able to pass
ventrisuspension (23.12). urine. Make her also strain hard (when standing) to see if it
N.B. A vaginal hysterectomy, when the uterus is comes out. Many women can learn to remove it and
completely prolapsed out of the vagina, is much easier replace it themselves: it is not difficult and only needs
than an abdominal hysterectomy: the uterine arteries are some explanation/encouragement.
far away from the ureters, so you can readily ligate them Teach the old ladies how to remove and insert it:
and amputate the vagina. it is probably better off for sexual intercourse and most
If there is ulceration of the prolapsed uterus, apply women do not need it at night anyway. This will help in
oestrogen cream: (you can make this up by crushing reducing discharge and ulceration. Also sometimes the
tablets in vaseline). ring comes off (e.g. after defecation), so it is helpful if a
woman can wash and replace it herself rather than visiting
MARY, 80yrs, complained that her husband was accusing her of having
hospital just for this.
given him an STI, because he was having pain in passing his urine.
She wanted a letter she could take to the court saying that she was free of Review her in 3months; if all is well then, review annually
any STI. On examination the uterus was grossly prolapsed, ulcerated and and ask if the pessary is comfortable. Ideally, she needs a
stinking, but she had no evidence of any STI. A Manchester repair cured new silicone pessary each year. This may become
her completely. LESSON Patients’ diagnosis are not always correct!
permanently coated with solid material which you cannot
wash off; then replace the pessary.
If the vagina is ulcerated at the annual check-up, leave
the pessary out for 1-2months and apply oestrogen cream
nightly. When the ulcers have healed, insert a smaller
pessary, and review in 3months.
23.12 Ventrisuspension
In this operation the prolapsed uterus is sutured to the
anterior abdominal wall. This relieves both the prolapse,
and the rectocoele or cystocoele, which will probably also
Fig. 23-16 A RING PESSARY is often very acceptable to an older be present. Ventrisuspension alone does not interfere with
patient with moderate prolapse. Choose its size (40-120mm) as you the bladder, the urethra, the rectum, or the vagina.
would a diaphragm, by measuring the depth of the vagina with your
fingers. After Garrey MM. Obstetrics Illustrated Churchill Livingstone It is not difficult, and is a convenient operation if you are
1974, permission requested. inexperienced; it does however sometimes fail.
Aim to make the anterior wall of the uterus, cervix, and
RING PESSARIES FOR PROLAPSE bladder stick to the rectus muscles, and to make the
Many old women prefer to avoid surgery, and can be peritoneum over the bladder, and the anterior wall of the
treated with a pessary. Semi-rigid polythene ring pessaries cervix stick to the back of the pubis, so that there is no
are suitable. If they are comfortable they can be left in chance of bowel herniating between them.
indefinitely and may even not be noticed by the patient.
Menstruation and sexual intercourse can take place as INDICATIONS.
usual (1) Prolapse involving a considerable descent of the uterus.
(2) Prolapse in old postmenopausal patients.
INDICATIONS.
(1);Moderate prolapse especially in an older patient. CONTRA-INDICATIONS.
(2);Weak perineal muscles; they will not hold a pessary A woman who still wants to become pregnant.
and it will keep falling out. If too big a ring is required,
the vaginal wall or cervix may prolapse through. METHOD. (GRADE 2.5)
Open the abdomen through a Pfannenstiel or midline
CONTRA-INDICATIONS. incision, extending well down towards the symphysis
(1) Ulceration of the prolapsed uterus. pubis. The upper limit of the incision will depend on how
far up you can pull up the uterus, when you have examined
METHOD. Choose the size of a ring pessary, as you it. Separate the uterus and adnexa from any adhesions,
would a diaphragm, by measuring the depth of the vagina bring them into the wound, and examine them.
with your fingers. It will usually be c.70mm. Lubricate it, Identify the peritoneal reflexion of the bladder, so that you
compress it, and insert it like a diaphragm, with the can avoid it. Separate the rectus abdominis muscles from
posterior part behind the cervix, and the anterior part the peritoneum, along their whole length on each side of
behind the symphysis. the wound (23-17C).
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Pass three #2 parallel monofilament sutures through the If the cervix comes down to the vulva, she needs a
outer surface of the rectus sheath on one side, through the Manchester repair (23.12), not just an anterior repair.
rectus muscle, and then out of its bare posterior surface.
Then pass it deeply in and out of the bare area of the If she is postmenopausal, treat her with a course of
anterior wall of the uterus, across into the bare area of the oestradiol cream before operating.
other rectus muscle, and out through the anterior rectus
sheath on the other side. Leave no gap between the uterus If there is a rectocoele, usually accompanied by a
and the anterior abdominal wall. deficient perineum, repair this at the same time.
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ANTERIOR COLPORRHAPHY (GRADE 3.4) Insert a catheter to identify the urethra. Put vulsellum
forceps on the cervix and draw it down. Incise the vaginal
INDICATIONS. Prolapse of the anterior vaginal wall wall covering the cervix about 1∙5cm from the cervical os,
which is troubling, especially if the patient has to push it and continue this laterally for 2cm on each side.
back to micturate, provided there is little or no descent of Undermine the edge away from the cervix, and continue to
the uterus. Preferably wait until childbearing is ended, within 1cm of the urethral orifice, using the 'push and
because a prolapse may recur after pregnancy. spread technique' with scissors (4-9).
PREPARATION. The tissues must be clean before you Cut the wall of the vagina in the midline (23-18A).
operate, so insist on a bath just before surgery. Dissect the vaginal wall away from the underlying tissues
Clear the rectum with an enema. with a combination of blunt and sharp dissection, until you
expose the bulging bladder fully on both sides.
Where possible, use a gauze-wrapped
finger (23-18B). Take great care to
separate the bladder from the vagina
in the lateral part of the flap near the
cervix. Dissection should be almost
bloodless, until you reach the veins
which lie well laterally.
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POSTERIOR COLPORRHAPHY
(GRADE 3.4)
INDICATION.
Prolapse of the posterior vaginal wall,
with little or no descent of the cervix.
Do this at the same time as an anterior
repair, if indicated (23.13).
CONTRA-INDICATIONS &
PREPARATION are as for an anterior
colporrhaphy (23.13).
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23.15 Hysterectomy
You may occasionally need to perform an emergency Fig. 23-20 AVOIDING THE URETER.
A, notice how the ovarian vessels pass in front of the ureter. B, the
hysterectomy if a patient has: ureter passes over the pelvic brim, (i.e. the pelvic inlet at the level of
(1);A ruptured uterus, and repair is impossible the promontory of the sacrum and the pubic symphysis, 23-21C),
(not uncommon). just after the common iliac artery has divided into its internal and
(2) Uncontrollable postpartum haemorrhage. external iliac branches. C, the ureter passes close round the vault of
the vagina under the uterine artery (remember this by ‘water under
N.B. Hysterectomy for a ruptured uterus (21.17) differs the bridge’). D, the relation of the urethra, the trigone of the bladder
in approach from the operation described below. (a smooth surface delimited by the openings of both ureters and the
N.B. If possible, try to refer all elective cases. urethra) and the ureters when you retract the cervix.
They may have disastrous complications, even in the After Garrey MM. Gynaecology Illustrated Churchill Livingstone, 1977,
p.308-9. with kind permission.
hands of experts, and their patients even die occasionally.
So don't perform a hysterectomy, unless you are If you are inexperienced, start by doing a subtotal
experienced. Fibroids may cause disability, operation, particularly if you are operating for fibroids.
but they seldom threaten life. But even this can be difficult, if there are adhesions from
A total hysterectomy removes the entire uterus; chronic PID.
the advantage being that you remove the cervix, which is a
common site for carcinoma. Don't attempt a radical hysterectomy which also removes
A subtotal hysterectomy leaves a stump of cervix behind. the pelvic lymph nodes. It is the only adequate surgical
It is contraindicated if there is any suspicion of carcinoma treatment for carcinoma of the cervix, but this really is a
in either the cervix or the body of the uterus. But it is an task for an expert with services of an expert anaesthetist
easier operation, because you can more easily avoid the and urologist available.
ureters. It may also prevent a vaginal prolapse later, in
populations prone to this complication.
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PREPARATION.
Make sure that consent is signed and
the patient understands that she will
have no more children and no
periods.
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With a Pfannenstiel incision, arrest all the bleeding before Ask your assistant to pull on the clamps, so as to
you enter the abdomen; you might otherwise forget later demonstrate the thin avascular part of the broad ligament
and the result will be an enormous haematoma. more clearly. Push your finger through this thin part near
Open the peritoneum with your finger in the middle of the the uterus, from behind forwards, to make a hole (23-22B).
incision, firstly upwards, so as to avoid the bladder more Do the same on the other side.
easily.
N.B. An improvement on the Pfannenstiel is the Reflect the bladder. Incise the peritoneum on the front of
Joel-Cohen incision. The incision is not curved and the cervix, near to its vesico-cervical reflexion (23-22C).
slightly closer to the umbilicus; the skin (and later the Dissect the bladder off the front of the cervix and upper
rectus sheet) is only incised full thickness transversely for vagina (23-22D,E), until you can feel the tip of the cervix
3-4cm across the midline. The rest of the skin is not (23-22F). This dissection is best done bluntly with your
incised full thickness. With digital blunt dissection, gloved finger or a gauze while your force is exerted in the
the wound is opened further, again after the horizontal direction of the uterus & cervix, not the bladder.
incision of the middle portion of the rectus sheath. If there was a previous Caesarean Section, you often need
The rectus muscle (vertically) and peritoneum are sharp dissection: so cut even into the cervix superficially,
separated/opened with the index finger. The opening in the rather than into the bladder. Feel the cervix from in front
wall is made as large as that in the skin by manual traction and behind. Separate the bladder from the underlying
after the peritoneum is opened (to prevent disrupting tissues somewhat laterally also.
vessels between posterior rectus sheath/peritoneum and Find the ureters. They enter the pelvis at the bifurcation of
rectus muscle). This approach is very fast, works also the iliac vessels. Trace them distally to beyond the tip of
excellently with a Caesarean Section and minimises blood the cervix; recognize them by their feel: they are rather
loss from the abdominal wall. hard, they do not pulsate, and you can roll them between
Exploration is the first step: inspect the pelvic cavity. your finger and thumb (23-20).
If you find an inflammatory lesion, don't proceed to
explore the upper abdomen, because you may spread the CAUTION! Ureters are apt to be easy to find when they
infection. Otherwise, put your left hand into the wound to are in no danger, and almost impossible to find when you
feel the organs in the abdominal cavity quickly and need to find them!
thoroughly. Follow a set pattern: look particularly for
metastases in the liver. If you cannot find the ureters, these steps will protect
Clear the operative field. This is often the most difficult them:
part of the operation. Don't start removing any organs (1);Free the adnexa from adhesions before you remove
until you have cleared the site of operation. them.
Carefully pack the bowel out of the way with large damp (2);Lift the infundibulo-pelvic ligament and find the
packs, attached to a cloth tape, to which a haemostat is ovarian vessels before you clamp them.
fixed. Protect the wound edges with moist gauze, and (3);Very carefully dissect the bladder away from the
insert a 3-blade self-retaining retractor. You can put the cervix, and the adjoining part of the broad ligament.
crossbar towards the head or towards the feet, and use the (4);Cut and mobilize downwards the posterior peritoneal
3rd blade to retract the bladder. Make sure it does not leaf of the broad ligament from the posterior surface of the
compress the caecum, the sigmoid, the small bowel, or the cervix and somewhat beyond, and a tiny bit laterally so
iliac vessels. When necessary, use Deaver's retractor. that it is possible to apply a clamp from lateral just under
Clear any adherent bowel or omentum from the pelvis. the cervix at the last stage of the hysterectomy without
Use blunt dissection to free any loose adhesions between having any peritoneum in the clamp.
the uterus and its surrounding structures: the sigmoid
colon, the ovaries, or the walls of the pelvic cavity. Now deal with the ovaries. You must now decide if you
The tubes and ovaries may be stuck down behind the broad want to retain them or not. If they have multiple large
ligaments; get your fingers under them and free them from cysts, they are better removed, but try to retain at least
below upwards. You may have to divide denser adhesions one ovary if the patient is pre-menopausal, or <5yrs
with scissors, or if you think they are likely to contain post-menopausal. If there are any cysts it is better to
blood vessels, clamp, divide, and tie them. Divide any remove the ovaries in an older postmenopausal woman.
adhesions between the fundus of the bladder and the
fundus of the uterus. To remove an ovary, going lateral to it, but very near it,
If you can deliver the uterus out of the abdomen, clamp its vessels, taking care not to clamp the ureter at the
especially if it is very big, this will help greatly. same time (23-22G). You do not need a counter clamp if
If you restore the proper anatomy first by removing you have already placed clamps on either side of the
adhesions, you are far less likely later to damage ureters, fundus (see above): this makes it possible to ligate very
bladder or bowel. near to the ovary. Otherwise place the other clamp medial
Put clamps on either side of the fundus of the uterus, to the ovary. Divide the ovarian pedicle medial to the
(23-22A) and over the tubes and round ligaments lateral (not the counter) clamp, and tie it with a double
(23-22B). Use them to exert traction, and control arterial transfixion suture using #1 absorbable. Ease and squeeze
bleeding. the clamp while tightening the suture to make sure the
Alternatively, if these structures are friable, use a tissues can be compressed properly by the suture.
myomectomy screw or traction sutures to hold the fundus.
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If you remove the ovary, be sure also to remove the Put the convex side of the clamp near the uterus so that it
Fallopian tube with it. is easier to get the clamp very near it.
If you want to retain an ovary, apply a clamp across the If the bladder is well down and the posterior leaf of the
Fallopian tube and its pedicle, 1cm lateral to the first broad ligament out of the way and the clamp (and suture)
clamp that you applied to these structures near the uterus very near to the uterus, then the ureters should be out of
(23-22H). Divide the tissues between these clamps harm’s way. The clamp is then not on the slippery
(23-22I). Ease and squeeze and then remove the lateral peritoneum. Sometimes it needs 2-3 steps to clamp the
clamp and tie its pedicle as above. Do the same thing on tissues on each side of the uterus. Place the suture 1mm
the other side, removing or retaining the ovary, medial and 1mm distal from the point of the clamp while
as you decide. laterally, tie it c.1cm under the clamp. This will prevent
Define, tie, and divide the lateral end of the round oozing later.
ligament. Do this by pushing your finger under it and tying Complete the task of pushing the bladder down the cervix,
it (23-22J,K). if you have not already done so (23-23A). Blunt dissection
is usually enough.
Find the uterine artery (23-22L). Cut the posterior leaf of
the broad ligament with the loose areolar tissue inside it, Now decide if you want to proceed with a subtotal or total
almost as far as the artery (23-22K,L). If your assistant hysterectomy. If you are inexperienced, do the former.
stretches the broad ligament
well by pulling on the clamps,
you may see the artery through
the tissues you are going to
cut. Repeat this on the other
side.
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SUBTOTAL HYSTERECTOMY
If you have placed 2 clamps for the
uterine vessels with their points
1·5-3cm above the distal end of the
cervix on the lateral uterine wall,
release each slightly in turn,
squeeze again and tie them
individually after the ligating
needle has gone through the uterus
just under the point of the clamp.
In this way, you will be sure to
have tied all the vessels lateral to
the uterine part you are going to
remove.
When you are sure you have
reflected the bladder adequately
(23-23A), pull on the clamps
attached to the uterus and incise the
anterior wall of the cervix, above
the reflexion of the bladder and the
stump of the uterine vessel
(23-23B). Then draw the uterus
sharply forwards towards the
symphysis, and incise the posterior
wall of the cervix (23-23C). Place a
clamp on its anterior incised edge
(23-23D).
Place a clamp on the posterior cut
edge of the cervix (23-23E), so that
you can maintain traction. Bring the
two cut edges of the cervix together
to control bleeding. Use a cutting
Mayo half-circle needle, and place
the first stitch in the edge of the
cervix, close to the point where you Fig. 23-24 TOTAL HYSTERECTOMY.
tied the uterine arteries. Control bleeding by placing the A, Reflect the bladder. B, feel for the cervix. C,D, incise the fornices
sutures through the posterior peritoneal reflection, deep of the vagina. E, cut the uterus free. F,G, close the vagina. H, suture
into the muscle of both lips (23-23F,G,H). Suture the the round ligaments to the plicated vaginal vault. After Parsons L,
Ulfelder H, An Atlas of Pelvic Operations. WB Saunders 1968 p.33,34,
round ligaments to the cervix if you can do this easily with kind permission.
(23-23I).
Before you open the vagina, insert clamps on the vaginal
TOTAL HYSTERECTOMY angles immediately below the cervix. Ask your assistant to
pull up the uterus. Make absolutely sure no bowel or
Cut through the cardinal ligaments flush with the cervix, bladder is in these 2 clamps placed below the cervix.
until you feel their ends on each side (23-24A). Use a broad-bladed or right-angle retractor to pull back the
You should now be able to feel the cervix abdominally bladder carefully.
through the wall of the vagina from in front and behind Cut the vagina above the clamps as near as possible to the
with your finger and thumb (23-24B). cervix. If you can see easily, complete the cut with curved
Often it is possible with a total hysterectomy to have the scissors (23-24D).
cardinal ligament including the utero-sacral ligament in CAUTION! To avoid damage to the ureters, always
the same clamp and hence in the same pedicle as the make sure you find them. Clamp the uterine pedicles away
uterine artery. from them, and cut the vaginal wall very close to the
So, on one side, you should have the following pedicles: cervix.
(1) the round ligament;
(2) the doubly ligated infundibulo-pelvic ligament; Use #1 long-acting absorbable transfixion sutures to tie the
(3) the doubly ligated uterine artery including the cardinal vaginal angle and top pedicles bilaterally, making sure that
ligament; you do not include the ureters, keeping the ends long in
(4) tissue just lateral to the distal cervix plus the top ⅓ of order to tie the uterine artery on each side, once again for
the vagina. extra security. If there is some oozing from the open part
of the vagina, control it with mattress or figure of 8 sutures
(4-9H).
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If you can easily do so, suture the round ligaments to the If there is a fibroid in the cervix, removing it can be very
ends of the vaginal vault (23-24H). This will help to difficult. Limit yourself to a subtotal hysterectomy.
prevent prolapse, but is not essential.
If there is a fibroid low in the posterior uterine wall,
Remove the swab holding the bowel, and close the make a transverse incision over it and shell it (partly) out
abdomen in the usual way. There is no need for a drain if with your finger: this will help mobilise the uterus.
the operation was not for an infection in the first place and If the uterus is thus mobilised, a hysterectomy will be
the bowel or urinary tract was not damaged. Otherwise routine. You may then be able to ligate the vessels leading
leave the vagina open to help drainage. In serious infection to the fibroid and can then close the resulting cavity, so
leave a large tube draining into the vagina, fixing it from that the hysterectomy is no longer necessary.
inside the abdomen with a thin absorbable suture.
If you divide the ureter and recognize that you have done
POST-OPERATIVELY, check the vaginal pads, pulse, so, repair the ureter with continuous 3/0 or 4/0 absorbable
BP and urine production to make sure there is no bleeding. over a fine feeding tube which you have inserted into the
proximal and distal ends of the divided ureter. If you can
THE SPECIMEN. Open the uterus to see if there is a perform a cystoscopy, you will be able to withdraw the
carcinoma of its body. Do this after the operation, to avoid feeding tube after 10days. If not, make a small cystostomy
contaminating the wound with tumour cells if any are and find the distal end of the tube: do not pull on it! Attach
present. its distal end through the eye of a Foley catheter that you
have placed in the bladder. You can then remove the
DIFFICULTIES WITH HYSTERECTOMY feeding tube simply by removing the catheter.
Otherwise, fix the feeding tube in place in the proximal
If adhesions from old PID or endometriosis prevent ureter, and lead the other end of the tube out of the
you starting, begin by dividing the round ligaments. abdomen through a separate stab incision, and allow urine
Then put your hand behind the uterus and push a finger to collect in a sealed bag. This will preserve kidney
through the broad ligament under the tube and out through function till you can refer the patient for ureteric
the divided round ligament. You now have the tube and re-implantation later. Place a tube drain into the abdomen.
ovarian vessels and can clamp and divide them safely.
If you open the bladder, repair it in at least 2 layers with
If the uterus is so large that it obstructs your access to long-acting absorbable. Leave a catheter in for 10days.
the pelvis, perform a subtotal operation first, The tear is likely to heal uneventfully.
and cut across the cervix quite high up. When you have
removed the body of the uterus you will have plenty of If you have injured the colon, repair the tear in 2 layers.
room to complete the operation. Fashion a defunctioning colostomy if there is severe
soiling, or if there is severe scarring, and you are uncertain
If you cannot find the ureter, but must proceed with the of the reliability of your closure.
operation, keep extremely close to the uterus.
You will nearly always be safe there. If there is bleeding at the end of the operation,
Perform a subtotal hysterectomy only. try packing the pelvis with warm packs and tie off any
arterial bleeding vessels. If this fails, don't close the
If a fibroid extends into the broad ligament, vaginal vault. Instead, insert a purse string suture in the
this may be: (1) growing out from the uterus and displace vaginal vault around a tube drain and pull it tight.
the uterine vessels and ureter downwards, laterally or This will leave a central hole in the vagina through which
upwards; (2) separate from the uterus and arise de novo any fluid can escape.
from the connective tissue in the broad ligament.
Both are difficult to dissect out. If there is postoperative retention of urine, it is likely to
be due to detrusor failure, and to be difficult to treat.
First of all, make sure urine is being produced.
In the 1st case, divide both the ovarian vessels and dissect Try 4wks of catheter drainage and urethral dilatation.
out the upper part of the fibroid. Then proceed with the If this fails, teach intermittent self-catheterization,
operation as usual on the normal side of the uterus only. which is effective and safe. Use a clean but not sterile
Clamp and tie the uterine artery and utero-sacral ligament. simple plastic catheter, which she can use for at least a
Cut across the vagina. As you reach the affected side of the week. A retentive bladder is much more comfortable than
vagina you will see the uterine artery on that side. a leaky one, and easier to manage.
Clamp and divide it (it may be large) and shell out the
remainder of the fibroid.
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23.16 Vulval carcinoma Make the diagnosis by inspecting the introitus and when in
doubt, by a finger in the rectum. If the membrane feels
If a patient has an ulcerating lesion of her vulva, this may thin, incise it with a cross-shaped incision.
possibly be a carcinoma which may need a wide and Don't do anything more than make a cruciate incision in a
mutilating excision of the primary, with a margin of thin membrane. Don't insert a drain; you risk introducing
normal tissue of ≥2cm all round, and 1cm deep to the infection.
lesion. If the groin nodes are involved, she needs a
bilateral groin dissection. This is a major intervention. If the gap between the upper and lower vagina is more
There is often an offensive discharge, and dyspareunia, than a membrane, the operation to establish patency is
as well as dysuria. not easy. Re-stenosis is common. The problem is not
urgent: you would be best to refer to a specialist.
DIFFERENTIAL DIAGNOSIS includes:
(1) vulval warts or condylomata (23.17), If a girl 6-24months after puberty has a lower
(2) syphilis (20 or 30: 23.17), abdominal mass, one of the possibilities is a
(3) chancroid (23.17), haematometra in the horn of a uterus didelphus (double
(4) tuberculosis (23.17), uterus with double cervix) with one cervix stenosed so that
(5) donovanosis (granuloma inguinale: 23.17) a haematometra develops. You can usually manage this by
(6) lymphogranuloma venereum (23.17), repeatedly dilating the stenosed cervix. Rarely, an
(7) Schistosoma haematobium (23.17), isolated horn is not connected at all to the vagina; then a
(8);extensive anorectal cancer, particularly in HIV+ve laparotomy is needed. Beware: abnormalities of the
patients (26.7). ureters are likely as well.
CAUTION! Before contemplating a radical operation on
the vulva, be sure to take a biopsy: it is tragic to perform a If there is a swelling in the anterior vaginal wall behind
mutilating operation for an innocent lesion. Inguinal the urethra, especially before the reproductive years,
lymphadenopathy does not necessarily mean cancer! consider the possibility of a URETHRAL
DIVERTICULUM, and don't confuse it with a cystocoele
or a urethrocoele. If you can squeeze its contents into the
urethra, the diagnosis is confirmed.
23.17 Other gynaecological problems
If you are not sure, perform a urethrogram (38.1).
Consider excising the diverticulum, which is usually not
CONGENITAL ABNORMALITIES OF THE GENITAL difficult. Operate with a urethral catheter in place. Repair
TRACT the small defect in the urethra which was the neck of the
diverticulum.
If a girl 12-16yrs has low abdominal pain & an
abdominal mass, examine the vagina and vulva. OTHER ABNORMALITIES
If you find a bulging membrane (the hymen), the first
menstrual discharges have distended the vagina If there is a vaginal stricture from chemical irritants
(haematocolpos) and perhaps the uterus (haematometra) (including crushed beetles) or trauma (including genital
(23-25). The distended vagina may cause retention of urine cutting), or existing congenitally, consider inserting a skin
by compressing the urethra. graft on a large mould, as soon as the vaginal cavity is
clean. A dentist may have suitable material for the mould.
Make it otherwise round a syringe barrel with the distal
end cut of and made smooth, so as to make a passage for
the menstrual fluid to escape. Hold the mould in place with
sutures through the flanges (wings) of the syringe. Remove
these 21days later, and immediately re-graft any raw areas.
You can use Hegar’s dilators of different sizes to dilate a
narrow vagina.
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Outside pregnancy, ARV therapy is indicated if there are If there is chronic or recurrent vulval ulceration,
huge condylomata. Repeated diathermy is successful and it the differential diagnosis includes:
is surprising how the large 3rd degree burns created by the
treatment re-epithelialise within 1wk. Wear a mask and (1).Small and usually ulcerated granulomata arising in a
make sure the operating theatre is well aerated, to prevent perineum that is permanently wet from a vesico-vaginal
aerosol spread of the condylomata. fistula (VVF) (salt baths will improve this temporarily,
but a barrier vaseline/silicone cream will be best).
If there is a spontaneous recto-vaginal fistula, (2).Cellulitis, furunculosis, folliculitis, candidiasis;
this may develop in baby girls without a congenital or test the blood or urine for glucose. High humidity related
traumatic reason, related to HIV infection (5.6). to obesity or nylon underwear might also be involved.
Differentiate this from a congenital lesion where the anus
is usually closed (33.6). Do not be tempted to operate. (3).Secondary syphilis; painless, greyish, moist,
The baby does not know there is a problem! The best flat-topped broad-based raised swellings (condylomata
treatment is the use of a seton (as well as ARV therapy). accuminata). You may also see these around the anus in
the patient’s baby.
If there are papular nodules in the lower genital tract,
consider SCHISTOSOMA. (4).Tuberculosis; ulcers, sinuses and gross thickening are
These take various forms: the most common types of vulval TB, which is usually
(1);Frond-like (fern-like) lesions with a narrow base or transmitted sexually. Histology will help if there is a
plaques developing on the vulva, usually from 6-15yrs. suspicion, especially if the woman is HIV+ve.
These are often single, cause no problems, seldom bleed, Chronic skin TB is notorious for developing into cancer.
and can be removed easily.
(2);Multiple granulomata of the vagina and cervix in the (5).Donovanosis (granuloma inguinale); beefy, red, angry,
reproductive years and after them. These also seldom destructive, irregular sometimes tender lesions develop
bleed, but they may be so extensive that they distort the with a raised edge. It is caused by Klebsiella granulomatis.
bladder/urethral angle and cause incontinence. Initially no swollen groin nodes are present, but these may
(3);Cervical ulceration or papillomas, closely resembling appear after secondary infection. The inguinal nodes can
carcinoma. also become involved by extension of the original
(4);Granulomata might present as infertility by blocking infection. Donovanosis can cause a pseudoepitheliomatous
the tubes. hyperplasia, which may be mistaken histologically for
Look for ova in the urine, stool, vaginal discharge, carcinoma.
and tissue scrapings or biopsies.
CAUTION! (6).Lymphogranuloma venereum (LGV, 26.11).
(1) If schistosomiasis is endemic, don't think all suspicious The initial vulval lesion, caused by chlamydia, is painless
vulval or cervical lesions are carcinoma. and small and may be missed. Later there are enlarged,
(2);Carcinoma may co-exist with some other pathology. matted, firm, painful nodes (more often in men than
Don't excise large vulval lesions without a biopsy first. women) which can suppurate and cause several sinuses.
(3);There is an increase in bladder carcinoma in these A ‘groove’ caused by the separation of the inguinal and
areas. These might present as supposed vaginal bleeding. femoral glands (the bubo) by the inguinal ligament is
typical. A so-called genital syndrome can develop, an
If there is a profuse vaginal discharge or post-coital oedematous swelling (elephantiasis) of the genitalia
bleeding, one cause is CERVICAL ECTOPY. The normal combined with destructive painless hypertrophic lesions
columnar endothelium of the endocervix bulges out onto involving often urethra and/or rectum. This might result in
the ectocervix, visible when you do a speculum fistula (watering-can perineum) and strictures.
examination. Cervical ectopy usually causes no symptoms. Distinguishing between (6 & 7) can be difficult, and both
Exclude Chlamydia cervicitis, cervical carcinoma, severe may be present. Fortunately, they both respond to
trichomonal infection or a foreign body. Use diathermy to tetracycline or chloramphenicol over 3wks.
make 6-8 radial burns from the external os to the junction
of the glandular ectopy (the erosion) with the normal (7).Herpes simplex (type 1 or 2); the first manifestation
squamous epithelium. Or, using a stick of silver nitrate, can be very painful and can even cause urine retention.
just touch all the glandular epithelium. Warn that the Vesicles soon rupture and become skin lesions which can
discharge will get worse for 1wk before it improves. No become secondary infected. Repeat infections appear in a
anaesthesia is necessary. Cryotherapy also needs no subgroup of patients. These are far less painful start with
anaesthesia and is very effective. itching, pain or a ‘funny’ feeling. Small, itchy, painful
vesicles lasting for 2-3wks appear.
These lesions are typically grouped. If you treat with
acyclovir cream at the earliest suspicion that a new attack
is coming, an attack can be shortened.
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(8).HIV infections might facilitate all sorts of chronic If there is lymphoedema of the vulva, think of:
ulcerations (5.6) of the vulva (and penis). Micro organisms (1) tuberculous lymphadenitis in the groin (17.4),
which normally are not a problem or only a minor (2) lymphogranuloma venereum (LGV: 26.11),
nuisance, now grab the opportunity like the different (3) donovanosis (see above).
herpes infections, molluscum contagiosum, candidiasis, (4) filariasis (27.34, 34.14),
vulvar warts, chancroid, and LGV to cause huge and (5) 20 or 30 syphilis.
chronic sores, erosions, necrosis and warts. It is best to
restore immune competence with ARV’s before N.B. Vulval oedema, especially in donovanosis and
intervening surgically. filiarisis can sometimes be so gross as to mimic
elephantiasis of the scrotum. Don't excise associated
(9).Amoebiasis (rare); painless ulcers which may mimic lymph nodes; this will only make the condition worse.
carcinoma and usually respond dramatically to
metronidazole (14.5). Suggesting LGV (26.11): a fistulated inguinal adenitis
with a sour smell, a concealed indolent sore of the vaginal
(10).Chancroid; single or multiple, painful/tender, soft, vault, vesicovaginal or rectovaginal sinuses and rectal
bleeding shallow ulcers with minimal to no surrounding strictures; absence of pain. Histology is often non-specific.
induration arising within 1wk of a sexual contact.
The inguinal nodes are enlarged, tender and may Suggesting donovanosis or hydradenitis:
suppurate. extensive destruction with oedema with scarring.
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Fibrocystic disease (or fibroadenosis) is the commonest A lipoma (uncommon) feels like breast tissue, but has an
cause, especially between 25-50yrs, and makes both breasts indistinct outline separating it from the surrounding normal
abnormally granular, usually with premenstrual pain and some breast.
tenderness. One or more of these granular areas may be
sufficiently obvious to be palpable as a cyst, and there may be A serous, dark or blood-stained nipple discharge may
a clear discharge from the nipple; rarely, this is blood-stained. herald the presence of an intraduct papilloma, adenoma or
carcinoma. If a lump is palpable, it is more likely to be a
Breast abscess may present by finding pus on aspiration, carcinoma. The prognosis after local resection is usually good.
especially in HIV disease, when there is not much
inflammatory response: this still needs drainage (6.13). An organizing haematoma or fat necrosis may occur after
trauma as fairly discrete mildly tender lumps.
Other rarer causes are:
Galactocele: a residual milk-containing cyst, the contents of Tuberculosis is less often seen in the breast than in the
which may solidify. axillary lymph nodes (17.4) but you should suspect it if there
are signs of HIV disease; it closely resembles carcinoma.
Intracystic papilliferous carcinoma: aspiration yields blood- Suspect tuberculosis if there is a sinus and the swelling and
stained fluid, and does not make the cyst disappear entirely. ‘peau d’orange’ is generalized. The mass is painless, and may
be attached to the skin or the muscles of the chest wall.
Carcinoma of the breast with colloid degeneration: The nipple may be retracted. Look for signs of tuberculosis
aspiration yields only a little thick fluid, and does not make elsewhere. The breast itself may be swollen due to
the cyst disappear. enlargement of axillary nodes, and may not be the seat of the
primary pathology.
Cystadenoma phylloides: a rapidly growing benign giant
fibroadenoma, which becomes partly necrotic and fluctuant. A carcinoma (usually squamous) may be ductal or lobular
The skin over it may ulcerate, but is not infiltrated. (both common). It is a hard, painless, fixed mass often with
tethering of the skin or attachment to pectoralis major,
Hydatid cyst (15.12): a possibility in endemic areas: look for overlying localized ‘peau d’orange’ and fungation of tumour
cysts elsewhere, especially in the liver. through the skin.
DIAGNOSING SOLID LUMPS IN THE BREAST Mastitis carcinomatosa (rare) is a highly malignant form of
carcinoma seen during pregnancy. It is more generalized,
Careful palpation will give you a good idea of the nature of a and more like inflammation, or Burkitt's lymphoma, than the
lump, but even experts are misled. These are the classic hard, fixed mass of a typical carcinoma.
features:
Burkitt’s lymphoma (17.6) is rare, usually bilateral,
An 'antibioma' is the result of treating an abscess with occurring at 14-25yrs. It may simulate mastitis carcinomatosa,
antibiotics, and not draining it. The lump is usually tender, but is not particularly associated with pregnancy.
but not always so. It is indurated but smooth; aspiration may The skin is stretched, and may ulcerate; there are usually other
produce pus. There may be tender axillary nodes and even tumours elsewhere.
'peau d'orange'.
MANAGING CYSTS IN THE BREAST
A fibroadenoma (common) is a smooth, well-defined usually First exclude a hydatid cyst (if that is at all likely),
painless firm lump 2-5cm in diameter (but which may be by looking for hydatid cysts (15.12) elsewhere.
much larger), that moves freely in the breast (a 'breast
mouse'). There may be several fibroadenomas in one or both Aspirate the cyst with a wide bore needle as completely as you
breasts (24-2). From its firmness such a lump could still be a can.
carcinoma; mobility is the important sign, so is lobulation.
Be careful to distinguish a fibroadenoma, which is an isolated If the fluid you aspirate is blood-stained, explore and excise
lump, from an area of nodularity due to fibroadenosis, the lump.
which is a different disease, featuring pain and nodularity
increasing before and during menstruation. The patient is If a lump remains after you have aspirated the cyst,
almost always 15-45yrs, and usually 18-30yrs. excise the lump completely.
A giant fibroadenoma (uncommon), presents as a large If the fluid is clear and the lump disappears, as is usual in
breast filled with a large, deeply lying, firm, smooth, lumpy, fibrocystic disease (the commonest cause), no further
mass (24-6). If it is untreated it may fungate (24-1) or develop treatment is necessary. Do a regular follow-up. If the cyst
into a sarcoma. appears again, or other cysts appear, aspirate again. If at any
time lumps do not disappear, remove them as above.
A neurofibroma (rare) feels hard, like a fibroadenoma,
but may be soft, and may be one of many similar tumours
elsewhere (neurofibromatosis).
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24.3 Other benign breast conditions In a pregnant woman, if the fluid is clear and comes from
many ducts in both breasts, reassure her.
MANAGING A DISCHARGE FROM THE NIPPLE If both breasts continue to discharge milky fluid from
many ducts, this is galactorrhoea, which may be due to
This can be: medications (sedatives & anti-depressants), or rarely a
(1).The normal action of breasts in pregnancy. Colostrum can pituitary tumour raising prolactin levels. Jasmine is effective if
be discharged from the 16th week of pregnancy, and even you cannot get bromocriptine.
earlier in multipara.
(2).The normal usually milky discharge after lactation stops. If there is a recurrent discharge from several points on the
This may however still persist for months and occasionally nipple, watery or viscid, green, white, black or
years, especially if lactation is prolonged. occasionally bloody, suspect duct ectasia and/or periductal
(3).The clear, or less often blood-stained discharge, due to an (plasma cell) mastitis, which is common in smokers.
intraduct papilloma, adenoma or carcinoma. It can also present as a hard, tender swelling with redness of
Or rarely, the overlying skin, which you can confuse with an acute breast
(4) The discharge associated with fibroadenosis. abscess, or a rapidly growing carcinoma.
(5) The discharge associated with periductal mastitis.
If there is fibrocystic disease, the retention cysts it causes
Discharge is more serious if it comes from one duct rather may occasionally cause a discharge from one breast, seldom
than from many, if it is bloody, or if it is associated with a both. Aspirate the cyst if there is one. If it does not disappear,
lump. At the start of the examination, do not palpate the or if the fluid is blood-stained, perform an excision biopsy.
breast in the normal way, because this may squeeze out any
secretion which has accumulated, and you want to see exactly If there is a watery, or bloody, or dark discharge from one
where it is coming from. duct, usually without a lump, this is probably due to an
Instead, with the patient supine, gently wipe the nipple clean. intraduct papilloma or adenoma. If there is a lump, it is more
Then, press with one finger 3cm distal to the areola, and move likely to be a carcinoma; even so, the prognosis is usually
it towards the nipple. Start at the 1 o'clock position and move good. Excise the lump with the duct (see below).
progressively all round the breast to the 12 o'clock position.
If there is any discharge, wipe it away and note its position.
Then examine the breast in the usual way.
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Aim to excise a single duct system with its surrounding tissue. If there is evidence of acute inflammation: a recent history,
Try to make sure that neither the patient, nor anyone else, throbbing pain, and tenderness, do not wait for fluctuation.
squeezes the breast during the 2-3days before you do so. Treat as for a breast abscess (6.13). Acute infection may be
Under GA, find the orifice of the affected duct by squeezing difficult to differentiate from mastitis carcinomatosa (24.2).
the secretion out of it. You may be able to feel the lesion
under the areola (24.2). Pass a fine probe or a hypodermic If both breasts are enlarged, with pitting oedema, suspect
needle with a blunt end along the duct (24-7C). some generalized disease, such as cirrhosis, nephrotic
Ask your assistant to hold this, while you excise an oval of syndrome, or heart failure.
skin and breast tissue with the duct and the lesion.
Make sure that you excise the probe with a margin of at least If there are small fibrotic axillary nodes,
2cm of macroscopically normal tissue horizontally and not the typical enlarged matted tuberculous nodes, and no
vertically all round the duct, except at the nipple (24-7D). signs of tuberculosis elsewhere, there may be chronic non-
Suture the deeper layers with plain absorbable suture to specific infection following repeated infection of the hand and
obliterate the dead space. Close the skin with 3/0 arm, usually from wounds, or filariasis (34.14).
monofilament. There is no need for a drain.
If haemostasis is not good, apply a pressure dressing. If the nipple is chronically ulcerated, suspect that this is
Send the specimen for histology. Remove sutures at 7days. associated with an underlying duct carcinoma, unless there is
a clear history of trauma. Get a biopsy to exclude rare causes
At review, if it is a papilloma (75% chance), nothing further is such as syphilis and tuberculosis.
needed. If there is an in situ carcinoma (15%), do a careful
follow up for at least 6months. If there is one swollen breast with pitting oedema and no
palpable mass, this may be:
The operation itself should be sufficient, but if there is an (1) Primary TB of the breast, or
invasive carcinoma and the tumour is >2cm diameter, (2).Secondary to chronic axillary lymphadenitis.
perform a mastectomy unless radiotherapy is available. The affected breast is larger than the opposite one, is not
tender or only slightly so, and almost always shows
MANAGING A SINUS OR FISTULA IN THE BREAST 'peau d'orange'. The axillary nodes (usually the lateral
pectoral group) are commonly matted together, and may be
A sinus or fistula may discharge milk, or a non-specific fluid. attached to underlying structures and the skin. In TB, there
A milk fistula can follow a breast abscess, trauma, may also be a discharging sinus. Look for signs of TB
tuberculosis, a cancer of the breast, or occasionally the elsewhere, especially enlarged nodes in the other axilla,
presence of a foreign body, or fungal infection. groins, and abdomen. Get a chest radiograph, and do an ESR.
This manifestation of TB affecting the breast via the axillary
If there is a milk fistula, and the patient is or should be nodes is more common than primary TB of the breast.
breast-feeding, try to improve or re-establish breast-feeding In endemic areas, think of filariasis (34.14)
soon. The fistula will probably heal. If it does not, it will
probably do so when breast-feeding ceases at the normal time. If both breasts enlarge prematurely, associated with
CAUTION! A milk fistula is not an indication to stop menstruation, there is precocious puberty. Look for an ovarian
breast-feeding. Rather, it is an indication to re-establish tumour, or an intracranial lesion, which may disturb the
breast-feeding soon, if lactation has stopped. gonadotrophin releasing mechanism.
NIPPLE DISEASES If one breast is very much larger than the other during
puberty, but is otherwise normal, this is probably congenital
Paget's disease of the nipple, a localized eczema, is unilateral GIANT HYPERPLASIA, and may affect both breasts. Later,
and, though rare, a sure sign that there is an underlying the breasts usually become the same size but may enlarge
intraduct carcinoma. Biopsy the nipple skin and if you find again in the 3rd decade, especially following pregnancy.
‘Paget’ cells, perform a mastectomy. Do not remove breast tissue in a child for a biopsy because
you will destroy the normal development of the breasts.
Chronic eczema, (uncommon) is bilateral. Clean the nipples
frequently with soap and water. Apply zinc and salicylic acid If both breasts enlarge hugely in an adult, this may cause
paste (Lassar's) 1%, or hydrocortisone ointment 1%. backache; very large breasts can be made smaller by reduction
Make sure you follow up the patient and exclude Paget’s mammoplasty but this is difficult plastic surgery.
disease!
If extra breasts develop, they may develop anywhere along
A painless ulcer on the nipple may be a syphilitic chancre if the nipple line from the axilla, along the chest wall down to
there is a history of nursing an infected child or kissing by an the thigh. Rarely, these breasts are functional. You should be
infected individual; check the RPR or VDRL and treat with able to excise them easily.
penicillin.
(N.B. The mother of a syphilitic infant does not get re-infected
by her own child)
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If there is a soft fatty lump in a lady >70yrs, Treatment is mainly surgical but as in any other part of the
which feels as if it might be a lipoma, suspect that it is in fact body, surgery can only cure, if it remains localized and has not
a carcinoma, which can be as soft as a lipoma at this age. spread elsewhere. If radiotherapy is available, it is the
preferred treatment for affected axillary nodes.
24.4 Breast carcinoma Anti-oestrogens improve survival and chemotherapy can
result in remission. Many patients present late with foul,
Carcinoma of the breast is common and can occur at any age stinking ulcers. Metronidazole often helps here to remove the
>20yrs, but is most common from 50-70yrs, particularly in odour and a ‘toilet’ mastectomy, if it is possible (the growth
nullipara and in women who started childbearing late; may be fixed to the deep structures and make it not
it is also common in the sisters of patients with the disease, worthwhile), relieves suffering, and may make the last months
and to a lesser extent in their daughters. It appears to arrive more bearable.
earlier in HIV disease, and may act more aggressively.
It may be a consequence of the use of hormone replacement STAGING and PROGNOSIS.
therapy which used to be advocated to prevent menopausal
osteoporosis. The Manchester system of staging describes:
Stage I: growth is confined to the breast, skin involvement
Carcinoma of the breast may also occur in males, but is not smaller than tumour
related to gynaecomastia (24.6). Stage.II: growth is confined to the breast,
palpable mobile axillary nodes
Breast tumours arise commonly from the duct system or less Stage III: skin involvement larger than the tumour,
commonly from the lobule. When confined and not invading or tumour fixed to underlying fascia
the basement membrane, they are described as in situ Stage IV: distant metastases, fixed axillary nodes, palpable
carcinoma, and therefore potentially curable by surgical supraclavicular nodes, satellite nodules
excision. Most invasive ductal carcinomas have no specific
features, but medullary, tubular, mucinous, papillary and The TNM classification describes tumour size, nodal
cribriform have better prognosis, whilst signet ring, clear cell involvement and distant metastases:-
and inflammatory types have worse prognosis. T0: no tumour,
Mastitis carcinomatosa is of this last type. T1: tumour <2cm diameter,
Lobular carcinomas are often bilateral but have better T2: tumour 2-5cm,
prognosis than invasive ductal carcinomas, unless they are of T3: tumour >5cm,
the pleomorphic type. T4: tumour fixed,
N0: no nodes,
Sarcomas are rare and arise from fibrous stromal tissue. N1: mobile axillary nodes,
They occur in young girls <20yrs as phylloides tumours N2: fixed axillary nodes,
(24.2). These may be well circumscribed but tend to recur if a N3: supraclavicular nodes,
margin of excision is not included with the tumour, and rarely M0: no distant metastases,
metastasize. M1: distant metastases.
Lymphomas (rare) also occur, especially the Burkitt’s The systems overlap as follows:
lymphoma (17.6) T0 T1 T2 T3 T4
N0 Stage I
Breast carcinomas form no capsule; they invade locally N1 Stage II
through the lymphatics, and spread widely through the N2 Stage IIIa
bloodstream. The prognosis is related to: N3 Stage IIIb
(1);the stage at which treatment starts, M1 Stage IV
(2);the histological tumour type, and
(3) less significantly, the treatment. 5-year survival should be >65% for stage I and 60% for stage
The stage at which the diagnosis is made is critical, II, but dropping to 15% for stage III and <5% for stage IV.
so persuade your staff to include breast palpation in every
general clinical examination. On microscopic examination the axillary nodes are involved
A 1cm lump represents 30 doublings; growth however occurs in 10% of patients in stage I, although they may not be
in spurts and dormant periods are frequent but irregular. obvious for 20yrs. Tumours in the lateral half of the breast
Occasionally you may detect a carcinoma as a suspicious have a better prognosis.
lesion on a mammogram or ultrasound when it is still not If the tumour is stage I in the lateral half of the breast, there is
palpable. a 90% chance of cure surgically. If it is in the medial half of
the breast (less common), the prognosis is worse, because it is
Carcinoma of the breast may present as a painless lump in the more likely to spread to the internal mammary nodes.
breast (80%), as enlargement of a breast, as ulceration, Inadequate local removal of tumour will result in local
or as a discharge from the nipple, which is usually but not recurrence; wide excision of a tumour >2cm diameter without
always blood-stained. radiotherapy will result in a 30% chance of local recurrence.
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However, the more radical operations (the standard Patey’s, STAGE IIIb.
removing pectoralis minor, or Halsted’s, removing pectoralis Perform a mastectomy only if you think you can clear tumour
major) do not confer any survival benefit by virtue of their with a 2cm margin (unlikely) or if there is fungating tumour
more guaranteed clearance of tumour. eroding through the skin (a ‘toilet’ mastectomy).
You probably will not be able to close the defect except with a
MANAGEMENT skin-graft; unless the tumour mass is very infected, it’s best to
STAGE I. do this at the time of the mastectomy rather than delaying.
Excise the lump with a 2cm of normal tissue around it Interference with fixed axillary nodes may damage nerves and
(24-5D-F) and send it for histology. If the result confirms a blood vessels and is unlikely to be helpful. If the tumour is
carcinoma <2cm diameter, do a follow-up every 6months for a firmly fixed to the chest wall, only very extensive surgery is
year, and yearly thereafter. likely to be successful. Radiotherapy is probably palliative at
If the carcinoma is >2cm diameter, or the excision margin is this stage, but tamoxifen 20mg daily may help, and if you can
<2cm, perform a mastectomy. administer chemotherapy it may benefit, but you probably will
You can try to map sentinel nodes especially in the axilla if have more deserving cases for your valuable resources.
you inject 0·5-2ml of blue dye around the lump, and then Alternatively advise bilateral oophorectomy.
10-15mins later explore the axilla (17.3). You may be able to
increase your detection of axillary nodes by ultrasound. STAGE IV.
If you then remove sentinel nodes which have taken up the No surgery is likely to be helpful here. Treat with tamoxifen
blue dye, as well as obviously palpable nodes, you will get a 20mg od: occasionally it can produce dramatic results.
better definition of the spread of the disease, and be able to Radiotherapy to bone metastases may remove constant pain,
advise better about further treatment options. and bilateral oophorectomy in pre-menopausal women results
N.B. Nipple-sparing mastectomy may be feasible in a in remission in c.20%.
younger woman, with a view to later insertion of a prosthetic
implant (i.e. silicone): think about this if you can arrange to DIFFICULTIES WITH CARCINOMA OF THE BREAST
get it done.
If you suspect Burkitt's lymphoma of the breast, take a
STAE II. needle biopsy, stain a slide preparation, and interpret it
Perform a mastectomy and remove as many obviously yourself (17-1). Or, less satisfactorily, send a biopsy.
involved nodes as you can. This ‘axillary sampling’ is If you are not confident that you can interpret a slide
controversial, but axillary clearance is difficult and may result preparation, do both; excise the lump, make a slide from it,
in damage to the axillary vein and nerves, and may not give and send the biopsy for histology. If the tumour is large and
any better result. Administer radiotherapy if axillary nodes are ulcerating, excise it, and skin-graft the exposed pectoralis
involved, if available. major as for Stage IIIb tumours. If Burkitt's lymphoma is
likely and histology reporting slow, start chemotherapy
If the patient cannot contemplate removal of the breast, immediately. (17.6)
you could do a wide excision of the lump but this should
include axillary node excision and radiotherapy if the nodes If you find breast carcinoma in a pregnant woman,
are involved. So it may not actually be the best option if it may not necessarily be mastitis carcinomatosa (24.2).
radiotherapy is not available; also the risk of local recurrence Treatment of the breast carcinoma takes precedence, however,
is higher, and if the breast is small, a wide excision might not over the pregnancy.
lead to a better oncological result.
If no cytology or histology is available,
Treat with tamoxifen 20mg od if nodes are involved, for 5yrs. do not delay treatment inappropriately to seek confirmation,
Administer chemotherapy (cyclophosphamide 100mg/m² od but always consider TB as an alternative diagnosis.
for 14days, and methotrexate 30mg/m² plus either
5-fluorouracil 500mg/m² IV on days 1 & 8, or doxorubicin The patient may not return, the report may be lost, and there
60mg/m² every 3wks for 6 cycles) if the patient is <40yrs old will be too long an interval between the biopsy and the
and HIV-ve. definitive operation. The biopsy scar may interfere with your
proposed mastectomy incision.
Alternatively, as good an effect can often be achieved by
bilateral oophorectomy. If there is a suspicious impalpable lesion found on
mammography or ultrasound, and you have no way
STAGE IIIa. yourself of localizing the lesion, repeat the ultrasound scan if
Perform a more extensive mastectomy to clear tumour with a you can. move the affected breast quadrant and make sure you
2cm margin and remove as many involved nodes as you find. get a histology report. If the lesion is malignant and >2cm, it
Occasionally the tumour becomes fixed to the chest wall is best to proceed to mastectomy.
without significant lymph node spread; if you can remove all
of the tumour the first time round you may give her long
disease-free survival, otherwise local recurrence is inevitable.
Advise radiotherapy to the chest wall and axilla if possible,
and tamoxifen 20mg od up to 5yrs.
Alternatively advise bilateral oophorectomy.
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PREPARATION.
Check the side to be operated upon is
correct when the patient is still awake
and can confirm the side; mark it with
indelible ink.
Cross-match blood if the breast is large,
you are inexperienced or your diathermy
is faulty.
Position the lady supine with the arm on
the affected side abducted to 120º and
carefully place sterile towels underneath
the axilla. It helps to flex her elbow and
place her hand under the head.
ANAESTHESIA.
You can use intercostal nerve blocks
instead of GA.
CAUTION!
(1) Do not make the skin flaps too thin, or open up tissue
planes more than is necessary. The flaps should be ≥1cm
thick. Move the Allis forceps lower on the flaps as you
proceed.
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POSTOPERATIVELY, cover the wound with layers of gauze If the tumour is fixed to the pectoralis major or minor,
and cotton wool, and hold them firmly in place with adhesive remove the affected muscle with the breast. If you dissect
strapping. Apply a pressure dressing for 3-4days. Remove the along the clavicle, be careful not to damage the vessels deep
drain when no more blood or serous fluid comes out, usually to the muscle. Remember that this is probably palliative
at 3-7days. Remove the sutures after 7-10days, the alternate surgery, so do not attempt anything too heroic.
ones first. Encourage active movement of the arm and
shoulder. If a solid mass forms in the scar after you have performed a
mastectomy for carcinoma, excise it with a 2cm margin, and
DIFFICULTIES WITH MODIFIED SIMPLE MASTECTOMY send it for histology: it is probably a recurrence.
If you accidentally button-hole the skin flap during
dissection, use the hole for a drain. If the patient is unable to pull the shoulder down post-op,
you have damaged the nerve to latissimus dorsi. If there is
If you damage the axillary vein, do not panic! also much pain as well, explore the wound to see if you have
Press firmly, arrange suction and extra light, and call for tied a ligature round the nerve: if so, carefully untie it.
assistance. Do not apply haemostats. You can use bulldog
clips if you have them. When you can identify the hole in the If the shoulder becomes stiff, you have omitted exercises
vein, try to close it with a round-bodied 4/0 or 5/0 continuous post-operatively. Start them now!
monofilament suture.
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24.6 Gynaecomastia
If a male <20yrs has a firm tender discoid swelling deep to
the nipple just larger than the areola, and concentric with it,
this is physiological. It occurs as a normal variant in infants, in
boys near puberty, and in young men. In infants it is nearly
always bilateral, and is sometimes complicated by mastitis.
In young men it may be uni- or bi-lateral. Reassure all these
patients.
DIFFERENTIAL DIAGNOSIS
SUBCUTANEOUS MASTECTOMY
FOR GYNAECOMASTIA (GRADE 2.5)
INDICATION.
Social embarrassment with significantly enlarged breasts.
N.B. It is difficult to make both sides look the same post-
operatively!
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Inspect the neck from in front, and feel it from in front and
from behind. Give the patient a drink, and confirm that the
thyroid swelling moves up on swallowing. Feel the size of
its lobes and its isthmus; feel its surface and consistency,
and listen for a bruit. If it is woody hard, it is likely to be a
thyroiditis, and if it is fixed in the neck, an anaplastic
carcinoma. Note the position of the trachea.
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25.2 Hyperthyroidism (Thyrotoxicosis) Make sure you control the blood pressure well before the
operation. Remember to make sure the patient receives
There are two main types of hyperthyroidism: both medications with a little water on the day of
(1) idiopathic, often related to introduction of iodine to the operation! (1.8)
salt in an endemic goitrous area, CAUTION! It is dangerous to operate on thyrotoxic
(2).auto-immune, where circulating antibodies cause patients who have not had antithyroid drugs for 6wks
exophthalmos. The first is much more common. preoperatively. Even then, postoperative thyrotoxic crises
Features are weight loss, sweating, heat intolerance, (hyperpyrexia (>41°C), agitation, confusion, and seizure)
agitation, and tachycardia. may occur, and prove fatal.
There is a much rarer form of hyperthyroidism Recurrence of hyperthyroidism after a bilateral subtotal
(de Quervain’s thyroiditis) which may be viral and starts thyroidectomy is very unusual. However, 30% of patients
with fever, pain and tenderness in the neck and transient become hypothyroid within 10yrs and need levothyroxine
release of excess thyroid hormone into the circulation. 0·1-0·2mg od. This is an especial hazard if surgery is
Occasionally the thyroid may be over-stimulated by the done on a small thyroid gland. You therefore need to
use of amiodarone in treatment of cardiac dysrhythmias. follow up such patients.
PREPARATION. No vital structures are in the way, and the divided hyoid
The patient must be euthyroid before surgery. does not need repair. If a remnant is left behind,
Propranolol orally is only effective for about 6hrs. the cyst may well recur.
If the presentation was with severe hyperthyroidism,
a crisis may follow the omission of a single dose.
Regular doses are especially important just before and
immediately after surgery; continue them up to 10days
afterwards to avoid a rebound phenomenon.
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If there is dyspnoea or dysphagia, or the gland is large, Follow up patients regularly, and measure the nodule.
subtotal thyroidectomy or thyroid lobectomy is indicated, If it enlarges try to persuade her to be seen again by an
but is seldom urgent. expert.
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Cut gently down to the thyroid gland along this ‘midline’ Tie two 0 absorbable ligatures around the most proximal
and pull the strap muscles laterally with retractors of haemostat, release this, and then tie another ligature
Babcock forceps (25-2B). It is important that you cut around the remaining haemostat; in this way you will
through all the fine layers including the pre-tracheal fascia avoid the ligature slipping and vessels disappearing deep
which covers the thyroid gland itself, because if you are into the neck causing a haematoma which will cause
not in the right plane of dissection at this point, you will respiratory compromise.
encounter much bleeding. Once you are down onto the
gland, you can use a Lahey swab to develop this plane. Finally you can mobilize the lower pole by ligating the
inferior thyroid vessels. If the isthmus is not too thick,
For very large goitres, where you simply cannot get far and you are only removing one lobe, you can insinuate a
enough round laterally, you may have to divide the strap forceps between it and the trachea and clamp it across
muscles between large straight artery forceps. (25-2E).
Now, put fine haemostats all around the margins of the
Stand on the opposite side of the lobe which you wish to mobilized lobe especially where you see veins crossing
remove. over the surface, staying well anterior to the position of
the recurrent laryngeal nerve and parathyroids
When you are confident that you are in the right plane (25-2F). Remove the excess bulk of the thyroid lobe distal
below the pre-tracheal fascia, place a swab over the to these fine haemostats with scissors or a knife,
thyroid gland so it does not slip from your hand, having haemostats ready to catch any bleeding points.
and gently insinuate your finger between gland and fascia, Aim to leave a remnant 5x1cm (25-2G).
pulling that thyroid lobe medially (25-2C). This is easier
with large goitres which have stretched the fascia. To control bleeding, take a running absorbable suture
At this point the middle thyroid veins may get in the way: along the ‘capsule’ (pre-tracheal fascia) of the thyroid and
you can divide and tie them. As you retract the thyroid secure it to the tracheal fascia.
lobe medially, you can use the Lahey swab gently to push
away tissues so that you can identify the crucial inferior If you are going to perform a bilateral thyroidectomy,
thyroid artery. you can now change sides and proceed as before on the
contralateral side.
This may be quite small, and runs transversely to the gland
as a branch of the thyrocervical trunk, behind the carotid When you are satisfied the bleeding is controlled,
sheath. Tease away surrounding fibres from the vessel so ask the anaesthetist to make the table level to horizontal,
that you can pass a fine well-curved forceps behind the or better, head down to 30º of Trendelenburg: some
crucial inferior thyroid artery; try to ensure that you pick vessels may then start oozing. Control these, and when all
up the artery on its own because its relationship with the is dry, insert suction drains through the strap muscles into
recurrent laryngeal nerve is variable but intimate. the thyroid bed, and secure them firmly with sutures on the
Pass a 2/0 absorbable ligature mounted on an artery clip, lateral sides of the neck, not in the middle where keloids
and tie this around the artery; do NOT divide it because the are more likely to form. If you have divided the strap
vessel may recanalize and the blood supply of the muscles, plicate and overlap them to reduce the dead
parathyroid glands may still depend on this later. space.
You may see the recurrent laryngeal nerve, but you should Close the investing fascia with a continuous absorbable
probably not go out of your way to look for it; suture, the subcutaneous layer with interrupted absorbable
in case, in so doing, you damage it inadvertently! sutures, and the skin with a subcuticular suture.
Once you have ligated the inferior thyroid artery, the DIFFICULTIES WITH THYROIDECTOMY
thyroid lobe will become a dusky bluish colour.
Now turn your attention to the upper pole; sometimes it is If there is heavy bleeding, make sure the head is tilted up.
easier to deal with this before the inferior thyroid artery Apply swabs soaked in adrenaline solution.
but the vascularity of the gland will still then be Press on the bleeding point(s) for 5mins by the clock.
undiminished. Obtain suction and then carefully expose the bleeding
point in order to catch it in a haemostat.
Develop the pre-laryngeal space lateral to the thyroid Do not plunge forceps blindly into the wound!
cartilage so that you can pass a curved artery forceps If the bleeding is from the surface of the thyroid gland,
around the branches of the superior thyroid artery and hold it firmly in a gauze and expose the inferior thyroid
veins to the upper pole. artery as above. Ligation of this will substantially reduce
haemorrhage.
Ideally you should avoid the external laryngeal nerve
which runs behind as division of this will affect the timbre If there is a retrosternal extension, you can usually
of the voice (25-2D). Put 2 haemostats proximally and one deliver this by gentle traction, with a finger behind the
distally, and divide between the latter. gland. Occasionally, you may need a sterilized spoon to
deliver it. Very rarely is it necessary to split the sternum!
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If during operation, the temperature, pulse, and blood 25.8 Other thyroid problems
pressure all rise alarmingly, this is a thyroid ‘storm’
where excessive thyroid hormone is released into the
circulation through manipulation of the gland, especially You may see the following three non-neoplastic diseases
when operating on a thyrotoxic patient. Speed up IV of the thyroid. Apart from lymphocytic thyroiditis they are
fluids, add propranolol 5mg IV, hydrocortisone 100mg IV, uncommon, and you may have to do a needle biopsy to
and carbimazole or propylthiouracil via a nasogastric tube. distinguish them.
Stop operating till the situation has normalized.
(If you don’t have propranolol IV, you can place crushed If a goitre is uniform and feels unusually firm and very
tablets in the vagina, where they are rapidly absorbed.) well defined, but is not particularly tender, suspect
autoimmune lymphocytic thyroiditis (Hashimoto's disease,
If there is continued oozing at the end of the operation, not uncommon). This occurs between 20-70yrs and is
be careful you do not put in sutures that may compromise usually found in females. Spontaneous resolution is usual
the recurrent laryngeal nerve. Use absorbable haemostatic but slow. Hypothyroidism often develops, and needs
gauze and insert drains. Keep the patient intubated and replacement therapy with levothyroxine 0·1-0·2mg od.
sedated postoperatively, and re-open the wound the
following day when identifying the source of the bleeding If the thyroid becomes woody hard, is fixed to the
will be much easier. surrounding tissues, and is either normal-sized or
a little enlarged, suspect RIEDEL'S THYROIDITIS.
If the goitre is huge and the trachea has been pulled Inflammation replaces the normal thyroid tissue and
forwards, insert a prophylactic tracheostomy before you adjacent tissues in the neck, and can lead to hoarseness,
close the wound. stridor, and dysphagia. Distinguish this from malignant
tumours by aspiration cytology.
If the patient cannot breathe properly after the
operation, suspect vocal cord palsy if there is stridor and If the thyroid becomes inflamed, hot and tender, often
cyanosis without swelling of the neck. You will need to with respiratory embarrassment, suspect a thyroid abscess,
pass an endotracheal tube rapidly, or else do a or HIV-related thyroiditis (6.12) or glandular fever
tracheostomy (29.15); the quickest access to the trachea (mononucleosis).
will be through the surgical wound: re-open the midline
fascial closure.
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You should have little difficulty diagnosing anorectal PROCTOSCOPE, Gabriel, 64x25mm. This is the standard instrument
for examining the rectum. The problem with it is that it needs a
abscesses (6.17), fistulae (26.3), fissures (26.5), separate light source. A simple instrument that circumvents this
warts (26.6), cancer (26.7), prolapse (26.8), problem is Dipankar Ray’s proctoscope (available from Calcutta)
haemorrhoids (26.9), pilonidal sinuses (26.10), juvenile which uses a laryngoscope handle and a cone speculum with a groove
polyps, rectal stricture, ulceration or lymphogranuloma for the light. You will also find an ordinary Sims' speculum useful for
examining the anal canal under GA.
venereum (26.11), and imperforate anus (33.6) because SPECULUM, bivalve, Goligher pattern with detachable third blade.
all you need is an examining finger and a proctoscope! Use this for doing minor rectal operations, such as division of the
internal sphincter.
But you do need to become familiar with anorectal SIGMOIDOSCOPE, Strauss, 330mm, Luer fitting, in case with bellows,
cord and standard endoscope bulb complete with biopsy forceps, etc..
conditions, and the only way to achieve this, is always to Keep sigmoidoscopes and proctoscopes in a case so that their various
examine the anus! Sometimes you will need histological parts do not get lost. This also needs a light source: a pen torch usually
support to confirm a diagnosis, but not always. fits snugly in the side-access of the light source if this does not work.
You may need technological help, though, in finding out N.B. Fibre-optic endoscopes are very much more expensive!!
SPONGE HOLDER, for sigmoidoscope, 430mm.
the cause of rectal bleeding (26.4). FORCEPS, for biopsy through sigmoidoscope, Officer pattern.
These are the most expensive part of the outfit. If necessary, you can
Remember the common causes of anal pain: use them to remove foreign bodies from the oesophagus, or even from
(1) anal fissure or ulcer, the urethra.
SUCTION TUBE FOR SIGMOIDOSCOPE. You can make this from a
(2) perianal haematoma, piece of ordinary copper tube, 15cm longer than the sigmoidoscope,
(3) perianal abscess, with a right angle bend at one end.
(4) excoriated or eczematous perianal skin, BELLOWS, spare for Strauss sigmoidoscope, Luer fitting.
(5) worm infestation, BULBS, endoscope, standard (34.1), small fitting. Endoscope bulbs are
very easily blown.
(6) thrombosed prolapsed haemorrhoids, BATTERY BOX, for endoscopes, holding D type dry cells. This must be
(7) coccydynia, the same voltage as the standard endoscope bulbs, and have a lead
(8) anorectal carcinoma. which fits the endoscopes.
PROBE, medium-sized, malleable silver.
DIRECTOR, probe-pointed. This has a groove on it. Pass it through a
Because the anus is always a contaminated area, fistula and then cut down on the groove.
any surgical wounds near it are prone to become infected PARKS’S ANAL RETRACTOR. This versatile retractor is almost
but the infection seldom spreads except in the presence essential if you want to do any anorectal operations (26-4).
of HIV disease or diabetes. The blood supply is normally LONE STAR RETRACTOR. This is a simple, but effective, self-
retaining retractor virtually essential for good vision in more advanced
good so wounds readily heal if you let them granulate anorectal surgery (26-17).
from below; make sure your nurses understand this.
Only rarely attempt primary suture, and instead make
wide, shallow saucer-like wounds.
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Draw the buttocks apart and look at the anal region for
skin tags, excoriation, eczema, lumps and the openings
of fistulae (26-2B). Feel any abnormalities, such as the
tracks or openings of fistulae, or tumours (26-2C).
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Lubricate the end of your finger well. Insert it so that its The first 12-15cm, as far as the recto-sigmoid junction is
larger broad dimension lies in the antero-posterior axis of usually easy. However, it is easy to miss a lesion in the
the anal canal. When you touch the sphincter, it will rectal ampulla. You will then see the smooth rectal
contract. Wait, give it a few seconds to relax or if it does mucosa giving way to the concentric rugae of the
not, ask the patient to strain as if he were about to pass a sigmoid colon. At this point the bowel passes over the
stool, as this will also relax the sphincter. Then press sacral promontory, and may turn in any direction.
firmly and gently in the axis of the anal canal. Proceed anteriorly and to the left. You should be able to
Keep pressing, until you can feel your finger suddenly reach 25-30cm, but do not force the passage of the
slip easily into the anus (26-2D). Note the tone of the instrument! Be sure you can distend the bowel with air,
sphincter and the presence of stenosis or spasm, and see where you are going before you push the
which may prevent you doing a rectal examination. sigmoidoscope further in.
In this case, you must administer an anaesthetic and do
it: otherwise you might miss an inter-sphincteric abscess If you are clumsy, you can perforate the bowel, so:
(6.17) or carcinoma (26.7). (1) Never push in a sigmoidoscope further, if you cannot
see the lumen in front of it. Follow the lumen at all times.
As you put your finger into the anus, feel for lesions (2) Never force it. If there is a pocket or a blind area in
below and above the anorectal line. Then palpate the the way, withdraw it a little, and then advance it again.
entire circumference of the anus between your two
fingers (26-2E). If your view is obscured by faeces, remove them with
In a man feel each of the 2 lobes of the prostate separated cotton wool on a swab holder, or if this fails, withdraw
by a median groove. the sigmoidoscope, clean it and start again. If the stool is
In a woman, look to see if she has a rectocoele, very loose or there is copious bleeding or mucus,
feel her cervix and uterus rectally, and feel for swellings make sure you have a good suction available.
in her rectovesical pouch. It may be helpful to feel a
mass bimanually through the vagina with one finger of Concentrate on getting the sigmoidoscope as far up as
the right hand and the rectum with one of the left hand: you can; note the presence of lesions by their position
be sure to change gloves before you do this! (in cm) from the anus, and review them as you withdraw
Sweep your finger round and examine the coccyx the sigmoidoscope. Rotate the sigmoidoscope, as you
between two fingers (26-2F). withdraw it, so that you inspect every part of the mucosa.
Finally, if you suspect an intraperitoneal mass, Be careful to examine the posterior wall of the rectal
a bimanual recto-abdominal examination will be useful ampulla. This lies at 90º to the anal canal, and you can
(26-2G). easily miss it.
N.B. You can use the sigmoidoscope to deflate a
PROCTOSCOPY (GRADE 1.1). Examine the anus with sigmoid volvulus (12.4).
your finger first. Lubricate the proctoscope and push it
firmly with its introducer in place in the direction of the
umbilicus. Remove the introducer. Examine the lining of
the anal canal as you withdraw it slowly, looking for
fissures, polyps, ulcers, or haemorrhoids as you do so.
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If you think you may have perforated the rectum or PREOPERATIVE CARE FOR ANAL OPERATIONS
colon, (when you see loops of bowel at the end of your Perform a proctoscopy or sigmoidoscopy before all anal
sigmoidoscope) or there are signs of peritonitis after a operations to exclude coexisting rectal lesions.
sigmoidoscopy, start an IV infusion of saline, commence For this to be possible, the bowel must be empty, so use
gentamicin and metronidazole, and get an erect chest an enema or a glycerine suppository pre-operatively.
radiograph to look for free sub-diaphragmatic air.
POSTOPERATIVE CARE AFTER ANAL OPERATIONS
If there was a clean bowel with good bowel BATHING is more effective than irrigation. Encourage
preparation before the sigmoidoscopy, particularly if soaking in a warm bath; you can add some antiseptic to
the perforation has occurred in the distal retroperitoneal the water if you are not sure about the cleanliness of the
section of the rectum (<12-15cm from the anal verge) tub!
and symptoms and signs settle within 12hrs, continue
this conservative treatment for a further 48hrs. DRESSINGS are much less important. Soiled dressings
Otherwise, do not hesitate to perform a laparotomy and will perpetuate sepsis, so encourage frequent bathing or
try to close the perforation with interrupted sutures; douching.
you may add a defunctioning stoma if there is significant
soiling. BOWEL ROUTINE. Treat with a laxative od from the
day of the operation for a maximum of 2wks.
Encourage mobilization from the first day. Do not use an
enema as introduction of the funnel will be painful and
may disrupt the wound. If there is no stool passed by the
3rd day, gently insert a glycerine suppository.
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(a) Idiopathic anorectal ulcer (26.5). This starts as a Because these fistulae are complex, multiple and often
mucosal laceration within the anal canal, and gives rise high or intersphincteric, they cannot be simply laid open.
to symptoms identical to the classical anal fissure. In fact, even for low superficial fistulae, the laying open
It is virtually pathognomonic of HIV disease. may result in non-healing perianal wounds, especially if
However, no anal skin lesion is visible on gentle parting CD4 counts are <200/μl. Treatment by passing one or
of the buttocks, because the lesion is internal, usually more setons (26.3) is not only simple, but very effective.
just proximal to the dentate line. Furthermore there is You need to be patient, however: these wounds may take
rarely anal sphincter spasm, and often diarrhoea rather 8-12wks or even more to heal.
than constipation. Pain is persistent, usually associated
with some intermittent bleeding per rectum, particularly (d) Proctitis (26.11). Just as in colitis, the rectum may
after defecation. be affected by a severe inflammatory process:
cytomegalovirus, herpes simplex, chlamydia or
The mucosal defect then deepens and becomes palpable enteropathic E Coli may be the cause. You will have to
as an ulcer with smooth benign-feeling edges. treat blind with broad-spectrum antibiotics, as it is
As this ulcer deepens further, it may penetrate into the unlikely you will have the resources to make a specific
vagina or appear as a large fistula externally. Often pus diagnosis. Avoid steroids and sulfasalazine, unless you
collects in the ulcer crater and discharges through the can confirm ulcerative or Crohn’s colitis.
anus. No specific agent is often implicated in this lesion,
although in some cases cytomegalovirus and herpes (e) Anal and perianal warts (26.6) are often very
simplex virus are found. The ulcer edge is smooth and extensive and may co-exist on the urethra and external
round, unlike the syphilitic ulcer which is irregular. genitalia, and even elsewhere on the body; their excision
Treatment with glyceryl trinitrate is unsuccessful, or diathermy ablation surprisingly results in rapid wound
because there is no anal spasm. Sphincterotomy, healing, presumably due to an epithelial growth factor in
or worse, anal stretch, is a disaster, resulting in faecal the causative papilloma virus, despite other types of
incontinence. If there is pus, use nalidixic acid, anorectal surgery having poor healing in HIV+ve
or ciprofloxacin with metronidazole. patients. Contact tracing in the developing world is a
N.B. A shallow triangular ulcer posteriorly placed, pipe-dream, and therefore recurrence by re-infection
without spasm or bleeding, may be due to syphilis (26.5). is frequent. Moreover, if you do not remove all
Check also for gonococcal infection especially if there condylomata, including penoscrotal ones, and they can
has been ano-receptive sexual intercourse (26.11). extend far up in the anal canal, they quickly re-establish
themselves. They may become infected and ulcerated,
(b) Superficial breakdown of perianal skin with and if chronic, develop into squamous carcinoma.
excoriation is often occurs with chronic diarrhoea.
There is often also excoriation in the intergluteal cleft, They may occur in children through cross-infection by
which may be due to excessive sweating. Vesicular sleeping in the same bed, and do not necessarily imply
excoriation is due to herpes simplex. Otherwise the sexual abuse, although this should always be kept in
causative agents are usually candida and/or trichuris mind and investigated.
(whipworm). It is vital to examine patients carefully to
exclude fistulae and abscesses. If the warts are extremely voluminous (then grandiosely
Use nystatin ointment bd, or miconazole 2% cream bd known as Buschke-Loewenstein tumours), you may
for 2wks or itraconazole 200mg bd for 1wk and remove them in staged procedures. Always use lidocaine
mebendazole 2mg/kg bd for 3days. Zinc oxide or with adrenaline infiltration, because they can bleed
manganese sulphate paste is better than mercurochrome. heavily. There is a risk of anal stenosis if you remove
You must try to control diarrhoea and sweating. crops of warts right up to the anal verge, or even inside
These patients are usually grossly cachectic, the anal canal. In this case, get the patient to use a
so encourage high- protein, high-calorie diets. plastic anal dilator bd for 6wks. Make sure he takes baths
N.B. If cortisone preparations have been used, post-operatively; a shower is not really adequate.
the perianal skin becomes paper-thin, and atrophied and
readily damaged. (f) Squamous carcinoma (26.7) may be the result of
neoplastic change seen in anal intra-epithelial neoplasia
(c) Sinuses and Fistulae (26.3) in HIV+ve patients are (AIN), or be the result of chronic infestation by
often complex and multiple. They are frequently high or condylomata, especially if florid, or arise de novo.
intersphincteric (intermediate). Many fistulae arise from There appears to be much greater risk of developing
sepsis, but some as a result of extension of the idiopathic malignancy if ano-receptive sexual intercourse is carried
anal ulcer described above. In these cases, the fistula is out.
wide and may readily admit the examining finger.
Fistulation can occur to the outside skin, but also to the You must establish a histological diagnosis; it is rarely
vagina or bladder. possible to perform a local excision without causing
This is found both in adults and small children, stenosis, or resulting in inadequate tumour excision.
where the history of whether the fistula is congenital or This means that an abdominoperineal resection will be
acquired is diagnostic. necessary (12.11) which is a formidable undertaking in a
patient with HIV disease.
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Lymphoma and Kaposi sarcoma may also be found at Typically, a fistula starts with a papule, abscess, nodule,
the anus, but you will only make this diagnosis by or ulcer, which either bursts and fails to heal, or is not
biopsy. Very rarely, a malignant melanoma is found at drained properly, after which there is a chronic painless
the anus: it looks like a thrombosed haemorrhoid. discharge which soils the clothes. The fistula is only
painful when it becomes temporarily blocked, when pus
(g) Rectal Prolapse (26.8) is often the result of a very builds up inside it.
lax anal sphincter. Although this may occur in patients
with chronic diarrhoea or neuropathy, it is much more Fistulae can take any of the paths shown (26-5);
common in homosexuals who practice invasive rectal they can be subcutaneous (common), low anal, high anal,
procedures for pleasure. or intermuscular (rare).
Local perineal operations do not correct the essential
problem of laxity; you can amputate redundant Rather wider fistulae exist as extensions of the idiopathic
prolapsing full-thickness rectum but you will need to be anal ulcer of HIV disease (26.2): these are usually
careful that you restore bowel continuity. superficial and have a significant absence of granulation
Doing a laparotomy to lift up the rectosigmoid is an tissue.
alternative: you should avoid using any foreign implant
material for fixation, and do this only if the patient is A fistula seldom heals spontaneously, and almost always
getting ARV treatment. needs surgery. The options are passing a seton, laying
open the fistula track (fistulotomy), or fashioning a
defunctioning colostomy.
The aim of surgery is to obtain a permanent cure while
26.3 Anorectal sinuses & fistulae preserving sphincter function; you therefore must know
the relationship of the fistula track to the sphincters, and
Anorectal abscesses (6.17), sinuses and fistulae are cause minimal damage to them.
usually part of the same disease process. An abscess is
the acute phase, and a sinus or fistula the chronic results. Fistulae which have external openings anterior to the
Both sinuses and fistulae are tracks lined by granulation anus enter directly into it by the shortest path. Posterior
tissue, which open on to the skin near the anus. fistulae usually curve round, so that they enter the anus
The difference between them is that a sinus has no posteriorly in the midline (Goodsall's rule: 26-6I).
internal opening, whereas a fistula opens into the anal In doing so they follow a horseshoe path, and are often
canal, or occasionally into the rectum. Usually, there is bilateral, one side communicating with the other.
only one internal opening, but there may be several There are exceptions, and very superficial fistulae behind
external ones. These can either be insignificant little the line may occasionally track directly into the anus.
holes, or prominent little nodules of granulation tissue, The track of a horseshoe fistula hugs the puborectalis
which heal over temporarily. With HIV disease, part (26.1D) of the levator ani muscle, as it forms a sling
they may be complex, multiple, and chronic. round the sides and back of the anorectal junction,
Likewise, if tubercular in origin (up to 15% in India), external to the external sphincter. Fortunately,
they may be complex, multiple and chronic, and often, the internal opening of such a horseshoe fistula is usually
but not always associated with HIV disease. The cause at the dentate line, although the fistula itself may go
may be mycobacterium tuberculosis or mycobacterium much deeper.
ulcerans.
Occasionally, the cause may be Crohn’s disease where PERIANAl ABSCESSES, SINUSES, AND
the appearance is very similar to tuberculosis. FISTULAE
Other infections may also give rise to fistulae: ARE NOT HELPED BY ANTIBIOTICS!
actinomycosis, gonococcus, chlamydia, schistosomiasis,
mycetoma and amoebiasis. EXAMINATION. Prepare for light GA or ketamine.
Another inflammatory processes which may also give (Spinal anaesthesia or using relaxants is unhelpful
rise to fistulae is so-called hidradenitis suppurativa because you will not then readily feel the anorectal ring.)
(Verneuil’s disease) or pyoderma fistulans sinifica Before you start, warn that you are going to examine
(fox-den’s disease: 34.9). These result in quite marked under anaesthesia to try to find where the fistula runs.
skin thickening and multiple skin bridges, but are If you use ketamine, be sure to put the legs up on
essentially superficial skin problems, and are related to lithotomy poles first before you start anaesthesia,
smoking. as muscle rigidity may prevent you doing so afterwards!
Introduce the Parks anal retractor well lubricated with
jelly.
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CAUTION!
(1),If the probe passes vertically, and not towards the
mid anal canal (even though there is an opening there),
it is probably a high complex fistula or a deep sinus.
(2) Only pass a probe into the rectum through a fistulous
track: do not force it through normal tissues.
In 50% of cases you will find the opening easily, in the
other 50%, it will be present but tiny. A probe may show
Fig. 26-5 PATTERNS OF FISTULAE. it, but if it does not, inject methylene blue (or similar
A, 2 subcutaneous fistulae, 1 opening at the dentate line, and 1 just dye) into the external opening, and look for this flowing
below it. B, two low anal fistulae. C, several high ones. into the anus: finding the internal opening is the key to
D, some more high fistulae. Fistula (1) is the commonest high
fistula; it goes high towards the levator ani, but does not penetrate all fistula operations!
it. The high extension is often missed, but it must be explored and You can add hydrogen peroxide to the dye: its bubbling
laid open. Fistulae (2) and (3) penetrate the levator ani. froth will help show the opening more easily.
E, high intermuscular fistulae (rare) may exist alone (4), or be an
extension of a low anal fistula (5).
After Goligher JC. Surgery of the anus, rectum and colon. Ballière PASSING A SETON (GRADE 2.2) is one of the oldest
Tindall 4th ed 1980 Figs 121-6 with kind permission. operations in history, first described by the Indian master
surgeon, Sushruta c. 6000BC. Tie a thread to the probe
If the opening is <5cm from the anus, the fistula is and withdraw it through the fistula track, release the
perianal; if it is >5cm away, it is probably high. Multiple probe and tie the thread loosely. By slow, progressive
openings suggest a horseshoe fistula. Record the position inflammatory response, allowing simultaneous drainage,
of all external openings carefully on a copy of the fibrous healing from deep to superficial parts occurs.
diagram (26-4A). This method does not divide sphincters and so preserves
Feel for the thickened track which runs from the external their function, and so can be used for low or high
opening(s) towards the anus. If a fistula is superficial, fistulae. Furthermore as there is no wound, it is ideal in
you can usually feel its firm, fibrous track quite easily. HIV+ve patients. It is also delightfully simple!
As you press it pus may exude from the external The disadvantages are varying degrees of discomfort,
opening. and prolonged treatment needing usually 8-12wks or
Put a finger into the anus and try to feel the internal more.
opening: you may be able to feel an induration at its
internal end. Feel the entire circumference of the rectum, You can use any non-absorbable thread such as ethibond,
as far as your finger can reach. Determine particularly though silk will stimulate more of an inflammatory
where the fistula might be in relation to the anorectal reaction; corrosive ‘soaps’ applied to thread such as the
ring and the dentate line. Try to feel the track between latex of Euphorbia neriifola or solution of ash of
your two fingers. Does it appear to come to an end low Achyranthes aspera increase the efficacy but may result
down, or high up in the anus? If you feel induration at in excessive inflammation and surrounding cellulitis.
the level of the puborectalis or above (rare), there is a A nylon suture is sharp and painful, and not well
complex high fistula. tolerated.
For best results, replace the thread weekly by tying a
Examine the anal canal with a proctoscope. You may be new one to the old one and pulling it through the track,
able to see the internal opening of the fistula, usually and tying it loosely. Remove it when the distal hole is
posteriorly in the midline on the dentate line. almost completely closed.
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LAYING OPEN (DEROOFING) THE FISTULA Pass a probe or director through the track, from the
(FISTULOTOMY) (GRADE 2.2). external opening towards the anal canal, either
completely through to its lumen, or as far as it will go.
You should now know where the fistula runs. Only open It may enter the anal canal, or it may stop before doing
a simple low fistula, superficial to the dentate line if so. Confirm that the probe enters the anus superficial to
there is no HIV disease. Do not open high or complex the dentate line, cut down through the skin on all
fistulae; you may render a patient permanently structures superficial to it, and lay the track open.
incontinent. If there is untreated HIV disease, If you are using a director (26-6C,D), cut down onto its
the wounds may never heal. groove through the skin. Look at the purplish track of the
opened fistula. If there is no such track, you have
probably opened up a false passage. Look carefully for
any side openings, and feel among the fatty tissue for
nodules of induration, which might be branches of the
fistula. As a general rule, all fistulous tracks
communicate with one another. Using a sharp spoon,
curette the tracks, so as to leave only healthy tissue, and
trim away any overhanging skin.
Alternatively, make a narrow pear-shaped incision to
include both the internal and external openings.
Excise both of them, and the track of tissue that still
clings to the probe.
Control bleeding with diathermy, or tie off bleeding
vessels with 2/0 absorbable suture. Bevel the skin edges
by making an inclined cut, so as to leave a conical or
pear-shaped concave raw area. Be sure that there will be
no pockets or overhanging edges, when muscle tone
returns.
Always send tissue for histology if possible to exclude
tuberculosis or other pathology.
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Obviously, patients who defecate in pit latrines are CAUTION! Never forget to perform a proctoscopy
unable to describe much about the blood they pass, and/or sigmoidoscopy in an adult presenting with rectal
and therefore you have the obligation to find out as best bleeding.
you can. There are clues, and you must try to distinguish
lower intestinal from upper gastro-intestinal bleeding: If attempted rectal examination is exquisitely tender,
the latter is usually dark purplish and sticky with a sweet stop and do it under anaesthesia.
pungent odour (melaena) or, if the bleeding is more
rapid, comes out as dark red burgundy-coloured blood. If you palpate a polyp, try to pull it down through the
This bleeding is not necessarily from the stomach or anus, tie the stalk, and cut it off. If you cut the stalk
duodenum (13.4) although that is the most common site, without tying it first, it may bleed massively.
and may come from the small bowel and rarely from the
large bowel. It is often severe, is usually more serious If you feel a craggy mass or stricture, examine under
than it looks, and frequently threatens the life. anaesthesia and take a biopsy. (26.7)
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INDICATIONS FOR LAPAROTOMY FOR RECTAL Later, the fissure may become indurated and infected,
BLEEDING. and may lead to a low perianal abscess (6.17). This may
(1).Loss of >1500ml of blood with unknown cause. discharge through the fissure, and externally, to produce
If he is in extremis, surgery may be life saving. a low anal fistula. The internal sphincter lies directly
(2) The presence of a mass. under the fissure, and after several months of exposure
N.B. Most colonic bleeding stops on its own, so do not this becomes fibrosed and spastic.
operate too early.
The HIV-related fissure arises often posterolaterally
PREPARATION. Resuscitate with IV fluids if shocked, proximal to the dentate line, and develops into a smooth
and tranfuse blood to get a Hb level of at least 8g/dl, shallow ulcer, which deepens and may collect pus.
and have more blood in reserve for operation. This may then fistulate with a wide track (26.3)
externally or into the vagina. The cause of this problem
LAPAROTOMY. Make a long midline incision. is rarely clear, and its treatment is unsatisfactory.
Look at the stomach and duodenum and feel for
irregularities and signs of ulceration. Then examine the EXAMINATION.
entire bowel from the duodeno-jejunal flexure down to An acute fissure is very painful, so do not try to do a
the rectum. Note the colour of the contents of the bowel, rectal examination if you thereby hurt the patient even
which is purplish if it has blood inside. more. You may not be able to pass a proctoscope until
What is the highest site in the bowel to show bleeding? you have gently introduced a submucosal injection
Look for abnormal vessels going to the bleeding area, of LA or administered a GA. You can, however,
and feel for induration or an ulcer. If necessary, open the usually see a classical fissure by parting the buttocks
bowel (11.3), or stomach (13.5) to find the level of the gently; there is often a sentinel skin tag. The HIV-related
bleeding. Using an endoscope (13.2) through the opened fissure feels like an irregularity inside the anal canal; you
bowel is very helpful. may see pus discharging from the anus. Distinguish this
If you are confident you have found the lesion, perform a from pus discharging from an adjacent fistula.
localized resection (11.3), but if there is severe bleeding
from the right colon, you do not find a lesion, and there If there is more induration, a larger ulcer,
is no bleeding more proximally, perform a 'blind' right and perhaps enlarged inguinal nodes, think of a
hemicolectomy (12.11). This will not be easy, so do not carcinoma or sexually-transmitted infection: a primary
do it lightly. Afterwards, open the specimen to see where chancre (the 1st sign of syphilis) has indurated margins,
the blood is coming from. a symmetrical lesion on the opposite margin of the anal
canal, and no pain. Secondary syphilis presents with a
If the bowel is severely inflamed, resection may be moist, pruritic anus, with flat, slightly-raised lesions,
more hazardous than a conservative approach which are usually symmetrical on both sides.
(12.3,4).
TREATMENT depends on how long the fissure has been
present.
26.5 Anal fissure If it is acute (<10days), only the epithelium is involved
and it will heal, if you keep the stools soft for 2wks with
An anal fissure causes suffering out of all proportion to a laxative. When it has healed, warn that it may return,
its size. There are essentially two types, the classical and if constipation recurs. So advise a high fibre diet.
the HIV-related. The latter is internal and not seen by To reduce severe acute pain, introduce a condom (or the
gentle parting of the buttocks, and not usually associated closed finger of a rubber glove) filled with water and
with muscle spasm. Both types present as a defect in the frozen, into the anal canal. You can also help with LA
mucosal lining in the lower part of the anal canal, which ointment (5% lidocaine): this should be smeared over the
makes defecation, and the half-hour following it, acutely sphincter inside the anus, not outside it. Injection of
painful. Even the thought of a bowel movement may fill submucosal LA, though effective, is rarely tolerated by
the patient with such dread that he suppresses the urge, most patients.
so that the hard constipated stools that he eventually
passes make the fissure worse, and may occasionally If the fissure is chronic (>30days), fibrosed, of classic
make it bleed. With HIV disease, however, he often has type, and has a sentinel skin tag, and especially if you
a loose stool. can see the exposed fibres of the internal sphincter under
it, it will probably not respond to non-operative
The classical fissure usually occurs posteriorly in the treatment, though it may improve with glyceryl trinitrate
midline, between the anal verge and the dentate line, 0.2% or diltiazem 2% cream locally. If symptoms persist
directly over the distal end of the internal sphincter. for months and there is anal spasm, and the HIV test is
A small oedematous skin tag commonly forms on the negative, consider a lateral sphincterotomy, or excision
anal verge, just posterior to the fissure. This is the of the fissure and skin tag. This second is a delicate
'sentinel skin tag'. procedure best left to an expert, though.
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If the fissure is the HIV-related variety, treat with N.B. NEVER PERFORM AN ANAL STRETCH!
laxatives, if there is constipation (unusual), and nalidixic (It is a crude uncontrolled way of doing a
acid or ciprofloxacin with metronidazole, if there is a sphincterotomy and may well result in permanent
purulent discharge from within the anal canal. incontinence, or even anal gangrene, especially in
Advise against using jelly with the spermicide, HIV+ve patients.)
nonoxylon-9.
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If you see suspicious areas like this early, and can excise If there is, you can usually replace the rectum manually,
them locally, you may be able to prevent the but it is likely to prolapse again. If it remains prolapsed
degeneration to invasive carcinoma. too long, it ulcerates.
Anal Kaposi sarcoma, and non-Hodgkin’s lymphoma
also occur in HIV+ve patients. The prolapse will however correct itself with age and
These lesions may be extensive and fungating on improved nutrition. You should make sure the child sits
presentation, when you will be unable to achieve properly during defecation, rather than squatting,
excision with adequate clearance. Special techniques in and you can also strap the buttocks (26-10). If this does
well-equipped centres may still effectively deal with not prevent prolapse recurring, apply gallows skin
such tumours; otherwise the alternative is an abdomino- traction (pulling the buttocks up off the bed) and watch
perineal resection, which many such patients will not be the prolapse reduce spontaneously.
able to tolerate. Consider carefully if a defunctioning
sigmoid colostomy (11.6) will benefit; biopsy is essential An adult's rectal prolapse is much more difficult to treat.
to make a diagnosis. Symptoms are the result to the prolapse itself.
Occasionally if the lesion is small and near the anal However, it may be due to chronic large bowel
margin, you can infiltrate it with LA solution containing obstruction from malignancy or Schistosomiasis,
adrenaline, and excise the tumour widely. You will need so ask about a history of constipation.
anal retractors and an assistant to achieve this.
EXAMINATION.
Differentiate between an anal carcinoma and LGV, If the prolapse is intermittent, the history may be of
chancroid, schistosomiasis, amoebiasis & donovanosis, 'something coming down', but there will be nothing to
all of which can produce a destructive ulcer see. In an adult, pass a proctoscope and ask the patient to
N.B. Rectal carcinoma, which arises above the dentate strain down. The anal mucosa will prolapse into the
line (12.11, 26-1) where the rectal mucosa starts. hollow of the proctoscope, and extend beyond the anus
as you withdraw it. If the prolapse is complete, the whole
thickness of the rectum slides out all round, sometimes
for several centimetres. At rectal examination,
26.8 Rectal prolapse (Procidentia) the anal sphincter feels weak.
Occasionally, the rectum prolapses out of the anus. To find out if the prolapse is partial or complete,
It may prolapse incompletely, so that only a pink fold of put you finger into the rectum, and feel the protruding
mucosa shows, or it may prolapse completely, so that the ring of mucosa between your finger and thumb.
whole thickness of the rectal wall is turned inside out If all you can feel is 2 layers of mucosa, it is incomplete;
(procidentia), and may ulcerate. At the same time the if you can feel more tissue than merely mucosa,
anal sphincter may stretch and become patulous, it is complete.
so that incontinence results. At first the rectum prolapses
only with defecation, later it does so on minimal In a child, distinguish a prolapse from a rectal polyp,
coughing and straining; finally it is outside all the time. or an ileorectal intussusception. Examine immediately
Although the rectum can prolapse at any age, after defecation. Feel the outer aspect of the swelling,
it commonly does so in children of 3-5yrs up to the anal orifice. In an ileorectal intussusception,
(usually incompletely), and occasionally does so in the you can pass your finger between the intussuscipiens and
aged (usually completely). Prolapse is more common in the anal wall: you can’t do this with an anal prolapse.
malnourished children, perhaps because of poor tone and A rectal polyp is mobile and dangles from the anorectal
weakness of the anal sphincter mechanism, and is also wall, and you can flick it with your finger: make sure it
associated with diarrhoea as well as straining when cannot be squeezed like faeces.
seriously constipated. If a child's diarrhoea and N.B. Strictly speaking, a rectal prolapse is a
malnutrition is treated, the prolapse is usually cured also. recto-rectal intussusception.
A chronic cough, especially with whooping cough and
cystic fibrosis, whipworm (trichuris) infestation and In an adult, you may find that the prolapse is reduced
coeliac disease (reaction to gluten) predispose to when you start your examination, but appears with
prolapse. Prolapse often occurs in babies with spina straining. The anal orifice may be widely open, and the
bifida (33.11) and ectopia vesicae (33.15). Prolapse sphincters abnormally lax. Assess their tone with your
occurs also in those who practice anal intercourse. finger, because this is an important determinant of
treatment and prognosis. You may feel very little
A child's rectal prolapse is usually noticed by the mother contraction. If it is very lax, you may be able to put 3 or
who says that something red appears at the anus after 4 fingers into the anus without discomfort.
defecation. When she brings him to you, there is usually This is especially so amongst those who practice anal
nothing to see. intercourse.
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(A) CHILDREN WITH RECTAL PROLAPSE THIERSCH'S OPERATION FOR RECTAL PROLAPSE
If a child has diarrhoea, treat that. If the nutrition is poor, (GRADE 2.1)
treat that first. These are the common causes of prolapse, This method is really only applicable to children with
and treating them usually provides a cure and avoids an severe anal hypotonia or other neurological problems:
operation. it is absolutely contra-indicated in cases of constipation!
Regular small doses of a mild sedative helps; put the Use the lithotomy position and give ketamine;
child on a potty-chair, not sitting on a pot on the floor. replace the prolapsed rectum (26-11A). Put your finger
in the anus and feel the sphincter. It may be so loose that
MANUAL REPLACEMENT AND STRAPPING. you can hardly feel it.
Using a glove and lubricant jelly, replace the prolapse
manually. You may have to squeeze it for 15mins to do
so. If it is very oedematous apply gauze with icing sugar,
which will soak up the oedema fluid and allow you to
reduce the prolapse later.
Strap the buttocks securely together with the large gauze
pad up against the anus. If this method is to work,
the strapping must be adequate, painless, and easily
applied. Apply a large square to each buttock. Join these
with a 2½-5cm transverse strip, so as to close the
buttocks, and leave this strip on during defecation.
Afterwards, remove it, clean the buttocks, and replace it
with a fresh strip (26-10). Ask the parents to repeat this
after each bowel movement, and give them some
vaseline gauze, plain gauze, and strapping, with which to
do it. After a time, the rectum will stay up where it
belongs. Strapping is often all that is necessary.
If, after 3-4 reductions the prolapse soon recurs after
defecation, put up gallows traction.
CAUTION! Too much trauma trying to reduce a
prolapse causes bleeding; in this case proceed to gallows
traction.
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METHOD.
Push some dry gauze into the rectum, and slowly pull it
out. The haemorrhoids will prolapse with it. Grasp the
skin at the mucocutaneous junction of each haemorrhoid
with haemostats, and pull them outwards (26-14B).
Take the purple mucosa-covered part of each
haemorrhoid in other larger haemostats, and draw
them downwards and outwards. This will bring all
3 haemorrhoids well out of the anus, so that you see the
pink rectal mucosa at their upper ends (26-14C).
Pull on all 6 haemostats until you see the rectal mucosa,
not only at the upper end of each haemorrhoid, but also
between them, and secure the haemostats with towel
clips to give you a clear field. Draw the haemorrhoids
out as far as they will go, which will allow you to tie
them at their upper poles, rather than around their
middles.
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Push some dry gauze into the anus, and examine for If the stools become impacted, this is probably the
haemostasis; you may need a lubricated speculum to result of being allowed home without adequate or with
look at the ligatures. Infiltrate 2ml bupivacaine into each constipating analgesia. You will need to extract faeces
pedicle for post-operative pain relief. The end result manually under anaesthesia. If the wounds are still raw,
should look like a clover leaf (26-14H). Apply petroleum start metronidazole and use sufficient laxatives.
jelly gauze to each of the three raw areas on the anus,
and cover this with cotton wool. Hold it in place with a If a stricture develops, you probably did not leave
T-bandage. adequate bridges of tissue between the excised
Remove the dressings in the bath the next day. haemorrhoids. Provide the patient with an anal dilator
Use showers on subsequent days. Treat with laxatives and show him how to pass this daily for 3months.
and adequate non-constipating analgesia, paracetamol or
NSAIDs. If no stool is passed by the 3rd day, use a If there is mucous prolapse post-operatively,
glycerine suppository. Do not discharge the patient do not rush in to excise further tissue. Healing will in
before he passes stool because otherwise faecal most cases cause the anal mucosa to retract
impaction may result! spontaneously.
If there are accessory haemorrhoids, only excise the 26.10 Pilonidal infections
main ones, so that that you only make 3 skin wounds.
Leave the accessory haemorrhoids: they will shrink of Long straight hair sometimes works its way into the skin;
their own accord. Do not try to excise separate skin tags this occurs especially in the natal cleft just posterior to
outside the main skin wounds. the anus but also at the umbilicus to form an abscess,
sinus or fistula. This occurs in people with copious long
If there is an associated anal fissure, treat it (26.5) and straight hair, most commonly young males. There may
leave the haemorrhoids alone. be one or more openings, sometimes with hairs coming
If there is postoperative PAIN, treat with pethidine. out of them, exactly in the midline 5cm posterior to the
If severe pain follows defecation, a hot bath will soothe anus. Often, there is another sinus, 2-5cm superiorly, and
the discomfort. slightly to one or other side of the midline,
with an indurated track joining it to the first one.
If there is difficulty passing urine, try using pethidine
and encourage passing urine in a warm bath. If this fails, Do not mistake a pilonidal sinus for a subcutaneous or
catheterize the bladder, and remove the catheter after perianal fistula (26.3). If you are in doubt, remember:
48hrs. Or, alternatively perform a suprapubic aspiration. (1).In a pilonidal sinus there will be no induration
between the lowest sinus and the anus.
If there is bleeding within 12hrs (reactionary (2).There will be no fistulous opening inside the anus.
haemorrhage), usually due to a slipped ligature, (3) When you probe the lowest sinus, the probe will pass
adrenaline wearing off, or a rise in BP: pull down on the towards the sacrum, not the anus.
ligatures, which you left long deliberately for this
eventuality, and try to secure the bleeding vessel with Aim to excise the sinus without any surrounding tissue,
artery forceps in the ward. If this fails, return to theatre make sure that the wound heals properly, and prevent
to perform a formal proctoscopy to find and ligate the hairs growing into it as it heals.
bleeding vessel under GA.
If there is no infection, excise the affected area,
N.B. There maybe torrential bleeding from portal otherwise if infected, aim initially only for simple
hypertension if the haemorrhoids are the sites of porta- drainage. The most important part of the postoperative
systemic shunts: in this case use Vitamin K, fresh frozen care, after either method, is to make sure that new hair
plasma and tranexamic acid if you can get these. does not grow into the granulating wound.
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METHOD.
Probe all the openings to find in which direction the sinus
tracks run. If this is difficult to elucidate, gently inject
methylene blue dye into the tracks to mark their
pathways: beware not to inject too brusquely, otherwise
the whole area will be coloured blue!
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RECTAL ULCERATION.
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You can fill an open glass jar with plaster around a long
forceps. For a smooth ball, use two long spoons and
apply traction as with obstetric forceps! For a soft object,
you can try skewering it with a myomectomy screw.
Beware if the object, or the tool you use, is sharp,
that you do not lacerate the colorectum on removal;
if you do so, and the damage is retroperitoneal, keep the
patient nil orally and treat with metronidazole. If the
damage is intra-peritoneal, perform a laparotomy to find
the perforation and close it primarily in 2 layers (11.5).
RECTAL STRICTURE
You may have to use your ingenuity to grasp it; pushing If obstruction is severe, fashion a defunctioning
on the abdomen from above may help. Extracting a sigmoid colostomy (11.6) whilst you prepare for an
round smooth object may produce an insurmountable abdominoperineal resection and a permanent end
vacuum; in this case, pass a catheter beyond the foreign colostomy. If you have an anastomosis gun, it may be
body and introduce some air. possible to place the anvil proximal to the stricture and
thereby resect it endo-anally whilst at the same time
improving the luminal diameter.
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If it still does not pass: If the Y-connection does not reach the meatus or urine
(1) It may be too large (try a smaller one). does not come out, do not inflate the balloon: it may still
(2) The sphincter may not be relaxed (27-2C) because the be in the urethra rather than the bladder, and inflating it
patient is frightened (try sedation). may cause urethral damage and ultimately stricture
(3).The urethra may not be properly anaesthetized formation. There is no harm in strapping or suturing the
(try introducing 5-10ml more lidocaine, with lubricant catheter in place, if you see no urine but are fairly sure the
jelly). catheter is in the bladder (e.g. in renal failure),
(4).The catheter may have caught in mucosal pockets in and waiting. If you can, check with ultrasound to see if the
the urethra: you can easily make these into a false passage, bladder is really full. If you are sure the catheter is in the
if you are not careful. bladder, it might be blocked with debris or blood:
(5).There may be a large prostate, which distorts the try flushing it gently with a little sterile water. If after an
urethra, and prevents the catheter following it into the hour, there is still no urine, and the bladder remains full,
bladder. Try passing a small Ch12 catheter folded back on the catheter cannot be in the correct position.
itself (27-2E); if this fails, perform a suprapubic Use ultrasound to check where it is (38.2H).
catheterization (27-9)
CAUTION! Ask your nurses to empty the urine bag
When the Y-connection of the catheter reaches the before it is full and at least every 24hrs, aseptically and
urethral meatus and you see urine coming out, without getting urine organisms on their skin. Do not let a
then you can inflate the balloon, not before! Do not fill it full bag pull on the inflated balloon: it may cause pressure
to its maximum capacity: 10ml is adequate to stop the necrosis of the posterior urethra. Be sure your nurses chart
catheter falling out. Remember to pull back the foreskin the urine output meticulously.
over the glans penis to prevent paraphimosis!
PASSING A CATHETER ON A FEMALE ADULT
(GRADE 1.1)
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If the urethra is stenosed, this may be due to mutilating N.B. A latex catheter becomes encrusted in 3-4wks,
surgery or damage from childbirth associated with a and a silicone one in 3-4months. Be safe, and change a
vesico-vaginal fistula (21.18). Simple dilation is usually latex one every 4wks and a silicone one every 12wks.
possible (27.9).
If you have inflated the balloon in the urethra,
If you cannot expose the urethra, especially in an elderly deflate it and remove the catheter; do not attempt
woman with atrophy of the vagina, mount a Ch16 catheter re-catheterization via the urethra. If the patient develops
on an introducer, and gently pass this along the anterior urinary retention, insert a suprapubic catheter (27.7).
wall of the vagina till it drops effortlessly into the bladder. If the balloon will not deflate, palpate it through the
You may need to palpate the urethral orifice with a finger penoscrotal skin, and rupture it with a needle.
and guide the introducer accordingly.
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CONTRAINDICATIONS.
Fig. 27-4 SIMPLE CYSTOSCOPY. Acute cystitis, until you have controlled the infection.
A, sheath. B, telescope. (The Albarran lever is for manipulating the
ureteric catheter). C, Introduce the cystoscope under direct vision of
the anterior urethra. D, the bulbar urethra, and E, the prostatic TESTING THE CYSTOSCOPE.
urethra. (N.B. The right leg has been removed for clarity!) Do this before you sterilize it. Look down the telescope;
the image should be clear. If it is misty, there is dirt on the
CYSTOSCOPE. There are more sophisticated operating, lens; clean with spirit-soaked swabs. If it is still misty,
and simple viewing cystoscopes. All need an irrigation water has probably entered the telescope, so return it to the
channel. makers or an agent for repair.
The urethroscope has 0º viewing angle (to look straight If a crescentic part of the visual field is cut off,
ahead), and a viewing cystoscope 30-70º (to look around). the telescope has been bent. If this only happens after you
Methods of irrigation differ. Some cystoscopes have a tap have inserted the sheath, it is the sheath which is bent.
with two positions, some have two taps, and in others you
have to remove the telescope and fix a tap ('the faucet') STERILIZATION.
in the hole where the telescope was. Even though you may be able to put your cystoscope
SYRINGE, bladder, Barrington's metal. Use this to wash (if it is an old-fashioned sort) in an autoclave, it will last
out the bladder during cystoscopy. longer if you use an antiseptic solution. Keep it in its box
CAN, douche, metal, 3l, with rubber tubing. until you want to use it.
Remove the compression ring and valve, and immerse it in
INDICATIONS. glutaraldehyde solution, 1% chlorhexidine, 1/1000 mercury
(1);Urinary retention, or difficult micturition, particularly oxycyanide, or 1/80 phenol for 10mins; immersion will
as a prelude to prostatectomy. If the patient has an kill all bacteria capable of infecting the bladder.
enlarged prostate, cystoscopy may precipitate acute Rinse it thoroughly in sterile water, and place it on a sterile
retention, so do it as the first stage of a prostatectomy towel. After use, rinse it in water, and dry it with swabs
(27.20). soaked in spirit.
(2);Haematuria in a patient >30yrs in areas where
schistosoma haematobium is highly endemic (27.5). ANAESTHESIA.
(3);To diagnose schistosomiasis when it is strongly You may be able to examine a woman as an outpatient
suspected clinically, but you cannot find ova in the urine. without any anaesthesia if you are gentle and use a
(4) Recurrent urinary infection. lubricated instrument, unless she has a painful stricture of
(5) Investigation of bladder stones. her external meatus, or a very irritable bladder.
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GA will be easier in the male and if you are inexperienced, INSPECTION. Distend the bladder with 250ml of water.
or he has carcinoma of the bladder (27.5) or tuberculosis (A normal bladder holds 250-400ml). You can also use air:
(16.7). this often gives a better view.
PREPARATION.
Use the semi-lithotomy position: flex the hips to only 75º
and abduct them 30-45º, so as to leave the buttocks further
up the table than the poles. Do not use the full lithotomy
position. To provide fluid for irrigation, you can use
autoclaved water in a receptacle maximally 60cm above
the patient.
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The other important cause is prostatic hypertrophy and 27.5 Bladder carcinoma
HIV-related cystitis. Other rarer causes are renal
tuberculosis, renal carcinoma, radiotherapy, ketamine
abuse and vascular abnormalities. Histologically, there are two main kinds of carcinoma in
the bladder:
Because cystoscopy is so necessary in the diagnosis of (1) Squamous carcinoma, related to exposure to
malignancy in areas where S. haematobium is endemic schistosoma haematobium. In areas where this is endemic
(27.5), it should be the first investigation after Hb, urea, (especially along the Nile), it is often the most common
urine microscopy and culture and ultrasound; cancer found.
an intravenous urogram is not usually helpful. (2) Transitional carcinoma, which has a 75% chance of
being papillary, and of such low-grade malignancy that it
Bladder stones seldom cause macroscopic haematuria. can be controlled with diathermy. Anaplastic degeneration
Ureteric stones usually present with renal colic and indicates end-stage disease.
microscopic haematuria. In non-schistosomal areas, most bladder tumours are
Haematuria in a male cannot be simply attributed to a transitional, papillary, and of low-grade malignancy,
urinary tract infection: there is always another underlying and associated with simultaneous tumours of the ureter or
cause. renal pelvis.
Haematuria in a woman may arise from the urine being
contaminated by a menstrual flow. In areas where S. haematobium is endemic, only about 5%
Confirm that there really is blood in the patient's urine by are like this, 10% are anaplastic, and 85% are squamous.
examining it microscopically. Of these, most are either sessile or ulcer-cancers, both of
which grow rapidly, and penetrate early into the muscle of
THE 2 GLASS TEST. Ask the patient to pass the urine the bladder or into the paravesical tissues. They may also
into 2 containers, and watch him do it: have obstructed the ureters or the urethra by the time they
(1) A constant ooze from the urethra, indicating a lesion present.
distal to the external sphincter.
(2) Initial or terminal haematuria, indicating a local lesion The patient is usually 35-60yrs and has a 2:1 chance of
of the bladder or prostate. Terminal haematuria is typical being male, complaining of:
of schistosomiasis. (1) haematuria, which is initially painless,
(3) Total haematuria which is equal in both glasses, (2);passage of white sludge, or small pieces of white
and may contain worm-like clots, indicates bleeding from material (necrotic tumour),
the upper urinary tract or bladder; it is common in (3);increased frequency of micturition, as the result of
schistosomiasis and carcinoma of the bladder. irritability, infection, and a small bladder,
(4) a suprapubic mass,
CYSTOSCOPY is usually best done after bleeding stops. (5);retention of urine (5%), as a result of the tumour
The exceptions are: obstructing the urethra.
(1) A bladder full of clot which needs immediate
evacuation. In areas where S. haematobium is not endemic,
(2) Recurrent haematuria when you cannot find a cause, you should cystoscope all patients with haematuria.
and when you would like to know from which kidney This is impractical in endemic areas, because so many
blood is coming: this is rare. patients pass bloody urine.
Macroscopic haematuria, due to S. haematobium alone,
ULTRASOUND (38.2H) will show if there is a foreign becomes less common as age advances, because of the
body or tumour in the bladder. fibrosis round the ova, so that by the time that someone is
30yrs, there is a 25% chance that, if he sees blood in the
RADIOGRAPHS. A plain radiograph (in oblique urine, it is caused by a bladder tumour, rather than merely
orientation) may show calcifications in the kidney or line by the worms laying their eggs. So, if you are in an
of the ureter. You can confirm these with an intravenous endemic area, cystoscope everyone >30yrs who complains
urethrogram (38.1) of haematuria (27.4). Few cases of carcinoma of the
bladder occur in anyone <30yrs.
CAUTION! Occasionally you may see red urine from
eating excessive amounts of beetroot, chewing huge There is little that you can do for aggressive schistosoma-
quantities of betel leaf, or in porphyria. Even more rarely, associated carcinoma of the bladder, but do try to confirm
a patient may have deliberately dripped blood into a urine the diagnosis.
sample! Patients need to know if they have a serious condition or
not. Do not give repeated treatment for presumed
schistosomiasis.
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Stage these tumours (27-8): most patients present in It will spare much suffering, but is unlikely to provide a
inoperable Stages III or IV. The only useful treatment for cure and may be socially unacceptable.
squamous tumours in stages I and II is total cystectomy;
the recurrence rate after partial cystectomy is high, Stage II. The tumour is palpable as a localized, but
but even total cystectomy has few 5yr survivors. definite thickening, which is mobile. It is <5cm in
No effective chemotherapy is affordable, except for those diameter, and is not larger than you expect from
rare patients with high human chorionic gonadotrophin cystoscopy. Treat as for stage I.
(β-HCG) levels. Ureteric diversion (nephrostomy, 27.14)
gives symptomatic relief, but this tends to be short-lived Stage III. The tumour is mobile, >5cm in diameter,
and not without its problems. All you can often do is to and is larger than you expect from cystoscopy. Cystectomy
palliate the patient (37.1). Death is likely from renal may be possible, but is highly unlikely to provide a cure.
failure, due to obstruction of the ureters by the tumour.
Stage IV. The tumour is fixed to the wall of the pelvis,
ULTRASOUND (38.2H) will show a thickening or mass or to the paravesical glands, or is infiltrating the vagina or
in the bladder wall. rectum. Palliation only is possible.
RADIOGRAPHS. An intravenous urogram (IVU) is Stage V. There is widespread disease. Palliation only.
helpful only where low-grade papillary transitional
tumours predominate, because there may also be tumours CAUTION!
of the ureter and renal pelvis. (1);Confirm the diagnosis histologically, before advising
radical surgery. Schistosomal granulomas (common in
endemic areas) and tuberculosis, can simulate small
tumours.
(2);Avoid a suprapubic cystostomy, because it can cause a
distressing, permanent urinary fistula if a malignant
tumour is present.
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Occasionally drugs may cause urinary retention, (3).Tenderness of the prostate is often difficult to assess,
especially opioids, and antipsychotics. but a genuine prostatic abscess or acute prostatitis is
Acute retention usually presents in much the same way, usually exquisitely tender to palpation.
whatever its cause, with acute discomfort, often late in the (4).An impacted stone in the prostatic urethra (uncommon,
evening when the realization dawns that no urine is going the meatus is the common site of impaction) or
to come out before bedtime. The bladder is usually tuberculous prostatitis can be readily confused for
distended to the umbilicus. No stricture is complete, carcinoma.
and the final stage of the obstruction is probably
congestion and oedema. This will subside if you drain the CAUTION!
bladder suprapubically; then, if you try to pass a urethral (1);The size of a prostate is no indication as to whether it
catheter after 1-2wks, you will probably succeed. If you is causing obstruction or not, but it is useful to know its
are going to perform a prostatectomy, and you can operate size when planning surgery.
during the next few days, you can leave the suprapubic (2).If the bladder is distended, the upper border of the
catheter in place until you do so. If there is a stricture, prostate may be difficult to distinguish from the bladder
you can dilate this as soon as the acute oedema subsides. base, and the prostate may seem enlarged, because it is
being pushed downwards by the distended bladder.
SUPRAPUBIC CATHETERIZATION IS MUCH You may find later, when surgery is scheduled, that the
SAFER THAN A DIFFICULT URETHRAL prostate has disappeared! So if you do think it is enlarged,
CATHETERIZATION examine it again, after you have relieved the retention:
do not diagnose prostatic enlargement from one
First make sure that there really is retention of urine, and examination while in retention.
this is not oliguria or anuria. If you cannot feel or percuss
the bladder, the reason for the inability to pass urine must Examine if the kidneys are palpably enlarged.
be in the ureters or kidneys, or be pre-renal. In doubt, Are the nerves to the bladder intact? Is there perianal
use an ultrasound to look at the kidneys and the bladder. sensation? Test the anal reflex during rectal examination,
One glance at the face will usually tell you if the retention and feel for a patulous anal sphincter. If you suspect any
is acute or chronic: acute retention is agonizing. neurological abnormality, examine the spine and legs
thoroughly.
If the bladder is grossly distended, but not painful,
the retention is either chronic, or neurological. SPECIAL TESTS.
Later, examine the urine for sugar, protein, and pus.
HISTORY. Diabetic and HIV neuropathy can cause retention, and
Has there been gonorrhoea, and how was it treated? proteinuria may indicate uropathy. Measure the Hb and the
Is it necessary to strain to pass urine? (suggests a stricture). blood urea, and repeat this after 7days’ relief by
Frequency, hesitancy, dysuria, nocturia? (prostatism). catheterization if it was initially abnormally high.
Prostate specific antigen (PSA) is highly specific for
EXAMINATION. prostatic carcinoma; it is very useful (27.22).
Look for heart failure, anaemia, and hypertension, which Acid phosphatase will only tell you crudely about the
might be the result of an obstructive uropathy. presence of metastatic deposits: you should do both tests
Look for signs of HIV disease (5.5,6). before doing a rectal examination, or else there may be a
false +ve result!
Examine the urethra from end to end, using your eyes and
your fingers. Start at the glans. Exclude phimosis and A PLAIN RADIOGRAPH of the kidney, ureter,
stenosis of the meatus. Feel the urethra in the penis, and bladder may show stones or evidence of metastatic
and the perineum, for palpable thickening. Extensive deposits in the pelvic bones, typical of prostatic
strictures are associated with a large palpable area of carcinoma. There is no need for a routine IVU: reserve it
scarring in the perineum. You may feel the distended for special indications, such as haematuria when the cause
proximal part of the urethra ending in a firm fibrous is not found on cystoscopy, or if you suspect some
stricture. Examine the membranous urethra with your abnormality of the kidneys.
finger in the rectum. Look for scars on the scrotum and
perineum. If there is a painful tender area in the perineum, ULTRASOUND. Look for the size of the bladder
it is probably a periurethral abscess complicating (when it is full), the thickness of its wall, any indentations
a stricture or a horseshoe ischiorectal abscess. or diverticula (38.2H) and the size of the prostate (38.2I).
Check for sensation in the ano-perineal area. Examine the ureters and kidneys, looking especially for
pelvi-calyceal dilation (38.2E).
Examine the prostate rectally:
(1) The hardness and irregularity of carcinoma are usually
easy to distinguish from the softer, smooth consistency of
benign hypertrophy, although the gritty feeling of a
calcified prostate may be misleading.
(2).A firm mass above the prostate is likely to be
carcinoma of the bladder.
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PREPARATION.
Make sure you have all the equipment ready that you need:
this is important, because you will otherwise find urine
flowing out uncontrolled when you stab open the bladder,
and then have to perform an open cystostomy!
Have ready a well-lubricated catheter, already mounted on
an introducer, with a filled syringe attached to the balloon
channel.
CAUTION!
(1) Avoid suprapubic scars: if the peritoneum is adherent
to the abdominal wall, you may injure the bowel.
It is quite acceptable to make your puncture wound 2cm
lateral to the midline, but beware the inferior epigastric
vessels! Use ultrasound if possible to check the position of
the bladder.
(2).Puncture the abdominal wall in the direction of the
lower sacrum. Do not direct the catheter too caudally you
may enter the retropubic space and fail to enter the
bladder. Do not direct it too cranially, you may enter the
abdomen and possibly injure the bowel.
Drain the urine into a urine bag. Make sure there is a daily
fluid intake of at least 3l/day: a generous fluid intake is the
Fig. 27-9 EMERGENCY SUPRAPUBIC CATHETERIZATION best way of preventing or clearing infection.
(CLOSED/BLIND SUPRAPUBIC CYSTOSTOMY). A, puncture the If there is a urethral stricture, drain the bladder for 1wk
abdominal wall and bladder with a #11 blade. B, introduce the before you attempt to deal with the stricture.
catheter with introducer inside and syringe attached.
C, immediately blow up the balloon when the catheter is inside the Before removing a suprapubic catheter, clamp it.
bladder. D, urine extravasating if you do not blow up the balloon You can then estimate the residual urine by measuring the
quickly enough! E, if the peritoneum is tethered by a previous volume which drains through the tube, after a good
operation scar, you may traverse the peritoneal cavity and damage passage of urine per urethram. If there is no residual urine
the bowel.
you have succeeded.
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Dilate the tract gently and then slide the catheter along the Urethral strictures can be dilated, although they are never
guide wire. To do this, cut a hole longitudinally at its end, cured. The problem with dilation is that you can very
so it slides along easily. Do not cut the catheter readily traumatize the longer male urethra further and
transversely at its end, because this creates a sharp edge worsen the stricture, or create a false passage by
which does not easily pass along an irregular track. perforating it. This is a disaster. Try, by all means,
CAUTION! Do not leave a persistent urinary fistula to treat strictures under direct vision with an urethrotome.
without a catheter in place as this is distressing causing a
smell and permanent wetting of clothes. This will mean If this is impossible, and it is not feasible to leave a
certain infection, and the probability of an early death. suprapubic catheter in situ, you may be justified in
attempting dilation. However, do not do this with rigid
sounds, and do not do this for:
(1) Acute retention of urine,
27.9 Urethral strictures (2) Prostatic or peri-urethral abscess;
(3) Extravasation of urine.
Gonorrhoea is the most usual cause of urethral stricture in
men everywhere. Some strictures are the late results of Use sedation, but avoid GA as you will then not know how
schistosomiasis, prostatectomy, tuberculosis, trauma, much you are traumatizing the urethra. Administer
or instrumentation of the urinary tract. Whatever its cause, gentamicin IV pre-operatively. Preferably, only use soft
you should try, if possible, to get a urethrogram, filiform bougies. These are long thin flexible nylon rods
urethroscopy, and the release of the stricture with an which you introduce into the urethra till they reach the
optical urethrotome. point of the stricture. Thread these into the urethra one by
Strictures can be of any length from 0·5-10cm. one, till one of the bougies passes into the bladder.
The commonest sites for gonococcal stricture are: The bougies have a thread on the distal end, onto which
(1) the bulbar urethra (27-18), and rarely you can screw the follower of greater size. Dilate the
(2) at the junction of the penis and scrotum, stricture by not more than Ch2 on each occasion!
(3) in the glans penis. Gonococcal strictures are the result Full dilation requires many repeated bouginages,
of fibrosis in the corpus spongiosum. Meatal strictures until you can easily, and completely atraumatically,
are different (27.31). Traumatic strictures due to pass a metal sound.
instrumentation occur usually in the prostatic urethra,
but from external pelvic injury in the anterior urethra. The optical urethrotome is a very useful instrument to
A urethral stricture increases the resistance to micturition, learn how to use, and useful to obtain.
which causes the detrusor muscle of the bladder to If you are not experienced, use it with great care.
hypertrophy. This may produce an adequate flow initially, The aim is to make a cut anteriorly in the stricture
but as time passes, sacculations and diverticula form in the (at the 12o’clock position) and occasionally at the
bladder; it no longer empties completely, and the high anterolateral (4 & 8o’clock) positions if the stricture is
residual urine it contains leads to frequency of micturition, dense. You can do this under LA if you introduce
and infection. Sensation is diminished, as its wall is lidocaine jelly, leave it in the urethra for 5mins using a
increasingly replaced by fibrous tissue. Finally, the result penile clamp. Generally leave a Ch16 urinary catheter in
is 'retention with overflow', and incontinence. situ 7-10days post-operatively and arrange follow-up
Bilateral hydronephrosis develops as high pressure is dilations (best done with plastic sounds by the patient
transmitted to the ureters, and thus secondary renal failure himself at home). You can do a great deal of harm by
(obstructive uropathy) results. enthusiastically dilating urethral strictures blind: leave this
Apart from acute painful retention, and chronic painless for an expert. In the absence of urethrotomy, it is best to
retention with overflow incontinence, the many other divert the urine flow, and allow the expert deal with a
complications of urethral stricture include: simple stricture, than to ask him to deal later with a
(1) False passages. complicated stricture which may prove impossible to
(2).Periurethral abscesses (6.18) causing extravasation of negotiate.
urine, with gross distension of the penis and scrotum
(sometimes leading to gangrene), and external fistulae. Prostatic obstruction is the main differential diagnosis
(3) Infection of the urinary tract. (27.19). Chronic retention distends the bladder greatly, but
(4).Infection of the seminal vesicles, epididymes, is painless, so that decompression is not needed so
or testes. urgently as it is in acute retention.
(5) Chronic non-specific infection ending in elephantiasis.
(6) Obstructive uropathy ending in renal failure. Urethral strictures in women occur often in combination
(7).Bladder neck stenosis, and detrusor failure. These are with vesico-vaginal fistula (21.18), after mutilating
common and may explain why bouginage and external surgery, or in the elderly due to perineal contracture.
urethroplasty often fail. The urethra is short and usually amenable to simple
(8).The results of straining, such as hernias or prolapse of dilation.
the rectum.
(9) Stones in the urethra and bladder (27.16,17,18).
(10) Infertility and impotence.
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LATE COMPLICATIONS.
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PERINEAL URETHROSTOMY (THE 1ST STAGE ONLY POSTOPERATIVELY, treat with frequent baths or a
OF A POSTERIOR URETHROPLASTY). (GRADE 3.2) douche, remove the catheter at 5days, and the sutures, after
premedication, at 14days. Make sure that there are no
INDICATIONS. Impassable strictures. cross-adhesions between the suture lines. If a tissue bridge
PREPARATION. Make sure the perineum is washed and has formed, separate it, and ask him to keep the passage
perfectly clean. Put the patient in the lithotomy position. open by inserting a sound daily in the bath.
Shave the perineum, and prepare the skin with care.
DIFFICULTIES WITH A PERINEAL URETHROSTOMY
METHOD. Make an inverted 'U'-shaped scrotal flap with Curiously, incontinence is uncommon.
rather a flat apex to end just in front of the ischial
tuberosities (27-11A). The key to the operation is access, If the tip of the scrotal flap necroses, take it down, trim
so the flap must go far back. Cut through the skin and it and resuture it; there is usually plenty of skin left.
dartos, tying and coagulating vessels as you go, and allow
the flap to hang down. If a haematoma forms, return to theatre, take down the
wound, evacuate it, and secure haemostasis.
CAUTION!
(1) Allow a generous lining of fat on the flap.
(2) Do not disturb the vessels in its base. 27.11 Urethral fistula
(3) Do not use diathermy on the flap, or you may cause
flap necrosis. A proximal urethral fistula in the male is usually the
Pass a Ch24 bougie down to the tip of the stricture, consequence of a periurethral abscess, but may arise
and ask your assistant to hold it in the midline. Feel for it, spontaneously, particularly with HIV disease.
and dissect down to it, until you see the bulbospongious Multiple fistulae may involve the perineum, scrotum,
muscle (27-11B). Dissect the muscle from the bulb and penis, perianal region and inner aspects of the thighs
reflect it on either side (27-11C). Cut down on to the (27-12). Sometimes a fistula forms between the urethra
bougie (27-11D), and immediately insert a 4/0 continuous and the rectum.
absorbable suture on either side of the cut corpus
spongiosum, to prevent bleeding from this spongy tissue. SPECIAL TESTS. Try to delineate the stricture with a
Incise until you have completely opened the stricture and urethrogram (38.1) and urethroscopy.
you reach healthy tissue; in a bulbar stricture you may
have to cut almost to the bladder within a few mm of the
verumontanum. Cut 1cm at a time, and control bleeding by
continuing your haemostatic suture down each side of the
split corpus spongiosum (27-11E). Do not divide the
external sphincter just distal to the verumontanum.
CAUTION! Be sure to continue the incision the full
length of the stricture. The only way to be sure about this
is to pass your finger past the stricture, to make sure there
are no strands of fibrous tissue remaining.
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If the fistula is recent, divert the urine by an open Make 5cm incisions on each side of the base of the penis.
suprapubic cystostomy (27.8), culture the urine from the Insert your index finger, and open up the tissue planes
bladder and use the appropriate antibiotic, and after 6wks widely towards the abdomen, and down the shaft of the
clamp the suprapubic catheter to see if urine still leaks. penis. Then make 5cm incisions on the inferolateral
If it does, repeat the process for a further 6wks, and if this aspects of the scrotum, and use your finger to open up the
fails, the patient needs an optical urethrotomy (27.9). tissue planes as far as possible (27-13).
PREPARATION
Replace fluids IV, which may be life-saving, and correct
electrolyte disorders. Treat with IV chloramphenicol,
gentamicin and metronidazole. Counsel the patient that
urinary diversion may be long-term. Exclude cardiac, Fig. 27-13 EXTRAVASATION OF URINE.
renal, and hepatic causes of oedema. Subfascial areas where extravasated urine may collect. A, incisions
for drainage. B, drawing showing the directions in which urine can
track.
METHOD (1-2) incisions for drainage. (3) triangular ligament. (4) Buck's fascia.
(1);DIVERT THE URINE FLOW so that it no longer (5) Colles' fascia. (6,7) Camper’s (superficial) & Scarpa’s (deep)
leaks into the tissues. Perform a formal open suprapubic fascia. (8) transversus perinei muscle. (9) Denonvillier's fascia.
cystostomy (27.8). A, from Dudley HAF (ed) Hamilton Bailey's Emergency Surgery. Wright
10th ed 1977 Fig 50.11 with kind permission
(2) DRAIN THE URINE OUT OF THE TISSUES.
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Place 2 long corrugated rubber drains (4-14B) into the SPECIAL TESTS. The presence of microscopic
depth of each wound in each direction, and suture them in haematuria is the most useful test. If there are pus cells,
place. Dress the wounds with gauze and cotton wool. or a patient's urine is alkaline, it is infected.
Arrange daily baths. The swelling will usually settle in RADIOGRAPHS. Take a plain radiograph of the kidneys,
about 5days. Shorten the drains 5cm/day. ureters and bladder (a slightly oblique abdominal view).
You can easily miss a stone if:
If you find any areas of necrotic skin and subcutaneous (1) the radiograph is poor,
tissue, debride these radically, otherwise Fournier’s (2) the stone is only moderately radio-opaque,
gangrene (6.23) will result. When infection has subsided, (3) it is obscured by bone or dilated bowel.
close the skin incisions by secondary suture, and graft the
bare areas unless it has healed spontaneously.
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Look for kidney stones opposite the second lumbar If there is anuria and renal failure, this can be due to the
vertebra, and for ureteric stones, as the ureter crosses the presence of bilateral stones, but it is more likely to be due
tips of the transverse processes of the lumbar vertebrae, to chronic interstitial nephritis or pyelonephritis.
runs over the sacroiliac joint, and descends in a gentle arch CAUTION! Some stones cause no symptoms,
to a point just medial to the ischial spine, from where it even when they are large.
turns medially to enter the bladder.
If there is right iliac fossa pain and fever, this may be
Do not mistake a gallstone, a phlebolith (calcified appendicitis (14.1) or PID (23.1) in a female, especially
thrombus), or a calcified lymph node, for a urinary stone. with tenderness on rectal or vaginal examination.
Most ureteric stones are slightly elongated and not round.
In a lateral view of the abdomen: gallstones are anterior; TREATMENT FOR URINARY STONES
renal and ureteric stones overlie the lumbar spine.
If there is a small kidney stone (<7mm), which is
AN INTRAVENOUS UROGRAM (IVU: 38.1H) peripheral in the kidney, and is causing no symptoms
will confirm the diagnosis. If no contrast medium is and no infection, leave it, but watch it carefully, to see if
excreted on one side, that kidney has stopped functioning, it gets stuck at the uretero-vesical junction and causes
or is excreting so slowly that you can be sure function is obstruction.
impaired. You will find the site of an obstructing stone that
is not visible on a plain radiograph easily only if there is If a stone is obstructing the renal pelvis, try to remove it.
still some function remaining. Take exposures The risk of hydro- or pyo-nephrosis is high. If there are
immediately at 1hr immediately after emptying the stones on both sides, operate on the side with the better
bladder, so that contrast medium does not obscure a stone function first.
at the lower end of the ureter; then at 3, 12 and even 24hrs.
Enough contrast medium may then have accumulated to If there is renal colic for a few days, after which
show up the urinary tract, down to the site of the oliguria, and then anuria gradually develop,
obstruction. this can arise from bilateral obstruction, or, more
commonly, from the obstruction of a solitary functioning
If contrast medium is concentrated in the kidney kidney. Catheterization of the bladder produces no urine.
(a 'nephrogram'), but does not show up in the renal pelvis, A plain film may confirm the diagnosis. The blood urea
a stone may have blocked the pelvi-ureteric junction rises. The episode may relieve itself spontaneously as the
(27-14E), and caused the contrast medium to be retained in result of the oedema in the ureter settling, and the infection
the kidney tissue. This is a hopeful sign, because it shows being brought under control. Observe for 24-48hours.
that there is still good renal function.
N.B. Clots in the ureter, and small calculi, may cause If you have a cystoscope and can pass a ureteric catheter, it
colic especially if the ureter is narrowed by may slide past the stone and produce urine; you can then
schistosomiasis or tumour. leave it in place for 2-3days, which will relieve the acute
situation. Or the catheter may dislodge the stone back into
ULTRASOUND: will demonstrate most stones easily in the renal pelvis. If there is no rapid improvement, urgently
the bladder because of their ‘acoustic shadow’ (38.2H), fashion a nephrostomy (27.14).
but not so readily in the ureter or kidney. It may be helpful
with the differential diagnosis and follow-up in checking If there is a stone stuck in the ureter, you should remove
for hydronephrosis. If a ureter is completely blocked, it extraperitoneally unless you can let the urine drain from
no spurt will be visible on Doppler from the ureteric above it (27.15).
orifices.
If there is a uric acid stone, try to raise the pH of the
DIFFERENTIAL DIAGNOSIS. urine. Make it alkaline with sodium bicarbonate tablets tid,
If there is moderate pain in the costovertebral angle, or potassium citrate mixture 20ml tid. If possible, measure
a high fever, chills, an obviously infected urine, and an the serum urate. Treat with allopurinol if there are
ultrasound shows that the renal pelvis and calyces are recurrent uric acid stones, or an elevated urate.
normal, acute pyelonephritis is present.
If the serum [Ca2+] is consistently high, it suggests a
If there is a palpable tender renal mass, this is probably parathyroid adenoma, or some other generalized disease.
hydronephrosis. If in addition there is fever, toxaemia, A raised urinary calcium is more common; advise against
and leucocytosis, it is probably a pyonephrosis. taking calcium supplements.
If there is a dull ache, with occasional fever and pyuria, TO PREVENT RECURRENT STONES encourage plenty
suspect that there is a stone which is not obstructing the of fluids and treat any associated infection.
urinary tract.
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Mark the 12th rib with a felt pen (27-15A). Then clean an If the kidney looks and feels fairly normal,
area about 20cm wide over the 12th rib, from the midline expose its pelvis, and put the drain there (B).
of the back to the umbilicus.
Stand at the back, and make a skin incision starting at the CAUTION!
lateral margin of the sacrospinalis. Cut along the line (1) Be careful not to damage the fragile and often flattened
you have drawn over the 12th rib. Proceed anteriorly, renal vein, which enters the renal hilum anteriorly,
and stop 5cm short of the umbilicus, at the lateral margin and may cover part of the renal pelvis: this is why you
of the rectus sheath. A shorter incision will suffice if there should approach it from behind.
is a marked hydronephrosis. (2);The end of the catheter must go into the drainage
system, and not into the kidney parenchyma itself.
You will have to cut through much muscle. If possible, use
a cutting diathermy, turned down low enough to cut A..NEPHROSTOMY THROUGH THE CORTEX
through muscle and coagulate the vessels in it at the same is easier, but does not provide such good drainage.
time. Or, use a scalpel, and carefully control the bleeding Choose an area on the convex surface of the kidney, where
points as you meet them. the renal parenchyma is thinly stretched over a tense
Start by cutting the latissimus dorsi over the 12th rib, fluctuant area, and which feels as if there is probably urine
until you can see the rib clearly (27-15C). Then remove it under pressure close below it. To confirm that you have
subperiosteally with a scalpel, or cutting diathermy. found a dilated calyx or pelvis, aspirate it with a fine
Cut the periosteum down the middle of the rib as far as its needle and syringe. Be sure that you are not dealing with
tip. Using a periosteal elevator, push the periosteum off its an isolated renal cyst.
raw surface down its entire length. Reflect the flaps of
periosteum. Take a curved periosteal stripper, and gently Make a ½cm incision into the kidney capsule over its
insert it under the distal part of the rib. Slide it up and convex border, and then plunge a fine haemostat into the
down, until the rib is completely clear of periosteum fluctuant area. If urine pours out, you are in the right place.
(27-15D,E). Cut the narrow strand of external oblique Suck it out. Take a small catheter, hold its tip with a
attached to the tip of the rib. Use rib shears, or bone haemostat, and push this far enough into the kidney to get
cutters, to cut off the rib as close to its neck as is a good flow of urine (27-18G). Remove the haemostat
convenient. Do not push towards the neck of the rib, it is and leave the catheter in. If blood oozes around it,
too close to the pleura! Smooth its stump so that it will not insert a haemostatic fine absorbable suture.
tear your gloves.
B..NEPHROSTOMY THROUGH THE RENAL PELVIS
Cut the 3 muscles of the anterior abdominal wall in line (PYELOSTOMY) drains a kidney better as it will drain all
with the skin incision. Cut the first 2, the external oblique the calyces, but is more difficult, because you have to find
and internal oblique, boldly. When you get down to the access to the medial side of the kidney.
transversus, stop temporarily. The peritoneum is under it,
and you do not want to risk opening it and flooding it the Turn the kidney forwards and medially, using finger
peritoneal cavity with urine, or having bowel obscure your dissection. When the perirenal tissues are oedematous and
view. thickened, separating the kidney from surrounding fat is
Return to the bed of the rib, and use the tip of a scalpel to not difficult. You will see the tense distended renal pelvis
cut its lowermost half. Carry the incision down on to the as the most posterior of the structures at the hilum.
remaining fibres of the transversus muscle. Split this in the Holding the kidney so as to expose the renal pelvis,
direction of its fibres. confirm that urine is present by aspirating with a syringe
You will now see the peritoneum, with the liver and part and fine needle. Make a short incision in the renal
of the colon under it (27-15F). Using a sponge on a holder, pelvis, well away from its junction with the ureter.
gently push the peritoneum down and away from you Urine should gush out (27-15H).
forwards and upwards. Use a self-retaining retractor to Pass a curved probe through this incision. With your other
separate the rib cage above, from the crest of the ilium hand, feel for an area on the convex surface of the kidney,
below, and so open up the whole area. where its cortex feels thin. Carefully (to minimize
Feel for the kidney up against the posterior abdominal bleeding) push the tip of the probe out through this point
wall. If you are not sure if it is the kidney, try moving it up (27-15I). Tie the probe to a catheter, and draw it back and
and down. Use a scalpel to make a short incision in the out through the kidney (27-15J). Close the pyelostomy
fascia over it. Insert your fingers, separate the perirenal fat, opening with two fine absorbable sutures. If the kidney
which may be extensive in an obese patient; and feel the bleeds where the catheter emerges, apply a purse-string
shape, size, and consistency of the kidney. The tissues suture.
around it will probably be engorged and oedematous. Bring the nephrostomy tube to the surface through a
separate stab incision where it will not be occluded on
If the kidney is enlarged, soft and feels cystic, lying down. Irrigate the tissues round the kidney, and close
it is probably hydronephrotic, but it may be polycystic, all the muscles over it in layers. Close the skin, and fix the
in which case nephrostomy does not help. If it is nephrostomy tube. Finally, as an extra precaution, tape the
hydronephrotic, it is probably safe to drain a dilated calyx nephrostomy tube to the skin. Connect it to a bedside
through the cortex (A), without exposing the renal pelvis. collecting bottle.
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INDICATIONS FOR SURGERY. CAUTION! Make sure you find the stone and place a
(1);Symptoms persist, and serial radiographs taken at sling around the ureter above the stone. If it slips upwards
6-8wk intervals show that a stone of >5mm is impacted. into the kidney, do not try to remove it by
(If it is not causing symptoms or obstruction, it does not extending the incision, or using a traumatic instrument.
necessarily have to be removed, but it is desirable to do so. Close the incision and wait. Try to refer the patient,
(2);Pain comes and goes over days or weeks without any or try again when ureteric colic recurs, after making sure
further descent of the stone. the stone is indeed in the middle ⅓ of the ureter!
(3) Ultrasound shows ipsilateral dilation of the kidney.
(4);An intravenous urogram shows a hydronephrosis or a POSTOPERATIVELY, the catheter will drain up to 1l of
hydroureter, or no excretion of contrast medium. urine daily, but the volume will gradually diminish.
(5);Infection supervenes with fever, chills, rigors, pyuria, By the 7th day the ureteric incision should close,
and toxaemia. and the drainage cease.
PREPARATION. Mark the side to be operated upon. If the volume draining remains undiminished,
Take a plain radiograph of the abdomen just before you there is an obstruction in the ureter distal to the site of the
operate to make sure that the stone has not moved. incision, or it is diseased locally. Wait another week, and
investigate this with an IVU (38.1H).
FOR A STONE IN THE RENAL PELVIS OR UPPER ⅓
OF THE URETER, perform a nephrostomy (27.14) if the FOR A STONE IN THE LOWER ⅓ OF THE URETER,
kidney is obstructed. Do not try to remove a stone from perform a LOWER ⅓ URETERO-LITHOTOMY
the renal pelvis unless it is dilated. Try to refer the patient. (GRADE 3.3)
FOR A STONE IN THE MIDDLE ⅓ OF THE URETER, Ideally, you can remove a stone at the lower end of the
perform a MIDDLE ⅓ URETERO-LITHOTOMY ureter with a cystoscope and a Dormia basket which traps
(GRADE 3.2) the stone, but this is difficult. Otherwise, empty the
Use the supine position. bladder by passing a urethral catheter. Use the supine
Start the incision ⅔ from the umbilicus to the anterior together with a slight Trendelenburg position. There are
superior iliac spine, and carry it laterally for 7cm parallel 3 possible approaches. Remaining outside the peritoneum,
to the inguinal ligament. Divide the subcutaneous tissues, which should be your aim, is easier in the first.
and the external oblique aponeurosis in the direction of its (1) Start your incision ⅔ from the umbilicus to the anterior
fibres; likewise divide the internal oblique. superior iliac spine and continue medially parallel to the
Divide the transversalis fascia, and sweep the peritoneum inguinal ligament. Incise the external and internal oblique,
medially, until you reach the inner margin of the and open the transversalis fascia. Or,
quadratus lumborum muscle, and the bifurcation of the (2);Make a lower midline incision, starting at the pubis,
common iliac artery into its internal and external iliac and ending at the umbilicus. Incise the transversalis fascia.
branches (24-16). You will see the ureter lifted up by the Or, (3) use a Pfannenstiel incision.
peritoneum. Do not injure the spermatic vessels, which lie
lateral to the ureter. Carefully strip the peritoneum upwards with a gauze swab.
Look for the ureter at the bifurcation of the common iliac
Feel for the stone in the ureter. Carefully pass a long vessels (23-16) and follow it downwards to the bladder.
Lahey forceps round the ureter, and pass 2 fine catheters, It is crossed anteriorly by the vas deferens. You may have
or cloth tapes, above and below the stone. Exert gentle to divide the superior vesical artery so as to let you
traction on these. This will prevent the stone slipping mobilize the bladder medially sufficiently to allow you see
upwards or downwards. Cut longitudinally on the ureter the vesico-ureteric junction easily.
onto the stone with a #15 blade. Remove it carefully with Find the stone, and pass a fine sling or cloth tape under the
Desjardin's forceps. Wash the area free of grit with warm ureter proximally to prevent the stone slipping upwards.
saline. Pass a small paediatric feeding tube up into the Make a longitudinal incision over the stone, and remove it
kidney, and down into the bladder, to make sure there no carefully. Leave the ureteric incision open and close as
other stone, or if you suspect a schistosomal stricture at the above.
vesico-ureteric junction.
DIFFICULTIES WITH URETERIC STONES
Leave the ureteric incision open. If you try to close it, the If the ureteric colic resolves, but there is no evidence
sutures may well cut out and a stricture is likely to form. that the stone has passed, this is not uncommon. It has
Place a #12 catheter near this site, and bring it out through probably passed without notice, especially if it was small.
a separate stab incision. Close the abdominal incision in
layers, using interrupted absorbable for the muscle, and If a stone becomes impacted at the pelvi-ureteric
monofilament for the skin. Connect the catheter to a closed junction, and there is only one working kidney,
drainage system. perform a nephrostomy urgently. Try to refer the patient.
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If a stone is firmly impacted at the utero-vesical When you have removed a bladder stone it does not
junction deep in the pelvis, it might be that this area is usually recur, but nonetheless encourage a good intake of
diseased, especially as a result of schistosomiasis. fluids.
You can try to squeeze the stone
upwards into a more accessible
part of the ureter where it will be
easier to remove, but this does not
usually work. Alternatively, make
an incision 2cm above the site of
impaction, and try to remove the
stone carefully with Desjardin's
forceps (27-16D): this will,
however, not deal with any
disease. Take care: you can easily
tear off the diseased ureter from
the bladder; it may need
re-implantation anyway.
This is complex surgery.
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CYSTOLITHOTOMY (GRADE 2.5) If a fistula develops, it will probably be the result of some
obstruction to the urethra. Leave in a urethral catheter in
PREPARATION. long enough for the fistula to heal. You will probably have
Insert a urethral catheter and fill the bladder with fluid; to deal with the prostatic enlargement or urethral stricture
you can use the same catheter for postoperative drainage. later, though.
A steep Trendelenburg position will make exposure easier.
If the wound becomes septic, open it and drain it:
INCISION. do not rely on antibiotics.
Use a Pfannenstiel incision (11-4) because it is easier then
to remain below the peritoneum, and avoid opening it.
Incise the skin and subcutaneous tissue transversely.
Either part the rectus muscles to expose the peritoneum in 27.17 Bladder stones in children
the midline, or cut the rectus muscles transversely in line
with the skin incision, little by little, until you see the In some parts of Asia, smooth stones, mostly ≤5cm in
inferior epigastric vessels in the deep surface laterally. diameter, form in the bladders of underprivileged children
This will give you better exposure, and you will be less (mainly boys). Even an infant may suffer from them.
likely to incise the peritoneal reflection over the bladder in They may be the result of vitamin A deficiency.
error, which may spread infection into the peritoneum. When you have removed a bladder stone, it is unlikely to
Find the reflection of the peritoneum and displace this recur.
upwards (27-17A). A child's mother will say that he cries every time he passes
urine, and pulls at the penis as he tries to relieve the pain.
Grasp the bladder with stay sutures on either side of the Strangury, i.e. slow painful passage of small quantities of
midline, or with two Allis forceps, holding the entire urine, makes life unbearable; sometimes he passes blood.
thickness of its wall. Make a vertical incision in the Other symptoms include: interruption of the urinary
bladder. Avoid a transverse incision: it will bleed more stream, frequency, dysuria, and suprapubic pain.
than a vertical one, and if you are too inferior you may
damage the ureters. Suck away the urine as it gushes out. There are few physical signs: the bladder may be
distended, and the foreskin red and swollen from being
Put your finger into the bladder to feel if the stone is lying pulled. You may be able to feel the stone on rectal
free, or is impacted in a diverticulum. Feel for a tumour or examination.
other pathology. Remove any free stones with your It is likely to be made of urates, but it will probably
fingers, a scoop, or lithotomy forceps. contain enough calcium for you to see it on a radiograph.
CAUTION! Repeatedly wash out the bladder before you It will be readily visible on ultrasound (38.2H).
close it. If you leave any stony fragments, they will act as
the nuclei for the formation of more stones. Removing a stone from the bladder of a child is not too
Close the bladder in two layers with continuous or difficult. When you have done so, there is no need to drain
interrupted 2/0 long-acting absorbable. the bladder with a catheter, either suprapubically or
Place a suprapubic catheter to provide drainage, and put an through the urethra, if you have closed it securely.
extravesical drain as well; bring these out through a
separate stab wound. ASHVIN (3yrs) had repeated urinary infections which had been treated
with antibiotics on many occasions, but the symptoms always returned.
He then saw another doctor, who remembered that repeated urinary
POSTOPERATIVELY, remove the extravesical drain infections in children should always be investigated, so he X-rayed
after 48hrs. Leave the suprapubic catheter in place for Ashvin's bladder and was surprised to see a large stone. At operation, the
8-10days, to keep the bladder collapsed while it heals. stone was difficult to remove, and appeared to be lying in a diverticulum.
Take a urine specimen for culture before you clamp the After it was removed, he had no more urinary infections.
LESSON: Do not forget the possibility of stones in children, especially if
suprapubic catheter to see if normal voiding is possible. you are in a high-incidence stone area.
If so, remove it. An initial leak will stop in 24hrs.
CYSTOLITHOTOMY IN CHILDREN (GRADE 2.5)
DIFFICULTIES WITH BLADDER STONES IN ADULTS
PREPARATION. Distend the bladder with water before
If there is copious urine coming from the drain, you start, so that you can find it more easily. Pass a small
and little in the catheter bag, the bladder closure is plain catheter; then, inject 100-200ml of water into the
probably leaking. Check that the drain fluid is indeed urine bladder, depending on its size.
by measuring its urea concentration, or by inserting dye
via the catheter and seeing if it runs out via the drain. INCISION. Make a lower transverse subumbilical skin
If the leak continues for 48hrs without diminishing, incision. Reflect the skin flaps 1cm on either side.
take the patient back to theatre, open up the wound and Divide the linea alba strictly in the midline,
close the bladder wall again carefully in layers. without entering the peritoneal cavity.
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Keeping the umbilicus in view to help you stay in the 27.18 Urethral stones in children
midline, make a vertical incision through the whitish
aponeurotic fibres of the linea alba. Continue the incision
down to the symphysis pubis, where you will meet the In some areas, bladder stones are common; these are
pyramidalis on each side. With a sponge on a holder, mostly are passed spontaneously in the urine.
gently push the rectus muscles laterally, so that you can Occasionally, one impacts in the urethra, especially in
see the posterior rectus sheath. Insert a small self-retaining boys. It is usually possible to pass urine around it,
retractor to keep the rectus muscles apart. but pain, strangury, and dribbling are severe. Suspect this
especially if there is a distended bladder, and you can feel
Feel for the distended bladder: it should be easily palpable a hard mass somewhere along the course of the male
as it rises out of the pelvis. Using a sponge, or your index urethra. The patient may be able to show you exactly
finger, gently open the retropubic space. At the same time where the stone is stuck.
displace the peritoneum, so that you do not enter the
peritoneal cavity. You should now be able to feel and see If ultrasound or radiograph suggests that it might be
the distended bladder. wedged in the neck of the bladder, try to feel it rectally.
You may be able to push it back up into the bladder.
Insert stay sutures, and apply a haemostat on each side of If you fail, insert a well-lubricated sound into the urethra,
the midline at the most easily accessible part of the until it strikes the stone. You may be able to push it back
bladder. This will prevent it slipping away. Get the sucker into the bladder, but do not use force! If this fails,
ready. Then with a scalpel, or cutting diathermy, make a ask your assistant to exert upward pressure on the stone,
2cm incision in the bladder wall, between the 2 stay with the finger in the child's rectum, while you manipulate
sutures. Aspirate the urine which squirts out. it with the sound. If you can move the stone back into the
bladder, proceed to remove it suprapubically (27.17).
With your index finger, feel through the hole in the Otherwise open the bladder and try to dislodge the stone
bladder for the stone. Remove it with stone forceps or a out of the urethra from above: this may however be
sponge-holder. If the hole is not big enough, enlarge it. difficult.
Having removed one stone, feel again to make sure that
there is no further stone. Wash out the bladder. If it is readily palpable in boys between the bulbous
urethra, and the fossa navicularis (27-18A), removal by
Close the bladder carefully with continuous 3/0 manipulation under GA may succeed. Do not use force!
long-acting absorbable on an atraumatic needle. Include all
layers, and make the bites ≤5mm apart. The longer the If it is impacted, remove it by external urethrolithotomy.
incision, the more care you need in closing it.
If it impacts at the external meatus or the fossa
CAUTION! Make a small stab incision just beside the navicularis in boys, you may be able to 'milk' it free,
wound and insert a small soft extravesical drain. or release it by a meatotomy (27.31).
Do not forget to do this. Even if you think you have closed
the bladder securely, it may still leak. If urine extravasates, If it has developed in a diverticulum (rare), you may
it may cause serious cellulitis. have to cut down on this, and then close the diverticulum.
Suture up the linea alba with 2/0 absorbable. Make sure URETHROLITHOTOMY (GRADE 3.1)
that you have controlled all bleeding, and then close the
skin. If you think that the bladder may leak, or if you have Use the lithotomy position.
had to make a large incision, insert a Foley urethral Thoroughly clean the genitalia, the medial surface of the
catheter for 4-5days. Otherwise, do not insert one. thighs, and the perineum. Feel for the stone in the urethra,
It is, however, helpful to insert a small suprapubic catheter and steady it between the thumb and index finger of your
and have it for a trial of voiding. left hand. Infiltrate with dilute adrenaline solution:
this is a very vascular area. If you do not control bleeding,
POSTOPERATIVELY, urine will probably pass without everything will be obscured.
difficulty later that day. If urine leaks through the Make a 3cm midline incision over the stone, on the ventral
extravesical drain, insert a urethral catheter, and leave it surface of the penis. Cauterize or tie off the bleeding
there for a few days. Otherwise, remove the extravesical points. Ask an assistant to retract the skin flaps with
drain after 3-4 days. The child is unlikely to get another hooked retractors.
stone, but his siblings may. Incise onto the part of the urethra containing the stone.
Make the incision just big enough to deliver it. Lift it out
with stone forceps or a haemostat. Try not to break it.
Insert a small (Ch10 or 12) Foley catheter into the external
urethral meatus, and up past the incision into the bladder.
Inflate the balloon. Do not try to close the urethra:
its edges will fall together and heal naturally.
Close the skin. Remove the Foley catheter after 1wk.
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It is possible to perform a
prostatectomy by the trans-
vesical route, by the retro-pubic
route or endoscopically via the
urethra. Another method avoids
opening the bladder, but is more
difficult. It also needs good
lighting, more help, and better
postoperative care. Endoscopic
resection needs much skill and an
expensive resectoscope.
The advantages of the trans-
vesical method are:
(1);You can look into the bladder
to exclude diverticula, carcinoma,
and stones.
(2);You can control bleeding
more easily.
(3);When well done, mortality is
low. One of its disadvantages is
that it normally requires large
quantities of irrigating fluid,
although we describe ways of
doing without this.
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Remove the lateral lobes and the median lobe, If you have a shortage of drainable urine collecting bags,
by bringing it into the bladder with your index finger. or you cannot be sure the bags are surveyed properly,
If it is still lightly attached proximally to the mucosa of the it may be better to let the urine drain freely into a large
bladder, separate it with scissors. Removing each lateral narrow-necked plastic bottle.
lobe separately may be easier. One will bring the median
lobe with it. Remove the catheter after 8-10days. Alternatively,
you can use 2 large (Ch20-24) ordinary Foley catheters,
If the patient is very obese, or muscular, one urethral and the other suprapubic, passed through a
you may be unable to reach the lower border of the separate stab incision.
prostate. You can push it upwards with your opposite
index finger in the rectum while you enucleate the prostate Introduce fluid through the suprapubic catheter, and drain
from above. If you have to do this, cover your left hand it through the urethral one. Remove the suprapubic
with two gloves, and protect your forearm with a sterile catheter when the fluid is no longer bloody, usually
towel under the drapes; otherwise, get an assistant to do >3-4days. If you leave it longer it tends to leave a track
this. which leaks. You can improve diuresis by insisting the
patient drinks a least 4l water/day, or by using furosemide
When you have removed the lateral lobes, feel the inside 40mg bd – but make sure the patient still drinks plenty of
of the prostatic cavity, to make sure that no masses have fluids!
been left behind (27-19H).
CAUTION! You can easily leave a large mass of You will need about 10l fluid for irrigation. This can be:
adenoma behind, so compare one side with the other. (1);IV saline, which is expensive and will be needed for
Use your fingers, sponge holders, or vulsellum forceps to other purposes,
grasp and twist off any remaining pieces of prostate. (2);Sterile 3·8% sodium citrate (which is no better than
saline),
ENLARGE THE BLADDER NECK: first check the (3) Mannitol,
position of the ureteric orifices. Cut a wedge out of the (4);Sterile tap water or, better, distilled water.
bladder neck in the 6o'clock position level in between the The disadvantage of this is that it may enter the circulation
ureteric orifices (27-19K,L). Excess mucosa of the bladder through the prostatic sinuses and cause water intoxication,
may overhang the prostatic cavity, and if left may produce and if it is not pyrogen free, it may result in rigors.
a valve-like effect leading to retention of urine (27.21).
Teach your nurses to milk the catheter hourly, until all the
CONTROL BLEEDING: put a tight gauze pack in the clots have gone, usually in 2-4days. Continue irrigation
prostatic cavity (27-19I). After 3mins, take it out and just fast enough for the urine to be pale pink. It is usually
assess the amount of bleeding. Insert a running suture necessary for 24-48hrs. You will need about 4l in the first
inferiorly from the 3 to the 9o'clock positions (27-19J), day, and less the next day. You may need to continue
taking care to avoid the ureters. Then put a purse string irrigation until the 4th day.
absorbable suture in the floor of the bladder, around what
was the internal meatus (27-19M). Blow up the balloon of CAUTION! Do not raise the irrigation bottle too high.
a 50 or 75ml Foley catheter, until it fits snugly in the If it is >60cm above the bladder, and haemostasis has been
prostatic bed (usually 30-50ml is required). This will help poor, the fluid in the bladder may enter the circulation,
to stop bleeding. Then tighten up the purse string round it especially if the outflow catheter is obstructed.
to hold it in place (27-19M) where it will remain if the Keep the drainage bottle on or near the floor, to make use
balloon is inflated enough. of gravity.
Alternatively, if bleeding is still brisk, tightly pack the Deflate the balloon on the 3rd day, unless there is much
prostatic cavity once more, and leave the pack in place for bleeding; if so, wait until bleeding stops. The prostatic
a full 15mins. Then remove it. If the prostatic cavity is still cavity will then become smaller naturally, and there will
bleeding, remove the purse string and the catheter, and be less danger of secondary haemorrhage.
irrigate the prostatic bed. Then re-insert the balloon of the
catheter snugly in the prostatic bed. CLOSURE. Close the bladder with two layers of
Insert a #2 monofilament suture through the abdominal continuous absorbable suture. Insert a drain in the
wall and the bladder, and then through the holes in the retropubic space, through a separate stab incision, below
catheter to hold it in place. Knot it over a button outside or at the side of the previous one, and secure it to the skin.
the abdominal wall (27-19M). If the patient is confused Close the anterior rectus sheath with continuous
postoperatively, this will prevent him from pulling out the absorbable suture. Close the skin.
catheter, even if the balloon bursts.
N.B. Prostatectomy by a suprapubic approach avoids
IRRIGATION: The purpose of irrigation is to remove opening the bladder, but access is more difficult.
blood clots, which encourage infection and block the Do this if you can get an expert to teach you.
drainage tube. It is, by far, best to use a 3-way irrigating
Foley catheter. Introduce fluid down one channel,
and let it drain through another.
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DIFFICULTIES WITH OPEN PROSTATECTOMY If there is incontinence of urine, you can give
Besides the normal anaesthetic risks, and those listed reassurance that this is almost certain to improve during
below, the postoperative difficulties you will meet include the next 3months.
epididymitis, septicaemia, deep vein thrombosis (relatively The symptoms of urge incontinence are common in
unusual in low- and middle-income countries), ileus patients who had these symptoms preoperatively;
(12.16), uraemia and oliguria, postoperative shock, they usually resolve spontaneously. If you have damaged
and bladder tamponade. the membranous urethra by enucleating a prostate which
did not have a clearly defined capsule (27-19F),
If there is bleeding from the prostatic bed after return incontinence may be permanent. So, if the prostate feels
to the ward, within 48hrs of the operation (reactionary fibrous or carcinomatous beforehand, do not proceed.
haemorrhage, not uncommon), all that is usually necessary
is to keep the catheter clear by milking it hourly. Speed up If a suprapubic fistula develops, it will close
the irrigation, and wash out the bladder. Start an IV spontaneously unless the outflow is still obstructed.
infusion of saline. If the Hb falls <7g/dL, transfuse blood. So drain the bladder with a urethral catheter for 10 more
If copious frank bleeding persists, return to theatre, reopen days. If the leak persists, go back to close the bladder wall
the wound, and control bleeding from the prostatic bed again.
(27-19J).
If a recto-urinary fistula develops, drain the bladder with
If there is a distended painful bladder and no urine a urethral catheter. If this fails, perform a diverting
drains, this is CLOT RETENTION. This is one of the colostomy (11.6)
most feared complications of prostatic surgery, and occurs
within the first 72hrs. There has often been severe If there is a further episode of urinary retention some
bleeding, and the blood in the bladder has clotted and months or years later, perform a cystoscopy to see what
obstructed the catheter, usually because the irrigation has is the cause. It may be a urethral stricture, regrowth of the
been neglected. You may find urine leaking from the prostate or bladder neck stenosis. You may have to make a
extravesical drain or even from the wound. Start tansfusion wedge resection of the neck of the bladder.
if necessary. Inject 50ml sterile water or saline into the This is very unlikely to happen, if you routinely excise a
bladder and immediately aspirate it. wedge of tissue from the back of the neck of the bladder
CAUTION! Do not inject more than 50ml, or you may when you remove the prostate.
burst the balloon, and do not try this method more than
once. If you find bladder diverticula, leave them: they will
become smaller now that you have relieved the
If this fails to dislodge the clot, try using heparinized obstruction, unless they were very large.
water; or deflate the catheter balloon, and push it further
into the bladder and wriggle it about. Do not pull the If there is an inguinal hernia present, you may repair
catheter out: it may be impossible to re-insert without a this (18.2) at the same time as the prostatectomy,
GA. if you are having good results and your complication rates
If all fails, return to theatre, remove the catheter under GA, of bleeding and blocked catheters is minimal.
and perform a urethro-cystoscopy if possible. Otherwise Otherwise repair the hernia later.
gently insert a new 3-way Ch24 catheter, using an
introducer, and wash out the bladder through this.
If even this fails, re-open the bladder to remove the clots. 27.21 Bladder neck problems
If there is bleeding 8-12days post-operatively
There are 2 causes of urinary obstruction in which the
(secondary haemorrhage, quite common), it usually settles.
prostate feels normal rectally, with no sign that it is
Many cases are not severe, and will stop on their own.
enlarged, but in spite of this, urine cannot pass.
If bleeding does not stop, re-insert a urethral catheter,
Between 5-10% of cases of supposed prostatic obstruction
making sure (by ultrasound if possible) that the balloon is
are like this. The patient is usually younger than the others.
sitting nicely in the prostatic bed and it is inflated
If you can easily pass a sound, you thereby exclude a
maximally. Wash the bladder through this until the fluid is
stricture.
nearly free of blood. Leave the catheter in situ some days
and repeat bladder wash-outs till the urine stays clear.
Perform a CYSTOSCOPY: you will find that the bladder
If bleeding persists, or you cannot re-insert a catheter,
is obviously obstructed, as shown by trabeculation,
take the patient back to theatre and reopen the prostatic
a hypertrophied inter-ureteric bar (27-7A), and perhaps
bed to control bleeding (27-19J).
diverticula. But you cannot see any sign of an enlarged
prostate. Instead, the posterior lip of the urinary meatus is
unduly prominent (difficult to see with an ordinary
cystoscope).
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The cause is: Making the diagnosis on the basis of the clinical findings,
(1) Dyskinesia (which also occurs in HIV disease), or: a raised serum acid phosphatise and X-ray findings, is not
(2);Bladder-neck fibrosis, one cause of which is be wholly reliable; also microscopic differentiation of
schistosomiasis, affecting the trigonal submucosa. carcinoma from benign hyperplasia can be difficult.
PSA estimation is, however, highly specific.
DYSKINESIA: Try to make this diagnosis before you
operate, and use prazosin 0·5-2mg bd. (Beware: this is an RECTAL EXAMINATION. A normal prostate feels
α-blocker and may cause postural hypotension) smooth, symmetrical, and firm, usually with a median
groove and mobile rectal mucosa. A carcinomatous
BLADDER NECK FIBROSIS: you may find, when you prostate is hard, nodular, and asymmetrical; its median
open the bladder, that the prostate is not enlarged. groove is often obliterated, and the rectal mucosa may be
Instead, there is a tight internal meatus, which you cannot fixed to it. Late locally extensive disease may extend to the
put your finger into. pelvic wall, form a band round the rectum, and fix the
pelvic tissues. Sometimes, you can feel the spread of the
BLADDER NECK RESECTION (GRADE 3.4) tumour in the tissues round the prostate. If possible,
METHOD. confirm these findings by examining the patient
Get adequate exposure: you cannot expose the internal bimanually under anaesthesia.
urinary meatus through a short incision. Approach the
inside of the bladder as for open prostatectomy (27.20).
Put a self-retaining retractor into the bladder, open it,
and tilt the head of the table downwards slightly.
Use a Langenbeck retractor, or a bent copper retractor,
to draw the anterior wall of the bladder against the pubis,
so that you can see the internal urinary meatus.
Identify the orifices of the ureters. Make deep cuts in the
bladder neck in the 5 & 7 o'clock positions, sloping
towards one another so as to excise a wedge of the
bladder neck (27-7C. 27-19K). The cuts must go deep
enough to divide the circular fibres of the neck of the
bladder. This will then spring open, and the obstruction
will be relieved.
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RADIOGRAPHS. Look for lytic and sclerotic (typical but There is an 80% chance that there will be a good response.
less common) metastases in the pelvis, and lumbar spine. However, there are many side-effects: fluid retention,
Paget's disease and osteoarthritis produce similar bony gynaecomastia, impotency, hot flushes, osteoporosis, and
symptoms, but show different X-ray changes. itching. You cannot use this drug in the presence of heart
ULTRASOUND (38.2I) will demonstrate an irregular failure.
enlarged infiltrating prostate, but cannot detect an early
carcinoma, except if you can use a rectal probe. Anti-androgens, such as flutamide 250mg tid, are more
acceptable, but are more expensive, and interfere with the
SPECIAL TESTS. If the carcinoma is present the PSA is action of anti-coagulants and anti-convulsants.
>2U; where it has spread beyond the prostatic capsule, Other anti-androgens such as ketoconazole, cyproterone
the serum acid phosphatase will be >3 King-Armstrong acetate, and spironolactone have too weak actions to be
units. A normal level does not exclude it. A persistently effective.
raised level supports the diagnosis, and suggests A good alternative is finasteride, a 5-α-reductase inhibitor,
metastasis. It has no prognostic value; its main use is in but this is even more expensive.
diagnosis. It falls in response to treatment, and rises when An alternative hormonal treatment is a subcapsular
the disease reactivates. orchidectomy (27.26), which will avoid the need for
CAUTION! Take blood before you do a rectal life-long drug treatment and its side-effects. Most patients
examination, or wait for 48hrs. If you take it immediately object to castration, but they may accept a reduction in size
afterwards, you will get an abnormally high reading. of their testicles! You must therefore discuss such
treatment carefully.
NEEDLE BIOPSY OF THE PROSTATE. (GRADE 1.3)
To confirm malignancy (or, rarely, TB), biopsy the If there is retention of urine, start hormonal treatment
prostate with a trucut biopsy needle (24-3) through the and pass an indwelling Foley catheter. Leave it in for at
rectum (27-20). This is not difficult but you may miss the least 3wks, before trying to remove it, and if then there is
malignancy unless it is quite advanced. Ultrasound will still urinary retention, consider leaving it in for a further
help you guide the needle, but unless you have a rectal 3wks. Hormonal treatment will usually make the prostate
ultrasound probe, you will need to use a perineal route. shrink enough to allow micturition. If, unusually, it does
In spite of passing through the rectum, serious infection is not, try to arrange endoscopic resection of the prostate.
rare. You should, though, use a single prophylactic dose of If this is quite impossible, retain a urethral or suprapubic
gentamicin beforehand, and make sure the rectum is catheter. Do not try to remove the prostate by the open
empty. method (27.20): this is difficult, because it does not shell
out properly, leaves tumour behind and risks spreading it,
CYSTOSCOPY. Examination under GA is necessary with and there will be severe bleeding.
cystoscopy; this is particularly useful in distinguishing
carcinoma of the prostate from carcinoma of the trigone of If the urine becomes infected, treat with appropriate
the bladder infiltrating the prostate. You may feel a grating antibiotics; in itself infection will not influence the
sensation, as you pass the cystoscope through the outcome of the carcinoma.
carcinomatous prostate, or you may see puckering of the
apex of the trigone, or submucous nodules in the bladder
(late signs).
27.23 Epididymo-orchitis
DIFFERENTIAL DIAGNOSIS includes:
(1) benign prostatic hyperplasia, Acute epididymo-orchitis presents with an acute painful
(2) tuberculous prostatitis, swelling of one testis and epididymis. A few cases are
(3) bladder carcinoma infiltrating the prostate, viral: the important viral cause is mumps which occurs in
(4) bladder-neck fibrosis (27.21), adolescents. Occasionally it may be due to brucellosis.
(5) stricture of the prostatic urethra (27.9). The testicle is acutely tender, may be associated with a
hydrocoele, lies in its normal position, with pain partially
MANAGEMENT relieved by lifting the testicle in a scrotal support.
If the disease is still confined to the prostatic capsule at
age <65yrs, there might be benefit from radical Chronic epididymo-orchitis is common in the sexually
radiotherapy if available. active and in elderly men with urinary outflow difficulties.
It is the result of:
If there is severe bone pain from metastatic disease, (1).Previous untreated or imperfectly treated attacks of
localized radiotherapy may give much relief. acute epididymo-orchitis, which is usually gonococcal,
or chlamydial.
If the disease is advanced or you cannot access (2) Non-specific urinary infection (usually due to E.Coli).
radiotherapy, treat with hormonal manipulation. (3) Schistosomiasis which is usually confined to the tail of
The original drug, diethylstilbestrol, an oestrogen the epididymis, causes little pain, less swelling and only
analogue, is cheap. Start with 1mg od, and if this fails to mild tenderness.
control the symptoms increase it to 5mg od. (4) Tuberculosis, which results in a firmer swelling.
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Suggesting filariasis (34.14): tender swelling of the cord, The scrotum is famous for its tendency to bleed
epididymis and testes, with oedema and inflammation of postoperatively, develop a haematoma and swell up bigger
the scrotal skin. The vas deferens is usually not palpable. than it ever was before! Complete haemostasis is
Treat with doxycycline 200mg od for 6wks. important. Sharp dissection causes less bleeding than blunt
dissection. A continuous locking absorbable suture over
Suggesting mumps orchitis: the testis is affected but the cut edge of the tunica is more reliable than interrupted
the epididymis appears normal. Usually unilateral but sutures.
occasionally bilateral, not necessarily simultaneously.
Ask if others in contact at school have had similar illness. The sac may be tense, enlarged and tender if there is a
The boy will settle without treatment, but if both testes are scrotal abscess (6.21); occasionally it is not tender but
affected, he may become infertile, especially if he is a contains a necrotic brownish paste associated with an
young adult. atrophic or absent testis. The cause of this is unclear,
but may be related to filiariasis, and is found in Northern
CHRONIC EPIDIDYMO-ORCHITIS India, known as ‘kichad’. In either case, incision and
DIFFERENTIAL DIAGNOSIS & TREATMENT drainage suffice.
Suggesting testicular tumour: painless swelling of the
testis (27.28) Very occasionally in a lax hydrocoele, the testis is
abnormal and may contain a tumour: in this case use an
Suggesting tuberculous epididymitis: swelling with inguinal approach (27.26), and be prepared to perform an
low-grade pain affecting the epididymis and later the orchidectomy.
testis, not necessarily but often associated with
tuberculosis elsewhere, which does not resolve with the EVERSION OF A HYDROCOELE
usual antibiotics. (JABOULAY OPERATION): (GRADE 2.1)
Suggesting bacterial epididymo-orchitis: chronic urinary INDICATIONS. Moderate sized thin-walled hydrocoeles.
symptoms predominate: use the appropriate antibiotics
related to urine culture. METHOD. Hold the scrotum in such a way as to stretch
the skin over the hydrocoele. Make a vertical incision
Suggesting schistosomiasis or filiarisis: a globular mass (27.29A). Carefully deepen the incision through to the
in the spermatic cord, which may extend along its whole tunica vaginalis and pierce this to let out the fluid.
course; this suggests fibrosis which may not respond to The incision should only be just big enough for you to
medical treatment. deliver the testis through the opening. When you have
done this, evert the tunica vaginalis and suture it behind
If there are severe recurrent attacks of pain which do the testis, in such a way that the testis cannot return into its
not settle, even when the urinary infection is controlled sac (27-21A).
and the flow good, consider orchidectomy (27.26) taking
the epididymis necessarily with the testis.
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27.25 Testicular torsion Torsion can occur at any age, but is more common in the
first year of life and in adolescence (12-19yrs).
Torsion of the spermatic cord (strictly speaking) is a Typically, a teenage boy wakes with sudden severe pain in
surgical emergency which needs operation without delay. the groin or lower abdomen (owing to the surface
It is never wrong to operate to exclude torsion. neurotome representation of the testis), rather than in the
testicle. Often, there is severe nausea and vomiting,
Occasionally, the tunica vaginalis ends abnormally high and rarely a fever. The testis becomes tender and swollen,
up the spermatic cord, so that the cord can twist and and the skin of the scrotum may become red.
obstruct the blood supply to the testis and epididymis.
When this abnormality (the ‘bell-clapper’ testis) is present, DIFFERENTIAL DIAGNOSIS.
the testis usually hangs transversely, and does so on both Suggesting epididymo-orchitis: the slower onset of pain
sides. in an adult with history and signs of past or present
sexually-transmitted infection, infected urine, or prostatic
Unless you can untwist the cord, the testis will necrose, symptoms (27.23). Usually a mild fever is present.
become a purple-black, and fill the tunica vaginalis with a The testis lies normally but may be quite swollen and
blood-tinged fluid. If you do not relieve the torsion before tender.
this happens, the testis will atrophy. If you are going to
save it, you must operate within 6hrs of the start of CAUTION!
symptoms. (1);Do not diagnose anyone as suffering from epididymo-
orchitis under 30yrs especially if there is no history of
PRESENTATION. sexual contact. If there is any doubt, operate. You will not
do harm by exploring orchitis, but antibiotics will not
relieve torsion. Do not rely on a Doppler test:
the presence of blood flow shows the testicle is still viable,
but not that it has not twisted!
N.B. Except for the orchitis of mumps, orchitis is very
rare in young boys.
(2);Treat painful testicular enlargement in an infant or
neonate as torsion.
INCISION
Make a vertical incision in the scrotum, over the area of
tenderness. Cut through the subcutaneous tissue
and fascial layers down to the tunica vaginalis.
Open it. You will find it filled with blood-tinged fluid,
and you will see the twisted spermatic cord. Untwist it.
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If you find only one testis, the other having been lost to
neglected torsion, perform an orchidopexy on the
remaining testis.
Fig. 27-23 SUBCAPSULAR ORCHIDECTOMY FOR PROSTATE
CARCINOMA. A, make a longitudinal incision in the patient's
scrotum. B, evaginate the testis. C, incise the tunica albuginea.
D, separate the substance of the testis from the inner surface of the
27.26 Orchidectomy tunica albuginea. D, close the tunica. E, close the skin.
After Rob C, Smith R. Operative Surgery, Butterworth 1981 p.667-8 with
kind permission.
You may occasionally need to remove the testes, either
because of infarction, chronic suppuration or a tumour SUBCAPSULAR ORCHIDECTOMY FOR………………
PROSTATIC CARCINOMA (GRADE 2.3)
(a sarcoma, seminoma or teratoma, 27.28). This is much
safer than biopsying it, which may spread the tumour.
Or, in treatment of prostate carcinoma (27.22), Raise the scrotum, and incise the stretched skin and dartos
you can perform a bilateral subcapsular orchidectomy. muscle, to expose both testes (27-23A). Evaginate each
This removes the testicular function whilst retaining the testis with its coverings, and incise its tunica vaginalis
semblance of testicles. vertically to expose the testis and epididymis 27-23B).
Do not mistake mumps orchitis or epidydimo-orchitis for a Incise the visceral tunica vertically over the globe of the
tumour. This causes rapid enlargement, and some pain testis. Use sharp and blunt dissection, to separate the
(which is minimal in the case of a tumour). substance of the testis from the inner surface of the tunica
Mumps orchitis may cause little pain, so if you are in albuginea (27-23C). Control bleeding carefully at the
doubt, wait for a few days rather than remove the testis. upper testicular pole. Remove all testicular tissue, and
You will have to exert some traction on the cord, close the tunica with continuous 3/0 absorbable sutures
but beware of its upper end slipping out of the clamp and (27-23D). Close the scrotum in 2 layers with continuous
retracting out of sight. Take great care to secure 3/0 short-acting absorbable sutures, without inserting a
haemostasis, before you close the wound. If possible, drain. After 2-3wks, blood clot in the tunica will become
apply diathermy to the smaller bleeding vessels, and tie off organized to form a small palpable nodule, not unlike a
the larger ones. Close the skin with continuous horizontal small testis.
mattress absorbable sutures.
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Expose the testis by incising through the scrotum About 3% of neonates and 0·5% of older boys have a testis
(27-23A), deliver the testis, clamp the spermatic cord and missing from the scrotum, and in 20% it is missing on both
ligate it with a strong suture. If it is very thick and sides. An incompletely descended testis lies along the
oedematous, ligate it twice with a fixation suture and track of descent of the testis: the common sites for it are in
divide it. If the area is infected, leave the wound in the the inguinal canal, or inside the abdomen.
scrotum unsutured to drain freely, dress it loosely, A maldescended testis, however, may lie in the supra-
and close it by delayed primary suture. inguinal pouch, just superior to the external ring deep to
the membranous part of the superficial fascia, in the
ORCHIDECTOMY FOR TESTICULAR TUMOUR perineum, or on the medial aspect of the thigh.
(GRADE 2.5) The distinction between incomplete descent and
maldescent may be difficult. A testis which is absent from
You will need to remove the cord with the testis, so open the scrotum will produce hormones but not spermatozoa.
up the inguinal canal as for a hernia with an inguino- So if neither of the testes is in the scrotum, there will be
scrotal incision (18-7A). Pick up the cord within its normal secondary sex characteristics, including potency,
covering of cremaster. Apply a soft bowel clamp to it but infertility. The less complete the descent, the greater
(27-24A), before you do anything else. Deliver the testis the chance of infertility. If a testis is absent on one side
from the scrotum by pushing it up from below. only, there will probably be fertility, but the misplaced
If the tumour is large, you will have to extend the opening testis is more easily injured. Spermatogenesis is normal in
in the external inguinal ring. an incompletely descended testis and in a maldescended
one for up to 2yrs. This is also the age at which nearly all
If you feel a hard irregular mass, which is not chronic 'retractile testes' will have settled normally into the
epididymo-orchitis, doubly transfix and tie the cord scrotum. So wait until 2yrs before you advise orchidopexy.
proximal to the clamp as near the internal ring as you can, If neither of the testes is in the scrotum by this time,
and excise the testis. orchidopexy may still produce adequate fertility.
If one testis descends, fertility may still improve with
orchidopexy. Its main effect, however, remains
psychological.
SPECIAL TESTS.
If you cannot feel the testis in the groin, you might be able
to see its position with ULTRASOUND (38.2).
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ANAESTHESIA.
(1);In a neonate, sucking on the mother’s breast with
some sugar on the nipple is usually good preparation.
Topical anaesthetic cream is useful if you are performing
many circumcisions. Wait for it to take effect!
(2) If the boy is <15yrs, use ketamine.
(3);If >15yrs and he is HIV-ve, use LA (27-25).
You will have to cut the inner and outer skin of the
foreskin, so you will have to infiltrate them both.
With the foreskin forward, infiltrate a ring of anaesthetic
solution without adrenalin at the site of section
(27-25A,B). Pull back the foreskin (27-25C). To do this
you may have to infiltrate a little more solution and make a
dorsal slit in it. Infiltrate another ring of solution at the site
Fig. 27-25 ANAESTHESIA FOR CIRCUMCISION FOR
PATIENTS >15YRS.
of section just behind the glans (27-25D). Pull the foreskin
A,B, with the foreskin forward, infiltrate a ring of LA without forwards and do the circumcision (27-25E). Or, perform a
adrenaline at the site of section. C, pull back the foreskin. To do this dorsal nerve block at the base of the penis at 2 & 10
you may have to infiltrate a little more and make a dorsal slit. o’clock positions with 1ml of 0·25% bupivacaine or 1%
D,E, infiltrate another ring of solution, at the site of section, just
behind the glans. Pull the foreskin forwards again, and all is ready
lidocaine, about ½cm below the skin.
for circumcision to start. (4),A caudal block is an alternative <5yrs: using a 0·9mm
N.B. Under 15yrs and in HIV disease, use a caudal block or ketamine. spinal needle, under sterile conditions, introduce up to 4ml
1% lidocaine through the sacral hiatus into the sacral canal
A STORY FROM A CITY HOSPITAL. to the level of S3.
Horrible shrieks used to be heard from the theatre whenever
circumcisions were being done. A caring surgeon put Fig. 27-25 on the
wall whereupon they stopped completely, to the gratitude of the staff and TIMING.
the patients! 10yrs later this event was still remembered. Neonatal circumcision is best done at day6 of age, and
before day10. Check that the child has passed urine, and
There may be a significant risk, in some cultures, that a look carefully for hypospadias or epispadias.
child has it done by crudely under non-sterile conditions.
You may be able to advertize a course in good surgical RESOURCES.
technique for traditional practitioners or nurses! Consider carefully if, because of financial incentives from
programme donors, the resources for performing
circumcisions are being diverted from other essential
surgery!
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CIRCUMCISION DEVICES
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The child goes home with the bell part of the device still The Mogen clamp (27-27G) technique is the quickest, and
attached. It will fall off with any foreskin left beyond the therefore least painful. You do not need to make a dorsal
suture in 6-12 days. slit, although this may help to visualise the glans.
Use your thumb and first finger of the non-dominant hand
If the device does not fall off during this interval, to grasp the foreskin firmly below the tip of the haemostat
you must remove it promptly. Sometimes oedema will trap and push the tip of the glans out of the way.
the plastic ring on the penis, so you will need a guide and
ring cutter to cut the ring off. Slide the Mogen clamp anteriorly to posteriorly just above
your fingers to protect the glans when applying the clamp.
If the child has difficulty urinating, it may be because Place it at the same angle as the corona with the hollow
the ring has slipped proximally from the glans onto the side facing the glans, so that you remove more foreskin
penile shaft; this can result in venous obstruction and a dorsally than ventrally. Before locking the Mogen clamp
compartment syndrome leading to necrosis of the glans. shut, manipulate the glans to be sure it is free of the clamp.
N.B. The advantages of the Plastibell are that you do Then close and lock it. Cut off the foreskin distal to the
not cut the frenulum and there is no free incised edge of clamp with a scalpel.
foreskin that can bleed. N.B. Beware! The glans is not well protected during
clamping and cutting. However, since the clamp only
The GOMCO clamp (27-27C) is a 3-part device opens 3mm, the chance of trapping the glans is minimal.
(base plate, bell, lock). The clamp crushes c.1mm of the
foreskin circumferentially, while the bell protects the glans FORMAL CIRCUMCISION IN OLDER CHILDREN &
by separating it from the inner preputial mucosa during ADULTS
removal of the foreskin. The bells come in 3 sizes; for a
correct fit, the edge of the bell should reach the frenulum After performing a dorsal cut of the foreskin, cut the outer
and minimally extend over the corona, slightly stretching skin only round the corona (27-26D). Cut the inner layer
the preputial skin. (For a newborn, use a clamp with a with scissors, leaving a 2mm fringe at the corona
1·3cm hole) (27-26E). One of the purposes of the foreskin is to provide
A dorsal slit is not always necessary. enough skin to allow the penis to erect, so when you
Place the bell inside the foreskin and over the glans, perform a circumcision, be careful not to take off too much
lubricated with a little lubricant jelly (27-27D), skin, or the pubic hair will later be drawn up the root of the
and remove the two haemostats. Make sure that the apex erected penis. On the other hand do not leave too much
of the dorsal slit is visible above the rim of the bell. skin, or there is the risk of recurrent phimosis.
Too small a bell may injure the glans and fail to protect
the corona. Slip the handle of the bell through the circular Use 3/0 absorbable individual ties to control bleeding,
opening of the base plate, without letting the foreskin slip and suture the fringe of the foreskin to the skin of the shaft
off. Tie the foreskin in place (27-27E). Check to see that of the penis (27-26F). Finally, control bleeding from the
the foreskin is not twisted and remains relaxed proximal to frenal vessels with a special encircling suture (27-26G).
the corona. If it is taut, you can remove too much foreskin Dress the wound with petroleum jelly gauze. No dressing
or even cut into the glans;if it is too loose, you will remove is needed after 24hrs.
too little foreskin! You may need to adjust the base plate:
this is the time to do so. Make sure that the crossbar at the CAUTION!
top of the bell sits squarely in the yoke of the clamp so (1) Do not cut the glans.
pressure is evenly distributed around the bell (27-27F). (2).Do not use diathermy on the penis, it can cause
Tighten the thumbscrew until snug to crush the foreskin gangrene of the whole organ.
between the bell and base plate; then cut the foreskin at the (3).Never use adrenaline in a local anaesthetic for the
base plate using a scalpel (27-27F). Carefully remove any penis, this too can cause gangrene.
remaining tissue in and around the groove that connects (4).Avoid LA in HIV+ve patients, as postoperative
the clamp and bell. vasculitis and infection may result in gross necrosis (6.21).
Leave the clamp secured for 5mins and then unscrew it to
remove it. DIFFICULTIES WITH CIRCUMCISION
N.B. You need care in adjusting the bell and base plate If you cannot separate the foreskin and the glans,
correctly, so not too much or too little foreskin is cut off: because the cleft between them is obliterated, you may
don’t try repeating the procedure with the clamp. find yourself dissecting the glans from the thick adherent
If the clamp is old and worn, it will not give a neat foreskin. If necessary, work slowly and carefully with a
closure! sharp scalpel. This will leave a raw area. Allow this to
granulate on its own, and do not try to graft it with split
If too little foreskin is removed, proceed to a formal skin.
circumcision.
If an adult has postoperative priapism,
If too much foreskin is removed, you may need a skin sedate him (27.32), but do not use propofol.
graft to cover the defect.
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If a meatal stricture develops in a child, If there are signs of BXO, hydrocortisone cream will help
give the mother a plastic rod to keep it dilated. to prevent recurrence. Apply it into the meatus from the
The rounded plastic containers used for disposable needles nozzle of a small tube, which will then act as a dilator.
are very suitable. Ask her to lubricate it with vegetable oil. You should continue this for 3months.
If necessary perform a meatotomy.
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DIFFERENTIAL DIAGNOSIS: includes condyloma Leave adequate spaces between the sutures joining ventral
acuminatum and the following: and dorsal flaps to allow blood to drain and prevent a
haematoma forming. Split the distal end of the urethra
Suggesting chancroid: an irregular undermined painful longitudinally.
ulcer caused by Haemophilus ducreyi with a grey base. Evert each half, and suture it carefully so that it everts onto
Enlarged groin nodes. Often associated with HIV disease. the ventral flap. Leave a narrow self-retaining catheter in
place for 5days. Epithelium will grow over the raw surface
Suggesting primary syphilis: a round or oval painless of the corpus spongiosum.
ulcer, often found under the foreskin, but which does not Warn him that, despite your efforts, you may need to
penetrate or destroy it. Enlarged groin nodes. Serological perform periodic dilations.
tests may be -ve early, but are always +ve later.
MANAGEMENT
The ulcer is almost always infected, so treat with
cloxacillin 500mg qid for 1wk pre-operatively.
If the growth is limited to the foreskin and is freely
mobile over the glans, make a circumcision and follow up
closely.
If it has involved the foreskin and the glans, or the
shaft of the penis, take a biopsy, and as soon as the
diagnosis is confirmed, perform a partial amputation 2cm
proximal to the lesion. If there is a recurrence, it will
probably be in the inguinal nodes, not in the stump of the
penis.
If the inguinal nodes do not seem to be clinically
involved, wait. 'Normal' nodes are palpable, and sepsis
may cause some enlargement and tenderness. If they are
palpable, and are clinically infected, wait. If they are
palpable and clinically cancerous, biopsy the primary and
get fine needle cytology on the nodes, if possible.
If there is cancer in the nodes, amputate the penis, with a
simultaneous bilateral block dissection of the groin (17.8)
after allowing any severe sepsis to settle.
Fig. 27-31 PARTIAL AMPUTATION for penile carcinoma.
A, incisions for partial and complete amputation. B, flaps and the
PARTIAL AMPUTATION OF THE PENIS (GRADE 3.1) amputation. C, repair. D, cross-section of the penis.
Aim to fashion the urethral orifice carefully, so that a
stricture does not develop. Remember the anatomical MODIFIED COMPLETE AMPUTATION OF THE
description of the penis assumes it is in the erect position PENIS (GRADE 3.5)
(27-31B).
Cut a long ventral flap based proximally. Make its width INDICATIONS.
equal to ½ the circumference of the penis. Cut a shorter Carcinoma of the penis, which you cannot excise with a
2cm dorsal flap. Dissect both flaps back to their bases. 2cm proximal margin by partial amputation.
Dissect the corpus spongiosum away from the corpora N.B. This is a difficult operation!
cavernosa, until you reach the planned level of section.
Divide the corpus spongiosum 2cm distal to the level METHOD.
where you intend to section the corpora cavernosa. The ulcer is almost always infected, so treat with
Pass transfixion sutures of # 1 absorbable through each of cloxacillin 500mg qid for 1wk pre-operatively.
the corpora cavernosa 0·5cm proximal to the intended Use the lithotomy position and pass a Ch20-24 metal
level of section. Divide the corpora, dissect proximally for dilator to define the urethra. Make a racquet-shaped
0·5cm, and then tie the sutures medially and laterally. incision round the base of the penis (27-32B). Extend the
Cut a small circular slit in the ventral flap, and pull the arm in the midline posteriorly for about 5cm, between the
urethral stump through it. Leave the end of the urethra two sides of the scrotum (27-32A) (extend it further
protruding. It is less likely to stricture if you do this. towards the perineum later).
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Dissect deeper, clamping all vessels; this area is very Cut a transverse 1cm hole in the perineal skin,
vascular. Find, clamp, tie, and divide the large dorsal vein 2-3cm anterior to the anal verge. Deliver the stump of the
of the penis (27-31D). corpus spongiosum through it, so that it protrudes about
Continue dissection until the shaft of the penis is free of 2cm. Suture the base to the skin, using 2/0 or 3/0
subcutaneous tissue. Extend the incision posteriorly to monofilament sutures. Do not try to evert the stump, or the
where the scrotum hangs from the perineum, about 4-5cm urethra may form a stricture. Leave the stump long
in front of the anus. Separate the testes with their covering because it tends to retract. Epithelium from the urethra and
tunicae vaginales. Ask your assistant to retract them skin will grow and cover it.
laterally with tissue forceps placed subcutaneously,
first on one side and then on the other. Insert corrugated rubber drains (4-14B) through 2cm
incisions laterally in the scrotum, and suture these to the
Dissect the corpus spongiosum on its ventral and lateral skin. Or, better, use suction drains.
aspects, as far as the bulb which lies on the perineal First close the wound in the midline using
membrane. Find it by feeling the expansion round the 2/0 monofilament. Then suture the anterior part of the
bougie. Remove the bougie, and cut the corpus wound. If the scrotum would hang down too much, trim
spongiosum 4cm distal to the bulb. Separate it from the off some skin and subcutaneous tissue before you suture it.
corpora cavernosa and retract it. When you have finished, the scrotum will lie more
anteriorly than usual. This allows good skin cover,
Now free the corpora cavernosa until they diverge as the and is less likely to get in the way when urinating through
crura, at the inferior border of the symphysis pubis the perineal urethrostomy.
(27-32C). Transfix each of them with #1 absorbable and
divide them 0·5cm distally. Only some connective tissue POSTOPERATIVE CARE. Pass an indwelling catheter,
will now remain. Divide this and remove the penis. and remove it at 7-10 days.
Apply much cotton wool padding, and a T-bandage
pressure dressing. Remove the dressings and the drains
>48hrs. Then start baths bd.
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PREPARATION.
Clean the skin thoroughly. If the scrotum is enormous
(27-33A), either operate with the patient sitting and the
legs over the edge of the table, or arrange a hook, and a
block and pulleys, in the theatre ceiling before the
operation starts (27-33B), so that you can raise the
scrotum.
INCISION.
If there are large hydrocoeles, tap them.
Make a midline incision downwards, from the pubic
symphysis, to just above the foreskin (27-33C).
Fig. 27-33 ELEPHANTIASIS OF THE SCROTUM. Make 2 lateral incisions round the root of the scrotum, to
A, the appearance at presentation. B, suspend the scrotum (optional). meet one another posteriorly in the perineum (27-33G).
C, catheterize the urethra and make the first incision. D, deliver the Carefully deepen these lateral incisions, until you reach the
penis. E, preserve a cuff of foreskin to cover the penis. F, cover the
penis with gauze while the operation continues. G, carry lateral
spermatic cords on each side. If necessary, find the cords
incisions posteriorly. H, find the testes and deliver them. I, deliver the them from the external inguinal rings. Follow the cords to
penis through the skin, and remove most or all of the scrotal skin. the testes, and deliver them (27-33H).
Partly after Bowesman, C. Surgery and Pathology in the Tropics, If the testes are of normal size and there are no
Livingstone, 1960 with kind permission.
hydrocoeles, do not open the tunicae vaginales.
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Remove the clamp from the cuff of skin that was the
foreskin, trim away the part that was crushed,
and roll the rest back to cover the shaft of the penis.
Deliver this through a slit in the apron of skin dragged
down from the abdominal wall (27-33I). Suture this to the
skin of the shaft of the penis, starting with a single
central suture, and proceeding laterally on both sides.
Graft any remaining raw areas with grafts from the thigh,
and dress them with vaseline gauze.
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If there is a transitional cell tumour of the renal pelvis, Treat with vincristine 1·4mg/m² (maximum dose 2mg) IV
it is likely to be associated with similar tumours in the and repeat after 2days. Arrange surgery 10-12days later if
bladder. These tumours usually project into the renal the kidney is of resectable size. Otherwise, continue
pelvis, so that you can see them on a retrograde urogram. downstaging chemotherapy with nutritional support,
Nephro-ureterectomy is indicated. prophylactic anti-TB therapy, antibiotics and
antihelminthics also to prepare for surgery. You will need
If it is a squamous carcinoma (HYPERNEPHROMA), to cross-match blood and prepare the bowel.
it is likely to be associated with chronic infection, CAUTION! Sometimes the tumour spreads into the
and a curative nephrectomy is seldom possible. inferior vena cava.
After nephrectomy, continue the chemotherapy régime
If a child has a nephroblastoma (WILMS TUMOUR), monthly for 4-6 months after a gap of 2-3days.
look for other congenital anomalies (eye defects,
hemihypertrophy, and urogenital anomalies),
which are sometimes associated. After Burkitt's 27.36 Schistosomiasis (Bilharziasis) in the
lymphoma, this is the commonest solid tumour of urinary tract
childhood in Africa. The tumour arises from embryonal
kidney cells and spreads locally through the capsule of the Schistosomes are trematode blood flukes infecting >2.10 8
kidney to neighbouring nodes (often fairly late), people; there are several types but S. haematobium in the
as well as to the liver, lungs, and sometimes the bones. Middle East and Africa causes urogenital disease, though
other types cause mainly liver and intestinal disease.
The young child presents with a fairly rapidly growing and The adult male fluke encloses the cylindrical female to
usually painless mass on one side of the abdomen. mate, assuming an elongated shape able to live inside
In 70% of cases this is <2yrs, and is seldom >6yrs. In 5% veins by attaching to their walls by suckers. The fertilized
of cases the mass is present at birth, and in 5% it is female then detaches itself and migrates to narrow veins,
bilateral. There is rapid weight loss and fever in 50% of preferentially in the vesical plexus, laying >200 eggs daily
cases. Haematuria is late. (27-35). The S. haematobium egg has a terminal spine,
unlike the S. mansoni egg which has a lateral spine.
STAGING and PROGNOSIS. Nephroblastoma is always
fatal without treatment. The survival figures below are for When these eggs are excreted in the urine, they can hatch
a combination of nephrectomy, radiotherapy, in fresh water and attach themselves to certain snails
and chemotherapy. Long-term cures for the stages I-III are (Bulinus truncatus) which lives in slowly flowing shallow
common. water. These snails can then produce 105 free-swimming
forked-tailed cercariae which have an enzyme that allows
Stage Definition 5yr them to penetrate human skin, and so continue the
Survival life-cycle.
I Tumour is confined to the kidney, 95%
and can be removed in toto. It is the eggs that cause the trouble, initially producing an
II Tumour penetrates the capsule, 85% immune dermatitis (‘swimmer’s itch’) and a Type II serum
but can be entirely excised. sickness called Katayama fever; later when they migrate
III Tumour, not completely 85% into the tissues eliciting a Type IV immunological
resectable, but confined to the response, a granuloma results which depends on its
abdomen. severity on the number of eggs deposited and the host’s
IV Tumour widespread, with 5% immune response.
metastases beyond the abdomen.
Although the eggs of S. haematobium predominantly
N.B. In bilateral disease (6%), palliation only is possible. affect the urinary tract, they can also travel into the lungs,
Do not try to remove the kidney, unless you are skilled. spinal cord and brain. The granuloma is accompanied
Diagnose the condition clinically, and organize subsequently by fibrosis and impaired collagen synthesis.
investigation, nephrectomy, and chemotherapy,
and perhaps radiotherapy. If this is not available, The eggs can survive ≥10yrs and so chronic disease is
it is acceptable to rely on nephrectomy and chemotherapy. common. Schistosomiasis affects >200 million people
It is not acceptable to leave the kidney and to treat with worldwide, and causes up to 200,000 deaths annually.
chemotherapy only.
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The results are: CYSTOSCOPY. Appearances are striking: you may see
(1) dilated cystic ureters, in active cystitis:
(2) thickened pipe-stem ureters, (1) reddened congested oedematous patches especially on
(3) ureteric strictures all with possible stones (27.15), the posterior wall, as well as raised yellowish tubercles;
(4) active cystitis, and in chronic cystitis:
(5) chronic cystitis, (2) ‘sandy’ patches,
(6) bladder ulcers, (3) nodules, polyps, ulcers, scarring and tumours,
(7) bladder-neck fibrosis (27.21), (4) cystic degeneration in the bladder wall,
(8) a contracted low-volume bladder, (5) narrowed or patulous ureteric orifices.
(9) bladder carcinoma (27.5),
(10) active or chronic prostatitis (27.19), TREATMENT.
(11) epididymitis & chronic spermatic cord inflammation Praziquantel 60mg/kg stat or 10mg/kg bd for 3days is most
(27.23), effective where fibrotic effects are not yet advanced.
(12) rarely urethral stricture, dilation and fistula.
Where the ureter is irreversibly damaged, reconstructive
Such pathology may obviously lead to renal failure as well surgery is necessary: this is complicated because excision
as infertility, or death from malignant infiltration. and spatulated end-to-end anastomosis is rarely feasible.
You should feel for an enlarged kidney, a pelvic mass, A re-implantation of the ureter into the bladder is usually
a hardened prostate or lumpy spermatic cord and necessary, and sometimes, if the ureteric stricture is
epididymis. very proximal, with a bladder extension (Boari) flap.
Active cystitis usually presents between 5-15yrs with Otherwise the whole ureter needs replacing with an ileal
painful micturition, frequency and terminal haematuria. segment.
This type of haematuria (27.4) is really the hallmark of
schistosomiasis. You can treat bladder neck fibrosis with excision
(27-19K) but a contracted bladder needs an augmentation
SPECIAL TESTS. cystoplasty and a urethral fistula may need a urethroplasty.
Examine urine or semen carefully for schistosoma eggs, as
well as red cells and pus cells (especially in bladder
carcinoma where you may find strands of tumour tissue in
the urine). You may need a cystoscopic or epididymal
biopsy, however, if all the eggs have migrated into the
tissues.
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27.37 Other urological problems Chyluria debilitates, through a persistent loss of fat,
protein, electrolytes, vitamins in the urine. Treat with a
single dose of diethylcarbamazine 6mg/kg with
If there is a foreign body in the urethra, try to remove it albendazole 400mg, or ivermectin 150µg/kg.
with as little damage as possible. Use GA.
If this fails, you can lavage 5-10ml of 1:10000 silver
Ideally, identify the foreign body with a cystoscope using nitrate solution into the renal pelvis after passing a ureteric
the 0º objective to look down the urethra. Failing this, catheter under direct vision by a cystoscope with the
locate it in the penis by palpation and with radiographs. patient in a Trendelenburg position. This can be done wkly
up to 4 times. It is effective in 70% of cases.
Try to disimpact its distal end from the wall of the urethra.
Use alligator forceps and, perhaps, a large bore cannula. If there is erectile dysfunction, examine the penis for any
If necessary, perform a urethrotomy (27.12), and cut down structural abnormality. Ask if there is ever a sustained
on the urethra through the ventral surface of the penis. erection: although ‘wrong time, wrong place, wrong sexual
partner’ is often the cause, it is not necessarily so.
If the foreign body is far back in the urethra, try to
dislodge it into the bladder, and if you cannot remove it The underlying problem may well be:
endoscopically, do so through a small suprapubic (1) HIV disease,
cystotomy. (2) obesity,
(3).vascular disorders (not only the classical Leriche
If it is a pin, you may have to remove it head first unless syndrome caused by aortic bifurcation occlusion),
you can secure the sharp tip in a biopsy forceps, so put its (4).medication (especially cimetidine, bendrofluazide,
point through the wall of the urethra, and turn it round. β-blockers and antidepressants).
If the opposing surfaces of the glans and foreskin are Sildenafil 25-100mg 1hr prior to sexual activity is most
acutely inflamed, this is acute BALANITIS. effective; intra-penile injections and prosthesis are very
Test the urine for sugar to exclude diabetes. The primary much second best, and can be subject to significant
treatment of balanitis is better hygiene. Demonstrate how complications, particularly priapism (27.32), and infection.
to retract the foreskin. and do this at least tid, to wash with
soap and water and to apply a mild antiseptic,
such as chlorhexidine or cetrimide and hexachlorophene.
Avoid systemic antibiotics. If there is associated phimosis,
arrange for circumcision.
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28 The eye
28.1 Introduction
There are c. 285 million visually impaired people in the
world, of whom >39 million are blind. WHO estimates
that 43% of the visually impaired are so because of a lack
of spectacles while 30% have cataract. Major causes of
blindness in the world are cataract (50%), corneal
infections (particularly trachoma, 25%), glaucoma,
vitamin A deficiency, and onchocerciasis.
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THE PIN-HOLE TEST is a useful way of screening for To examine the conjunctiva of the upper lid, evert it
refractive errors. If there is poor vision, place a card with several (28-8H-K). This is necessary to exclude a foreign body.
1mm holes (punched 5mm apart) in front of the eye.
For repeated use, attach the card to the insides of each lens of a Look for pus or mucopus in the inferior fornix.
pair of spectacles. Cover each eye in turn for testing. If there is
an uncorrected refractive error, the vision will be significantly
This is present in all cases of bacterial conjunctivitis, and
improved to 6/9 or 6/12. in some cases of viral conjunctivitis. Look also for signs
of vitamin A deficiency: dry-looking conjunctivae, or
CHECK THE VISUAL FIELDS, in all 4 quadrants, while Bitot's spots (white patches on the temporal side of the
sitting face-to-face with the patient, covering his right eye conjunctiva, produced by keratin mixed with gas-forming
and your left eye and vice versa, comparing them. bacteria).
EXAMINING THE OUTER EYE Look at the cornea of each eye. Is it shining and clear,
reflecting the light of a torch, or its surface irregular?
Start by looking at the whole face. Note any asymmetry (corneal ulcer). Is there clouding superiorly (trachoma,
of the position of the eyes, or any protrusion (best judged 28.13), or a general haziness? (oedema from trauma,
from above and behind the patient). Palpate for a lump, keratitis, or glaucoma). A bright light and a loupe can
and for high intra-ocular pressure. detect keratic precipitates and adhesions (synechiae,
28-9B, of iritis).
Ask the patient to look down and keep looking down,
but not to actively close the eyes. Put the tips of both your If you suspect the surface is injured or ulcerated,
index fingers on one of the globes, so as to feel the sclera instil 1 drop of 2% fluorescein, or dip the end of a
through the upper lid above the upper border of the tarsal fluorescein impregnated filter paper inside the lower lid
plate. for a few seconds. Mop out the excess fluorescein with
Gently press with alternate finger tips towards the centre tissue paper. Shine a light on the eye at an angle.
of the globe: Gaps in the corneal epithelium (ulcers, abrasions) stain
(1) Gently fluctuate it from one finger to another. bright yellow-green.
(2) Indent it with one finger and estimate the sense of
fluctuation imparted to your stationary finger. Look at the anterior chamber and note its depth.
(3) Estimate the indentation of the sclera as you relax Is there any blood (hyphaema), or pus (hypopyon, 28-9C)
your indenting finger. You can judge the eye to be at the bottom of the anterior chamber?
‘soft’ (<10mmHg), ‘normal’ (10-40mmHg), or ‘hard’ Look at the pupils. Do they look black and do they react
(>40mmHg). This is a crude test, and there must be a to bright light? Are the pupils grey or white? (opacities in
significant rise of pressure (>40mm Hg) before you can the lens, cataract). Note their size, shape, and if their
detect a raised intra-ocular pressure. outline is irregular (synechiae, due to iritis, 28.5).
If a pupil constricts incompletely when light is shone into
Test the movements of both the eyes together, and then that eye, and then constricts further when it is shone into
test each eye separately, in all directions, including the good eye, and when the light is shone back into the
convergence. Note any squint (28.9). abnormal eye, both pupils enlarge, this means there is
optic nerve damage, commonly caused by glaucoma,
If there is much pain, and the eyelids are in spasm, but you should exclude a stroke or brain injury.
a drop of sterile LA will make examination tolerable. This is known as a relative afferent pupillary defect.
This will allow also you to insert a speculum to examine
the eye more easily. Whilst the patient is looking, grasp FUNDOSCOPY (OPHTHALMOSCOPY) examines the
the top lid with your finger, and slip the top blade of the fundus and media of the eye. You must, either, dilate the
speculum under it. Then ask the patient to look up, pupils with a mydriatic such as cyclopentolate 1%,
grasp the bottom lid, and slip the lower blade of the or do your examination in a dark room.
speculum under that. Adjust the arm of the speculum until This is however ineffective where the vitreous or cornea is
the eye is exposed, and then tighten the locking nut. opaque, or very unevenly curved (extreme astigmatism).
CAUTION! Beware that the speculum does not press (1).Get the patient to keep both eyes open and look
on the eye or damage the cornea. straight ahead.
Note abnormalities of the lids, lacrimal apparatus, (2).Start with the '0' lens in the ophthalmoscope
puncta and canaliculi, the lacrimal glands and sacs, (unless you have a refractive error and are not wearing
and also any epiphora (tears running down the cheeks). glasses; if so select the appropriate correcting lens and
Do the eyelids open and close normally? You can see this remember this as your starting point.
best on blinking. Check the lids for swellings, and check (3).Use your right hand and your right eye for the
that the lashes are in their normal position. patient’s right eye and your left hand and your left eye for
Look at the conjunctiva. Note particularly the distribution the patient’s left eye.
of any redness. If it is maximal near the corneoscleral (4).Hold the sight hole of the ophthalmoscope close to
junction, this occurs in iritis and corneal ulcer. If it is your eye, resting it against your nose and orbit, and move
maximal at the periphery but often extending all over, it is it with you as if it was attached to your head. To find this
likely to be conjunctivitis. position, look through the sight hole at some distant
object.
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(5).With your thumb on the patient’s forehead, Explain what you are going to do, lay the patient flat and instil LA into
the conjunctiva. Ask him to open both eyes, and look straight up at a
gently raise the upper lid clear of the pupil.
target placed on the ceiling.
(6).Start with the ophthalmoscope 20cm from the eye, With the 5·5g weight in place, put the tonometer plunger gently on the
and shine the light into the pupil; it should glow centre of the cornea with the eye open, and read the scale. If in doubt,
uniformly red (the red reflex). This indicates the absence repeat the reading 3 times. Use the tables provided with the instrument
to calculate the IOP from the scale reading.
of a cataract.
The normal IOP is 7-25mmHg. In practice, using the 5·5g weight, a
(7).Move closer and watch for any opacities in the media scale reading of ≤2 (>28mmHg) indicates a raised IOP. A reading of ≥3
silhouetted against the red reflex. Corneal opacities (<25mmHg) is 'normal'. If the IOP is >40mmHg, the cornea is likely to
appear to move in the opposite direction to the become oedematous (the characteristic 'hazy cornea' of glaucoma), and
you can see this with a torch. This is usually a late sign of glaucoma.
ophthalmoscope; vitreous and posterior lens opacities
appear to move with the ophthalmoscope. If you see a BINOCULAR INDIRECT OPHTHALMOSCOPE
shadow, use the + lenses (+5 to +12) to see it more
clearly.
(8).Ask the patient to look straight ahead, and move as
close as you can to the eye without touching the eyelashes
or cornea.
(9).Find and look at the optic disc: it is 15º to the nasal
side of the optical axis of the eye.
(10) Turn the lens wheel in the ophthalmoscope with your
forefinger from +6 down to zero to get the best view of
the disc. Examine:
(a) the vertical cup/disc ratio (a ratio of >0·7 suggests
glaucoma, 28.6, 28-11),
(b) the disc margins; if these are blurred all round (360º)
it suggests papilloedema,
(c) the blood vessels, look for nasal displacement of the
central retinal vessels and for haemorrhages and exudates
suggestive of diabetic retinopathy,
(d) the macula (28-1C), by asking the patient to look
directly into the light source, for black and white
pigmentation which may suggest choroiditis (28.5)
involving the macula (maculopathy).
Fig. 28-4 BINOCULAR INDIRECT OPHTHALMOSCOPE.
This allows good examination of the anterior & posterior segments
at much less cost than a slit lamp: It is also portable (28-5).
After Chaudhury A, Chugh A, Role of Indirect Ophthalmoscopy in Rural
Settings, Rural Surgery 2009;5(3):19-20.
(www.mercoframes.net/product/binocular-indirect-ophthalmoscope)
INDIRECT OPHTHALMOSCOPY
A binocular indirect ophthalmoscope (28-4) provides
stereoscopic, wide angle, high resolution views of the
entire ocular fundus. It is not hindered, as is the standard
ophthalmoscope by a hazy media or scleral or central
opacification. With the addition of a +20dioptre
condensing lens, by varying the illumination and viewing
angle, you can readily look at both the anterior and
posterior segments.
N.B. Examine layer by layer: lid margin → conjunctiva
→ cornea → anterior chamber → lens → vitreous.
Lid margin: plugged orifices, lice, erosions?
Conjunctiva: foreign body?
Cornea: foreign body embedded in the cornea? Ulcer?
Fig. 28-3 SCHIÖTZ TONOMETRY.
The scale is merely an example; use the scale which is supplied with Note its size and shape after instilling fluorescein and
your instrument. 3 weights (5·5, 7·5, 10G) are usually supplied with using the blue light. On the back of the cornea look for
each instrument. keratic precipitates (KP, these are clumps of white cells),
indicating uveitis.
SCHIÖTZ TONOMETRY Anterior chamber: look for cells and flare, pus and blood;
You may well never see this old-fashioned, but simple, instrument. estimate its depth.
If you happen to find one, clean the instrument with a pipe cleaner and Lens: diffuse opacity, discolouration? Posterior synechiae
ether. You’ll find it quite useful to diagnose glaucoma. It is however, from the iris? Focal opacities?
a delicate instrument, so keep it carefully!
Using the standard 5·5g weight and the metal footpad, make sure the Vitreous: Particles from a recent posterior uveitis,
instrument is calibrated to zero. or bleeding?
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SLIT LAMP MICROSCOPY. Use this for accurate Close the eye for 2mins to allow the drug to enter the
visualization of the anterior part of the eye and its eye. Do not let the dropper touch the eye, and do not put
contents (28-6). the dropper down on a surface, as it may become
Position the head by placing the forehead and chin on the contaminated. If possible, each patient should keep his
rest. Vary the angle of the light as convenient. own drops, because of the danger of cross-infection.
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TO MAKE YOUR OWN CHLORAMPHENICOL EYE DROPS If it is in the right layer, you will see its point under the
dissolve two 250mg capsules in 100ml of water. Filter the solution into
conjunctiva. Then inject 0·5mL (max 1mL).
sterile 10ml dropper bottles. Screw the caps on loosely, and sterilize
them in a hot water bath or autoclave at 100ºC for 30mins, without
letting water splash over the necks of the bottles. Refrigerate them; their If the infection is getting worse, repeat the injection the
shelf-life is 2months at 2-8ºC. The shelf-life of commercial drops is only next day. A severely infected eye is likely to improve,
4months, so this is a useful method.
or be lost within 6hrs, so use a subconjunctival injection
usually only once. If you fear the development of an
Subconjunctival antibiotics are indicated if there is a endophthalmitis, use IV antibiotics.
severe corneal infection or ulceration, especially with
hypopyon (28-9A,C).
N.B. If you use 0·2ml of 2% lidocaine, the injection will 28.2 Operating on the eye
be almost painless, but be careful mixing antibiotics and
LA in the same syringe to maintain sterility. Try to get special training, especially for cataracts.
Learn how to do the more important procedures:
entropion (28.13), tarsal cysts (chalazion: 28.12),
tarsorrhaphy (28.10), and evisceration, enucleation,
and perhaps exenteration of the eye (28.14).
PREPARATION.
Prepare the face from the hairline to the chin and from ear
to ear, using iodine 10% in a non-alcoholic lotion which
will not harm the eyes, if it spills on them accidentally.
Make a special drape with a slit from the middle of one
end to the centre. Place this under the chin, and up each
side of the face. Fold it over the head and keep it there
with a towel clip. Place another drape across the forehead
over the eyebrows, and clip this to the first one.
If the patient is intubated, place a third drape over the
nose and the mount, which connects the patient’s
endotracheal tube.
If you are using LA, do not cover the nose or mouth.
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BLEEDING. The cornea is avascular and cannot bleed. The problem in a busy clinic is that conjunctivitis is so
If the conjunctiva or sclera bleed, apply a pad and very much more common that these other causes are easily
gentle pressure. Or irrigate the wound with saline from a missed. So your first task in managing red eyes is to make
syringe and an irrigating needle. The blood will stream in sure that these rarer causes are recognized. The history,
the clear saline, so that you can see the exact point where the visual acuity, and the examination of the eye with a
it is coming from, and control it with cautery. torch should enable you to distinguish between
Heat a squint hook or a small cautery in the flame of a conjunctivitis and something more serious.
spirit lamp, until it is hot, but not red hot.
Touch the bleeding point with this, through the stream of Conjunctivitis can be infectious, allergic, or chemical.
saline. This will cool its tip enough to prevent burning, Bacterial conjunctivitis is common (especially from
but will leave it hot enough to seal the bleeding vessel. neisseria, listeria and corynebacterium) in the developing
Do not use diathermy. world, and may be mild, or so severe that the conjunctiva
extrudes pus, and the lids swell so much that the eyes
PAD THE EYE if there is had a minor injury with no remain closed.
suspicion of perforation (28-8A). An eyepad, with gentle Bacterial conjunctivitis needs an antibiotic.
firm pressure, will reduce discomfort, and promote Viral conjunctivitis usually resolves spontaneously
healing by preventing the lids moving over the injured without, if the cornea is not involved.
area. Allergic conjunctivitis rarely needs steroid treatment.
Close the eye, put a pad of gauze over it; place 2 pieces of Besides infecting the conjunctiva, bacteria can infect the
adhesive strapping diagonally across the pad, from the lids (blepharitis), or the cornea, where they can cause
forehead to the cheek, to hold the pad in place. changes in the stroma (keratitis and sometimes a corneal
Change the pad daily, and look for signs of ulceration or abscess), which may result in corneal ulceration, through
infection. which infection may spread inside the eye as an
endophthalmitis, which may end in blindness.
CAUTION! The great danger of an eyepad is that it
may rub against an anaesthetized eye, and cause an A corneal ulcer may be due to:
abrasion. A layer of vaseline gauze on the pad will help to (1) Bacteria.
avoid this. So shut the eye when you apply the pad. (2) Herpes simplex virus.
(3) Fungi.
SHIELD THE EYE: (4),Other conditions such as leprosy, causing incomplete
(1).after any severe injury, especially if there is a eyelid closure (lagophthalmos) and exposing the cornea to
perforation. trauma.
(2) after any eye operation. Demonstrate a corneal ulcer with fluorescein.
Shielding it (28-8B) allows it to open and close, without Bacterial infection can follow even a minor injury which
anything extraneous touching the cornea, and perhaps damages the epithelium, or it can be spontaneous.
scratching it. A shield is the safest way to protect an Bacteria enter the eye through the anterior chamber.
anaesthetized eye, and is very helpful for a painful If pus gathers there, you will see a fluid level (hypopyon:
inflamed eye with photophobia. 28-9C) when the patient stands upright.
Cut an 8cm diameter circle from cardboard, or an old
X-ray film. Cut a radius in this, fold it into a cone, Endophthalmitis may be the result of:
and maintain the cone with a piece of strapping. (1) a corneal ulcer, especially bacterial.
Hold the cone in place with two pieces of adhesive (2) a perforating injury of the cornea or sclera, especially
strapping, or plastic tape from the forehead to the cheek. if a foreign body has been left in situ, or if a wound is
neglected, or after recent eye surgery. Once bacteria have
CAUTION! Never occlude the eye of a child <7yrs for entered the eye, the chance of total blindness is high.
>7days, because this may cause amblyopia (28.9). If presenting early, when the infection is fairly localized,
some useful vision may remain. If you cannot control the
infection, an evisceration is necessary (28.14).
28.3 The painful red eye DIAGNOSIS.
If there is conjunctivitis, the discomfort is of a gritty
Acute red painful eyes are due to: nature caused by rubbing of the conjunctivae on the
(1) conjunctivitis (much the most common cause at any cornea; pain varies from mild to severe:
age). In the newborn this is often due to gonococcus, (1) Both the eyes are usually involved.
in children between 6months and 6yrs secondary to (2) The visual acuity is normally good.
measles, and in adults in endemic areas, chlamydia. (3) There usually is a purulent discharge.
(2) a corneal ulcer. (4) Red conjunctivae, especially in the fornices (28-6C).
(3) acute iritis. (5) The cornea is clear and does not stain with fluorescein
(4) acute glaucoma. (unless the conjunctivitis has produced a corneal ulcer).
(5) trauma. (6) The pupils are normal.
(7) The tension in the globe is normal.
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Suggesting acute iritis (28.5): one (sometimes two) If the conjunctivitis is severe, use subconjunctival
moderately painful red eye(s) with no discharge. antibiotics. Watch carefully for a corneal ulcer, and if
Pain is often only mild. Reduction in visual acuity is necessary examine the cornea repeatedly with fluorescein.
usually mild. A clear cornea is surrounded by redness at If the conjunctivitis is very severe, and especially if there
the corneoscleral junction. A small constricted pupil is a corneal ulcer, instil chloramphenicol eye drops every
which becomes irregular on dilation, due to posterior min for 1hr, every hour for 1day, and then 3hrly.
synechiae (adhesions) is typical. An inflammatory
exudate in the anterior chamber is visible most easily with If the cornea is not clear and the visual acuity is poor,
a slit lamp: the aqueous is not as clear as it should be. there is a corneal ulcer and the eyesight is in danger.
The beam from the lamp shows a flare, like a beam of
light shining across a dusty room. You may also see little If a neonate has severe conjunctivitis after birth
lumps of cells (keratic precipitates or KP) sticking to the (ophthalmia neonatorum), this may be gonococcal or
back of the cornea, and posterior synechiae between the chlamydial. This is an acute emergency, which may cause
iris and the front of the lens. The inflammatory cells in the blindness. Treat with chloramphenicol drops as above,
anterior chamber may form a sterile hypopyon. and add either ceftriaxone or gentamicin IV,
The intraocular pressure (IOP) may be increased due to and oral erythromycin.
secondary glaucoma (28.6).
If you are treating a child between 6months and 6yrs,
Suggesting acute angle closure glaucoma (28.6): check for a combination of malnutrition, vitamin A
one (seldom 2) very painful red eye(s) with severe deficiency, and recent measles. Look for:
unilateral headache, and slight watering. There is severely (1) Night blindness (inability to see in dim light).
impaired visual acuity, often down to hand movements or (2).Bitot's spots (white foamy spots on the lateral
perception of light only, with haloes, and sometimes even conjunctiva).
blindness. Circumcorneal hyperaemia is mild in the early (3).Xerosis (dryness of the conjunctiva with inability to
stages. A hazy cornea (due to raised IOP) without its produce tears, or a dry hazy cornea).
normal shine is associated with a shallow anterior (4).Keratomalacia (corneal ulceration, softening of the
chamber; this is best seen by shining a torch from the cornea). Treat with vitamin A 200,000IU by mouth
side. A vertically oval dilated pupil which does not react immediately, again after 24hrs, and again after 1wk.
to light is classical. IOP is raised (28.1). Also, use a topical antibiotic such as ciprofloxacin.
Improve the nutrition especially with plenty of dark green
Suggesting a corneal ulcer: one severely painful red eye leafy vegetables.
with reduced visual acuity (if the ulcer is central), scleral
redness most marked round where the ulcer is situated, CHRONIC LOW-GRADE CONJUNCTIVITIS,
photophobia, swollen eyelids, and watering. characterised by yellow-grey dots (follicles) under the
Look for a grey-white spot (the ulcer) on the cornea, upper eyelid, in someone from an endemic area, is almost
which stains with fluorescein. If it is not obvious, certainly TRACHOMA caused by chlamydia trachomatis.
look for a defect in the smooth surface of the cornea in the
reflection from a focused light. If the infection is severe, N.B. Different strains of this bacteria cause 3 distinct
pus cells sediment at the bottom of the anterior chamber, diseases: urethritis & PID; lymphogranuloma venereum;
with a fluid level (hypopyon). The pupil is usually and trachoma.
regular.
Trachoma passes through 4 stages (28.13).
Suggesting a foreign body: The signs of an abrasion, and During the acute stage, make sure the patient actually puts
a foreign body, are similar to those of a corneal ulcer: tetracycline eye ointment 1% into the eyes bd for 6wks.
unilateral pain, photophobia, a watery discharge, Add a single dose of 1g azithromycin orally.
sometimes impaired vision, and hyperaemia, which is Advise thorough washing of the face and hands several
marked near the lesion. Ask if there is a history times daily, avoiding rubbing of the eyes. Explain that the
suggesting trauma, and do not forget that contact lenses disease is due to the entry of dirt, often from flies,
are foreign bodies and easily become infected if not kept but also from sharing face towels with an infected person.
scrupulously clean. Check underneath the upper eyelid!
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ALLERGIC CONJUNCTIVITIS Using a loupe, a good light, and a ball of cotton wool on
the end of an applicator, gently scrub the surface of the
Suspect this if large gelatinous vegetations have formed cornea in the region of the ulcer to remove its epithelium.
on the upper tarsal conjunctiva, and look like A chronic stromal keratitis with corneal scarring and
cobblestones, or on the bulbar conjunctiva surrounding blindness can complicate herpetic eye disease.
the limbus. It is common in children and young adults. CAUTION! Never apply steroids, because these may
Their eyes may or may not be itchy but typically there is spread the infection to the stroma of the cornea, and make
extreme watering. Suppress the inflammation with the condition worse.
antihistamine drops or a very weak steroid.
Beware of steroid glaucoma (28.6, 28.12D), ENDOPHTHALMITIS (PANOPHTHALMITIS)
because steroids, once started, may be needed for many The anterior chamber is full of pus.
years. Inject triamcinolone 1ml (40mg) IM into the upper
eyelid for severe symptoms. If the endophthalmitis is early, with some hope of
vision, try to control infection and minimize pain.
CORNEAL ULCER Use subconjunctival chloramphenicol and IV gentamicin
This is an emergency needing admission. Start aggressive for 7days. The infection may settle.
treatment with antibiotics urgently. A shield (28.2, 28-8B)
or sunglasses will make life more comfortable. If the endophthalmitis is due to a foreign body in the
Do not use an eyepad or patch. eye, remove it. It is usually superficial, so that it is
possible to remove it through the wound by which it
If the ulcer is severe, and particularly if there is a entered, which is usually in the cornea, even if this has to
hypopyon, inject subconjunctival (28.1) gentamicin be enlarged. Remove any prolapsing iris, and leave the
20mg, or chloramphenicol 100mg and apply hourly cornea unsutured. Use subconjunctival chloramphenicol
chloramphenicol 1%, or ciprofloxacin 0·3% eye ointment. and IV gentamicin.
If the ulcer is not so severe, and there is no hypopyon, If presentation is late, with no hope of vision and an
treat as conjunctivitis. anterior chamber full of pus, and the corneal ulcer has
weakened, softened, and distorted the globe
Also, with any corneal ulcer, provided it has not already (phthisis bulbi, 28.4), especially with no improvement
perforated, use atropine eye ointment bd or tid to keep the after 48hrs antibiotic treatment, eviscerate the eye (28.14).
pupil dilated. This will prevent adhesions forming Be sure that the patient understands the necessity of
between the iris and the lens (posterior synechiae, 28-9A). removing the eye because of the mortal danger of orbital
Advise warm soaks: their use is effective for soothing a cellulitis and meningitis.
painful eye. Wrap a cloth round a spoon, dip this into very
hot water, and let it cool till you can hold it as close to the DIFFICULTIES WITH RED PAINFUL EYES
eye as is bearable. Soaks are also useful for a stye
(infected eyelash follicle, hordeolum). If a chemical has got into the eye, the conjunctiva is
Use vitamin A supplements if there is any suspicion that intensely red (more so than in infective conjunctivitis),
it may be deficient. the cornea may be opaque (from keratitis or an ulcer),
and the vision impaired. Unlike infective conjunctivitis,
COMPLICATIONS of corneal ulceration include: mucopus is absent. Traditional medicine may have been
(1) Diffuse scarring of the cornea (28.4). inserted for a painful eye, which has made it worse.
(2) A dense white scar (leucoma: 28.4). If the chemical is still present, wash it out with much
(3) Perforation of the cornea, with adherence of the iris, water, making sure it does not spill over the other eye.
and perhaps staphyloma (an opaque protrusion of the Remember that if it is acid or alkali, a 1ml cavity needs 1l
cornea, not related to staphylococci). water to alter the pH by a level of 3. Use an analgesic, and
(4) Endophthalmitis. shield the eye. Instil an antibiotic ointment; its vaseline
base will be soothing, and the antibiotic may prevent
If there is pain and watering without a history of a secondary infection.
foreign body, look for a DENDRITIC ULCER (28-9E).
Stain the cornea with fluorescein and look for a branching If there is an acutely inflamed and oedematous lid or
irregular pattern. This is due to infection by herpes face, with a black slough, and surrounding thick
simplex. Dendritic ulcers occur especially after fevers, oedema, this may be ANTHRAX, especially if there has
particularly measles, malaria, and meningitis. been contact with animal carcasses or hides.
If possible use an antiviral agent: idoxuridine ointment
(x5 daily), trifluorothymidine drops (hourly), or aciclovir The eyelid may be completely destroyed, but the eye is
ointment (x5 daily). normal. Use high doses of IV penicillin and
sulphonamides. Anthrax responds rapidly to penicillin.
If the lesion is severe, combine this with mechanical Later, if necessary, toilet the slough and graft the raw
removal of the epithelium containing the virus. area. If you leave raw lids ungrafted, severe scarring and
Apply a topical anaesthetic, and stain the cornea with a scar-induced ectropion (lid eversion) will follow.
fluorescein.
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This is one of the common presentations of eye disease. Aim to insert an intra-ocular lens (IOL), which provides
Loss of vision in a white eye can be slow or fast. much better vision. The IOL can now be obtained for a
If there is slow loss of vision over months or years, reasonable price and is made in Eritrea & Nepal for
there may be: example, so this is no longer an impossible dream in the
(1) A corneal scar. developing world. It should be standard, as refractive
(2) Cataracts. errors are better corrected and waiting for maturity of the
(3) Glaucoma. cataract is no longer necessary.
(4) A refractive error. Manual small incision cataract surgery (MSICS) has
(5) Disease of the retina due to: become the preferred extracapsular method for removal of
(a) Senile macular degeneration. cataracts in low-income settings. It does not require
(b) Retinitis pigmentosa (congenital photoreceptor sutures, can be done inexpensively, and produces high
deficiency) quality results. High cost cataract removal alternatives
(c) Chloroquine maculopathy. are not necessary. An operating microscope is especially
(d) Old macular scars. valuable for reducing the incidence of complications;
(6) Optic atrophy. the less experience the surgeon has, the more important
the microscope quality becomes. If you are more
If there is sudden loss of vision over minutes or days, experienced you can use loupes, but if you are
the cause is usually inflammatory or vascular. less experienced, you may cause problems which you
If the complaint is simply that reading is difficult, may not even see. A cheaper special MSICS microscope
especially in poor light, this is usually presbyopia (28.8). is currently being developed.
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If the cause of the scar is still present, and it is getting If there is already loss of sight in the other eye for any
worse, remove the cause. This may include scratching of reason, and there is now a cataract in the remaining eye
the cornea by the inwardly turned eyelashes of trachoma (cataract in an only eye), delay surgery until there is
(trichiasis, 28.13). Vitamin A deficiency causes an acute difficulty getting around independently and near blindness
ulcer in young children, and does not cause progressive (CF <3m), because any complication will cause total
scarring. blindness.
If there is still adequate vision in the other eye and If the one cataract has already been successfully
disability is not severe, no treatment is indicated. removed, you can schedule the second cataract at any
time. But, this case now will be a lower priority.
If there is no light visible at all, explain that nothing can
be done. If the cataract extraction is not possible,
atropine ointment weekly, or minus (concave) glasses
If there is blindness, and a central leucoma which may improve eyesight.
obscures the pupil, with an area of clear peripheral
cornea, a peripheral iridectomy is necessary. CONTRAINDICATIONS.
This will provide an artificial pupil peripherally, behind (1);Unilateral cataracts with adequate sight in the other
the area of clear cornea, and should give enough vision eye.
for independent mobility. It is contraindicated if there is (2);Bilateral small immature cataracts with acuity above
already enough vision for mobility, or if the peripheral 6/60 in both eyes together; review the progress in
cornea is opaque. 3-6months.
(3) Active uveitis: do not perform a cataract extraction at
If there is blindness due to diffuse corneal scarring the same time as an iridectomy
which has not made the eye perforate, a corneal graft is
the only solution. METHOD
If the eye is blind and painful, consider evisceration or The principle is to make a self-sealing tunnel to extract
enucleation (28.14). the cataract and insert the new lens. It may be combined
with a trabeculectomy (28.6).
CATARACTS Dilate the pupil with cyclopentolate 1%.
(1);Measure the visual acuity accurately in both eyes.
The pupils should react briskly to light. If they do not,
suspect that there is also some other condition, such as
optic nerve disease.
(2) Measure the IOP to make sure that the loss of vision is
not due to glaucoma (28.6).
(3),Dilate the pupil and examine the red reflex with an
ophthalmoscope to assess how dense the cataract is,
especially if it is immature. If you can easily see the optic
discs, the cataract may not yet be dense enough to be
worth extracting.
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D, make the scleral tunnel trapezoid-shaped with a crescent blade. G, capsulotomy: pierce the anterior capsule in a complete ring
E, enlarge the tunnel. F, paracentesis: make a side port and inject c.7·5mm in diameter with a keratome.
dye to stain the lens capsule and air to protect the underside of the
cornea.
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Press the hook into the anterior capsular lens surface to If the cornea is hazy with a striate pattern
create a circular 360° opening about 7·5-8.0mm cutting (striate keratitis): it will probably settle.
parallel to the limbus (28-10H). If there is blood in the anterior chamber (hyphaema),
Irrigate this space to help free the nucleus (28-10I); pad the eye and insist on bed rest.
rocking it side to side, or turning it round may help free it.
Then introduce a lens loop into the tunnel, and pass this If the anterior chamber is shallow and the pupil not
under the cataract in the capsular bag and slowly ease it round, the wound may be leaking. (You may prove this
and the nucleus out of the anterior chamber (28-10J), with a fluorescin test.) Return to theatre and wipe the
at the same time pressing gently on the posterior lip of the wound with cellulose swabs, fill the anterior chamber
tunnel to help expel it. Avoid touching the inner corneal with 0·3-0·5ml air, and close the wound properly.
surface.
If there is pus in the anterior chamber (hypopyon),
Continue irrigating as you manipulate the lens nucleus there is infection (endophthalmitis). The eye is likely to
out, and once it is out, pick up the sclera edge and aspirate be painful and the visual acuity very low.
any cataract fragments, leaving a clear anterior chamber. Use subconjunctival gentamicin or cefuroxime (28.1),
Keep pressing gently on the posterior lip of the tunnel to and topical chloramphenicol or ciprofloxacin hrly.
allow débris to flow easily out. Do not irrigate for longer The eye may be lost in any case.
than 30sec. Do not aspirate the posterior capsule.
If the red reflex is absent after several months,
Inject 0.3ml viscoelastic (28-10L) and insert a 21dioptre there is some opacity in the media. This may be from
polymethylmethacrylate (PMMA) intraocular lens into re-growth of new fibres in the posterior capsule; perform
the capsular bag (28-10M). This is the standard size and a CAPSULOTOMY by holding the medial rectus tendon
is suitable for 80% or more of patients. Make sure the in forceps and pass a keratome through the cornea
lens is the correct way (flat or concave surface) up! laterally backwards to cut the posterior capsule.
Hold the lens with long smooth (e.g. McPherson Then keep the pupil dilated with 2 drops atropine 1% bd
long-angled) forceps with the leading haptic (curved hook and add 2 drops chloramphenicol 0∙5% 4hrly for 3days.
attached to the lens) sweeping to your left and the trailing
haptic curving to the right. Advance the lens by holding If there is much pain and the cornea is hazy, the IOP is
the haptic with the forceps, but don’t hold the lens itself probably raised (aphakic glaucoma) so measure it.
with the forceps. The vitreous jelly may be blocking the pupil. Immediately
Recreate the anterior chamber by injecting 0·3-0·5ml air dilate the pupil with cyclopentolate and phenylephrine
through the sideport without applying any pressure on the drops, followed by atropine ointment for 6wks.
tunnel (28-10N). No sutures are required since the
properly formed tunnel acts as a one-way valve to prevent If visual acuity is not improved and there is no evidence
leaks. The conjunctival flap becomes covered by of endophthalmitis, increase topical steroid to 2hrly and
the eyelid, and needs no suture. Apply topical check for improvement in 1wk.
chloramphenicol or ciprofloxacin, and dexamethasone
0·1% 3hrly for 1wk and then 6hrly for 2wks, with or RARER CAUSES OF GRADUAL LOSS OF VISION IN A
without LA. WHITE EYE
Examine the macula and the optic cup with particular
N.B. Don’t forget to remove the stay suture in the superior care. For many of the following, there is no remedy.
rectus muscle!
If an old person has gradual loss of central vision,
POSTOPERATIVELY, watch for a leaking wound atrophy, and irregular pigment at the maculae, suspect
(with or without iris prolapse), infection, bleeding, senile macular degeneration.
and a raised IOP. Gently open the lids, and examine the
eye with a torch. If there are pale, white, flat optic discs (distinguish
these from the pale cupped discs of glaucoma, 28-11C),
If the patient is restless and expels the air bubble in and normal maculae, there is optic atrophy. Try to find
the anterior chamber causing it to flatten, take him the cause (there are many, including a space-occupying
back to theatre and re-inject air through the wound. lesion around the optic chiasma).
If this keeps leaking out, suture the tunnel with 10/0
nylon. If there is gradual loss of vision at any age, often
starting with night blindness, a family history,
If the remaining lens matter is swollen and fluffy, and dark pigmentation which follows the retinal
keep the pupil dilated with atropine drops 1% bd. vessels and takes the form of 'bone spicules',
suspect retinitis pigmentosa, a congenital disease of
If there is any iris prolapse, return to theatre, reduce the photoreceptor loss.
prolapsed, make sure the anterior chamber is filled with
balanced saline, and suture the wound.
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If there is gradual loss of central vision from excessive 28.5 Anterior uveitis: iritis & iridocyclitis &
doses of chloroquine (>1·5g weekly for >1yr), posterior uveitis: choroiditis
or ethambutol, suspect maculopathy. The macula has a
typical 'bull's eye' pattern with a dark centre and a paler
surrounding ring. Stop the drugs. Any part of the uveal tract can become inflamed: the iris
(iritis), the ciliary body (cyclitis), or the choroid
If there are old macular scars (large white areas with (choroiditis). More than one part may be involved at the
black edges, often around the optic disc and the same time (iridocyclitis).
macula), they may be due to previous toxoplasmosis Although iridocyclitis may be caused by bacteria invading
(treat with pyrimethamine 25mg od & cotrimoxazole the eye through a corneal ulcer (28.3), it and other forms
40mg/kg od for 3wks) or toxocariasis (treat with of uveitis are more often due to a sterile inflammation,
albendazole 5mg/kg bd for 5days) usually from an unknown cause.
Uveitis of several kinds is common.
SUDDEN LOSS OF VISION IN A WHITE EYE Iritis (more strictly iridocyclitis) has several
consequences:
Loss of vision can occur over minutes, hours or days, (1) The inflamed iris may stick to the lens by posterior
in one or both eyes, which are white. synechiae (adhesions) or less often to the back of the
cornea by anterior synechiae.
If at any age there is steady loss of vision over 24hrs, (2) If the entire margin of the pupil sticks to the lens,
in one eye or occasionally both eyes, suspect posterior the iris balloons forwards (iris bombé: 28-9B), and causes
choroiditis (28.5) due to toxoplasmosis or other causes. secondary glaucoma (28.6).
The important sign is inability to see the retinal vessels (3) Abnormal proteins enter the aqueous, and cause an
due to hazy vitreous caused by inflammatory cells. aqueous flare, which you can see with a slit lamp.
Treat as above. You can also see leucocytes as tiny particles floating in
the aqueous.
If symptoms started with a flash of light followed by (4) These particles may stick to the back of the cornea as
black objects floating in the field of vision, and then a keratic precipitates (KP), and they may be numerous
curtain or cobweb across it, suspect retinal detachment. enough to gather at the bottom of the anterior chamber
Part of the retina may look grey-green. Dilate the pupil similarly to a hypopyon. Unlike the hypopyon that results
and examine the fundus. You will see an abnormal red from entry of bacteria through a corneal ulcer, the fluid in
reflex in one part of the fundus, with elevation of part of iridocyclitis is usually sterile. Untreated iridocyclitis
the retina, and tortuosity of its vessels, which are difficult eventually subsides spontaneously, typically in c.6wks,
to focus on. Expert surgery may save eyesight. leaving the eye severely damaged. It may relapse,
or it may be insidious and chronic, with few symptoms
If there is instantaneous loss of vision, suspect except progressive loss of vision.
occlusion of the central retinal vein (a swollen disc with
many haemorrhages all over the retina), or artery Uveitis presents in 2 ways (or when in both ways together
(a swollen disc, oedema of the retina, and often a as panuveitis), as anterior uveitis (iritis) or posterior
cherry-red spot at the macula). Or, suspect a stroke uveitis (choroiditis); the former presents as an 'acute red
(cerebrovascular accident). eye', so being one of the important differential diagnoses
Check the blood pressure. If it is not elevated, and visual of conjunctivitis (28.3), whilst the latter presents as
loss is less than 6hrs old, start anticoagulants. There is progressive loss of vision in a white eye (28.4).
otherwise no definitive treatment. If there is central retinal
vein thrombosis, follow up to check for secondary Iritis is usually a sterile reaction to one of the infections
glaucoma, which needs treatment. listed below. If onchocerciasis (28.7) is endemic, it will
certainly be the most common cause. Usually, no cause is
If there is loss of central vision with an abnormal pupil found, and iritis is presumed to be due to an autoimmune
response to light, suspect optic neuritis (any age, usually disease. Atropine will keep the pupils well dilated, and
in the 3rd and 4th decades, and usually unilateral). help break down synechiae. Steroid use is controversial:
The vitreous and optic disc are usually normal. This will it probably hastens resolution, but do not use it if there is
usually improve over about 8wks. Bilateral optic neuritis any sign of infection, especially a corneal ulcer.
following methyl alcohol or quinine is permanent.
There is no specific treatment. Remember also that steroids:
(1) will make a red eye white, regardless of the cause,
without necessarily curing it;
(2) will suppress the normal inflammatory response,
without killing the causative agent;
(3) may raise intraocular pressure, and may rarely cause a
secondary glaucoma that could produce blindness;
(4) may cause a cataract if used long-term, but this will
not happen in the short time needed to treat acute iritis.
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If the disease is bilateral, use eye shades. You can make For this to be possible, all health workers must be aware
these from exposed X-ray film. of the possibility of glaucoma in any patient who
complains of loss of vision. The key to early diagnosis is
STEROIDS. to pick up early changes in the optic discs and a raised
Iritis will subside spontaneously, but topical steroids will IOP, both of which can be recognized by eye assistants.
hasten its resolution. The aim of medical and surgical treatment is to lower the
CAUTION! NEVER use steroids if: IOP to a level which will stop further damage to the optic
(1) there are signs of infection. nerve, and therefore preserve vision at its present level.
(2) there is a corneal ulcer.
Trabeculectomy is a relatively simple operation, with a
If there is anterior uveitis (iridocyclitis), instil reasonable chance of preserving what vision still exists;
hydrocortisone drops 1% into the conjunctival sac 3hrly. however, you may need to repeat the operation within
2yrs because recurrence is common. Learn it from an
If there is posterior uveitis, use oral prednisolone expert at the same time that you learn cataract extraction.
20-30mg/day for 3-6wks. Do not continue beyond 6wks.
Tail these off over 1wk at the end of the course.
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The symptoms of POAG are non-specific. There is slow (5);CUPPING OF THE OPTIC DISCS is the important
loss of vision in one or both the eyes over months or years sign. Chronic glaucoma causes the discs to become
(28.4). Sometimes, there is marked loss of vision in one deeper and wider, and the remaining rims of disc tissue to
eye, while the other eye is normal, or nearly so. atrophy (28-11). One eye is commonly affected more than
Occasionally, there is pain and headache, but this is late. the other, so that a definite difference between the eyes is
Glaucoma is often familial. probably abnormal. Enlargement starts at the upper or
lower margins, so that a vertically ovoid cup with a
Angle closure glaucoma (ACG, acute glaucoma) usually cup/disc diameter ratio of >½ is probably abnormal.
occurs >35yrs, in women more often than men, with an Eventually, the margin of the cup approaches the margin
abnormally narrow angle between the iris and the cornea. of the disc, so that only a narrow rim of tissue remains.
If this angle should happen to close a little more than Its wall becomes steep, so that vessels bend abruptly as
usual, it causes an abrupt rise in the IOP with resulting they reach the level of the surrounding disc. If the edge of
unilateral episodic attacks of pain, misty vision, and the disc overhangs the cup, you may lose sight of the
rainbow-coloured haloes round lights. Between attacks vessels until they appear over the edge of the cup.
the eye is normal. Sooner or later, an episode of
raised IOP does not resolve, causing classical acute
congestive glaucoma (28.3). Acute glaucoma is
relatively uncommon, and is rare in Africa.
Its incidence is highest in Inuits and Mongolian
peoples, in Burma, and in South East Asia.
IF AN OLDER PERSON COMPLAINS OF POOR Fig. 28-11 SOME OPTIC DISCS OF THE LEFT EYE.
A, normal optic disc with a.moderately sized cup. The lamina
VISION, CHECK FOR GLAUCOMA. cribrosa is a mesh-like structure of collagen in the sclera wall which
maintains the pressure gradient. B, another normal optic disc.
PRIMARY OPEN-ANGLE GLAUCOMA, This has a large physiological cup and a temporal scleral crescent.
(POAG, CHRONIC GLAUCOMA) C, optic disc of a patient with gross 'chronic' open-angle
glaucomatous cupping. After Parr J. Introduction to Ophthalmology.
OUP 2nd ed 1982, with kind permission
DIAGNOSIS. Measure the visual acuity of any patient
who presents with loss of vision. A hazy cornea or a pupil
A large physiological cup can, however, be difficult to
which does not respond normally to light should make
distinguish from that in early glaucoma. With practice,
you suspect glaucoma. If the IOP is >28, or the cup/disc
eye assistants should be able to distinguish 'normal discs',
ratio is >½, there may be glaucoma (28-12G,H,I).
'suspicious discs' and 'advanced glaucomatous cupping'.
The end stage of glaucoma is a patient with a blind,
This is the most important sign to look out for in
or nearly blind eye, with a large pupil that does not react
glaucoma: you usually need to dilate the pupils.
to light. Aim to diagnose it long before this with the
Normal discs:
following three tests.
(a) The discs are the same in both eyes.
Loss of visual field is an early sign, but is not easy to test
(b) The ratio of optic cup to optic disc is ≤½ (28-12G).
with simple equipment.
(c) The cup is circular and the periphery of the disc
(the optic nerve rim) is pink.
CAUTION!
(d) The appearance of the disc remains constant over
(1);The level of IOP is useful in confirming glaucoma,
time.
but is not absolute, but is not always related to optic nerve
Signs suggestive of glaucoma:
loss.
(a) A cup/disc ratio >½.
(2);Glaucoma can occur with a normal IOP (30% of
(b) A vertically oval cup, perhaps with notching at the
patients with glaucoma have an IOP <22mmHg).
upper or lower poles.
(3);The IOP fluctuates, so if you are in doubt, repeat the
(c) An area of pallor >30% of the disc area.
measurements over a few days.
(d) Asymmetry of the cup/disc ratio of the 2 eyes.
(4) LOSS OF VISUAL ACUITY is not an early sign in
POAG.
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Medical treatment can lower the IOP, but it has to be Surgical treatment is a trabeculectomy which removes a
constant, consistent and continue for life, which is usually
piece of the filter (the trabecular meshwork), and so
impracticable, so that immediate surgery is better. allows the intraocular fluid to drain under the conjunctiva;
Start with pilocarpine 4% qid or timolol 0·5% bd this increases drainage and reduces the IOP.
(expensive), and if this fails to maintain the IOP The operation has an immediate success rate of >80%,
<20mmHg, add acetazolamide 250mg qid orally for short and is the recommended treatment for most patients with
periods. POAG, but it does not have a permanent effect.
N.B. Several side-effects may occur with continued use.
You should follow up these patients long-term; they may
To treat glaucoma effectively, measure the intraocular need repeat surgery.
pressure, and monitor the visual fields regularly.
Do this in a specialist clinic.
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ANGLE-CLOSURE GLAUCOMA, Make an incision through the cornea into the anterior
(ACG, ACUTE GLAUCOMA) chamber behind the hinge of the sclera flap and cut out a
4x2mm block of tissue containing the trabeculum and
Most acute glaucoma is usually this type, but secondary Schlemm’s canal (28-1B). Then grasp the peripheral iris
glaucoma (see below) may occasionally present acutely. with forceps, prolapsed it and excise it to make a
peripheral iridectomy.
DIAGNOSIS. N.B. If you incise too much sclera, you may reach the
Presentation is with an 'acute red eye' at any age ciliary body and cause a choroidal detachment.
(one of its rarer causes, 28.3), severe unilateral headache Return the sclera flap on its hinge to its bed, and close
in and around the eye, and sudden profound loss of vision. wound, and then close the conjunctiva at each corner both
Vision is reduced, the eye is red, the cornea is hazy from with with 9/0 or 10/0 nylon.
oedema, the anterior chamber is shallow, the pupil
is usually dilated, and IOP usually >40mmHg. SECONDARY GLAUCOMA.
CAUTION! Blindness is inevitable unless you treat this
quickly. This complicates:
(1).trauma, including hyphaema (blood in the anterior
TREATMENT. chamber).
(2) swollen cataract (see below).
Admit the patient as an emergency. If referral is delayed, (3).some cases of iritis. Treat the primary condition,
start treatment before operating. Use analgesic to ease the and try to arrange referral: in the meantime, treat with
pain, and treat both the eyes. Aim to: acetazolamide, mannitol, or glycerol as above.
(1).Lower the IOP by increasing the drainage of aqueous.
Use acetazolamide 500mg orally followed by 250mg qid, DIFFICULTIES WITH GLAUCOMA
as soon as the nausea has subsided. Apply timolol 0·5% If there is an acute red painful eye, a fixed dilated
immediately and repeat this twice. white pupil, a shallow anterior chamber and a hazy
(2).Keep the pupils constricted. This will keep the cornea, this is a SWOLLEN CATARACT, causing
periphery of the iris away from the angle of the eye, secondary glaucoma. Use acetazolamide 500mg
where the aqueous flows out, and so help it to drain. immediately followed by 250mg qid, and arrange cataract
Treat both eyes with drops of pilocarpine 1% every extraction.
15mins, for 2hrs. If this makes the pupil constrict,
the angle will be opened. If there is loss of vision from chronic use of steroid
(3).You can also lower the IOP by increasing the tonicity drops, suspect STEROID GLAUCOMA. Topical steroids
of the blood. Use 50ml of flavoured glycerine by mouth if cause a genetically determined rise in IOP in 30% of
nausea has settled. Alternatively, use 200ml of 20% people. This is sometimes severe enough to cause
mannitol IV over 20mins. glaucoma, exactly like POAG. Stop the steroids.
When medical treatment has reduced the IOP to normal,
arrange a peripheral iridectomy soon, to prevent a future If a child has big eyes, which may be associated with
attack; recommend a prophylactic iridectomy on the other photophobia, blepharospasm, and tears, suspect
side also. CONGENITAL GLAUCOMA (buphthalmos, ox-eye),
due to maldevelopment of the angle of the anterior
CAUTION! chamber. The sclera of a child are soft, so that the eyes
(1).Blindness can occur in 12hrs, so treatment is urgent. enlarge when the IOP rises.
(2).Rainbow-coloured haloes round lights, and misty
vision, are important prodromal signs, and need urgent Other signs are: an increased IOP, a corneal haze
investigation and treatment. (variable), sluggish reaction of the pupils to light,
(3) Atropine can precipitate an attack in a patient with a and enlargement of the cornea (>12mm), or of the whole
shallow angle! globe. Try to arrange an urgent incision of the trabecular
meshwork to allow flow of aqueous.
TRABECULECTOMY & PERIPHERAL IRIDECTOMY
(GRADE 2.4)
It helps to have a microscope to do this operation.
Insert the eyelid retractor. Secure the eye by means of a
traction suture of 4/0 silk through the belly of the superior 28.7 Onchocerciasis (River blindness)
rectus muscle. Select the site of the incision cranially
(usually at the 10-11 o’clock position) by injecting 0∙2ml Onchocerciasis is a parasitic infection of the skin and eyes
saline subconjunctivally. Incise the conjunctiva at the caused by Onchocerca volvulus, which used to be
limbus (28-19B) for 5mm and undermine it to free it from endemic in parts of West Africa, with foci in East Africa
Tenon’s capsule (28-1C). Control bleeding with a fine and Latin America. WHO-led programmes have virtually
cautery. Mark a rectangular sclera flap 5x5mm of half the eliminated this disease except in West & Central Africa.
scleral thickness hinged at the limbus, dissecting this
forward till you see the transparent cornea.
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In endemic areas 20% of the population are infected by a 28.8 Refractive errors: difficulty reading &
worm transmitted by the blackfly. Microfilariae invade all presbyopia
parts of the eye: the cornea (keratitis), the anterior
chamber (iritis), the retina (chorioretinitis), and the optic
nerve (optic neuritis). Blindness and irreversible eye In terms of comfort, increased efficiency and the number
lesions are most often found in people ≥30yrs. of people who benefit, the prescription of glasses is
among the most valuable procedures in medicine.
A patient from an endemic area complains of itching, So do what you can to supply them. You may be able to
with or without a rash. There may be skin nodules on the get cheap self-tuning glasses (which contain an adjustable
hip or shoulder (in Africa) or scalp (in S. America), amount of fluid between the clear plastic making the
night blindness (enquire about this), gradual loss of vision lenses). However these are difficult to maintain and
in both the eyes, and sometimes tears and photophobia. require skill to use.
Look for microfilariae in snips from the skin. There may
also be huge adenolymphocoeles in the groin (18-5). The refractive errors are:
(1) Myopia (short sight).
CORNEA. There is a sclerosing keratitis with (2) Hypermetropia (long sight).
opacification of the lower third of the cornea. Tongues of (3) Astigmatism (the refractive mechanism is aspherical).
opacification invade the cornea from the 3 & 9 o'clock (4),Presbyopia (common long-sightedness of old age).
positions, or from anywhere in the lower ½, where they (5).Aphakia ('no lens') after old-style simple cataract
may form an apron across the cornea. If this is not treated, extraction.
opacification slowly advances upwards over the pupil,
until all that may be left is a clear area at 12 o'clock. Presbyopia is part of the normal process of ageing:
Slit lamp microscopy shows 0·5mm linear and fluffy it appears earlier in the tropics than in higher latitudes,
opacities at all levels in the stroma, and minute wriggling and is easily diagnosed and treated. It is responsible for
microfilariae in the anterior chamber. 85% of the need for glasses.
IRIS. The final stage is a small, non-reactive, Whereas a myopic child has to be specially fitted, because
down drawn, pear-shaped pupil. Earlier stages are a loss the eyes may not be the same, a presbyope can,
of pigment in the margin of the pupil, exudation in front if necessary, be left to choose the glasses which best suit
of, across, or behind it, posterior adhesions which turn it him from a pile of second-hand ones. Astigmatism is
inwards, and small keratic precipitates (KP). A gelatinous more difficult to correct, but it is usually so mild that it
exudate sometimes drags the lower margin of the pupil needs no correction: its correction is often
down and everts it. Posterior synechiae and peripheral overemphasized.
anterior synechiae lead to secondary glaucoma. N.B. The visual acuity of all patients with refractive
errors improves when they look through a pin-hole,
RETINA AND OPTIC DISCS. which uses only their central vision. This is the basis of
Look for: the pin-hole test (28.1).
(1) Diffuse white areas and black pigmented ones most
marked temporal to the macula (the Ridley fundus). REFRACTIVE ERRORS
(2) Optic atrophy, with sheathing of the vessels close to If there is astigmatism, due to irregularly curved lenses,
the nerve. the vision is blurred.
(3) Microfilariae wriggling in the anterior chamber (after If there is hypermetropia (long-sightedness), a patient
putting the head between the knees for at least 1min) has difficulty reading or seeing things close at hand,
e.g. threading a needle.
TREATMENT. Use ivermectin once yearly as a single If there is myopia (short sightedness), a patient cannot
dose according to weight, for 15yrs (the lifespan of an see clearly at a distance, but near objects are clear.
adult worm): Unless you can perform retinoscopy, test each eye alone
15-25kg 3mg by trial and error with spherical lenses.
26-44kg 6mg Use the charts (28-2).
45-64kg 9mg For long-sightedness, start with +1 dioptres, the usual
65-84kg 12mg requirement at 45yrs, and by +0∙5 dioptre increments for
each 5yrs. The smallest number that gives the best acuity
If there is also loiasis, (28.18) with high quantities of is the prescription for glasses needed.
microfilariae, add prednisolone 20mg od 3days before For short sightedness, start -0∙5 dioptres and continue
starting treatment and till 3days afterwards to prevent adding -0∙5 increments. Again the smallest number that
severe encephalopathy. gives the best acuity is the prescription needed.
Aphakia after old-style cataract extraction requires
If there is an onchocercal iritis, dilate the pupil +10, 11 or 12 dioptre lenses for distance, and +13, 14 or
with atropine and use topical steroids (28.5). 15 lenses for reading. These are easily broken, rendering
If secondary glaucoma (28.6) develops, arrange surgery. the patient blind again!
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Check that the eye is not red, and that there are no other If an adult has a squint and no double vision it may be
serious eye problems. the cause of reduced vision in the squinting eye
A child with reduced visual acuity due to refractive errors (amblyopia). There is no treatment at this age.
needs glasses, whereas an adult probably does not.
A child <7yrs with a squint needs surgery (28.9) If a child <7yrs presents with a squint:
Remember glasses for reading and other close work, (1) Dilate both the pupils, and use an ophthalmoscope to
are not useful for seeing at a distance. make sure that the squint is not due to a retinoblastoma in
one of the eyes (an uncommon cause, 28.16: look for a
yellowish mass on the retina).
(2) If the retinae are normal, try to assess the visual
acuity in both eyes. This is relatively easy at >3yrs,
28.9 Disease of the neuromuscular system: but is difficult at younger ages (28.1).
squints, amblyopia, and diplopia
If there is reduced vision in either eye, or a definite
If the eyes do not look in the same direction, squint at >7yrs, there may be need for glasses,
this is known as a squint (strabismus). Squints are and perhaps surgery on the extraocular muscles.
common, and are usually accepted with resignation.
Although treating a squint needs relatively simple Correct any refractive error and occlude the eye that is
technology, it is time-consuming and needs skill. most used. Occlude it for ½-2hrs/day during close work,
reading, or drawing. The duration of treatment depends on
If the eyes do not look in the same direction, two images the duration of the amblyopia. If treatment is prompt,
are generated. This causes confusion, and to avoid this, 6-8wks of intermittent occlusion treatment may be
the brain suppresses one image. If this suppression enough. If it is delayed you may need to continue for 1yr.
continues for long enough, vision disappears in that eye.
This is called amblyopia, which is a reduction in vision, AFTER THE AGE OF 6 MONTHS
due to lack of use of an apparently normal eye. DON’T IGNORE A SQUINT!
If amblyopia is uncorrected in a child by 7yrs, it becomes
permanent. So try to diagnose a squint and arrange 28.10 Diseases of the lids & nasolacrimal
surgery before this age.
apparatus
CAUTION! Never occlude the eye of a child <7yrs for
several days, because this may cause amblyopia.
Diseases of the eyelids and nasolacrimal system include
SQUINTS AND AMBLYOPIA tumours, deformities of the lids, and watering (epiphora).
DIAGNOSIS. Globally, the most important disease of the lids is
trachoma, which scars the lids, and causes them to turn
The corneal light reflex: Shine a pen torch directly in inwards (entropion, 28.13).
front of you, and ask the patient to look at it. If each of the The commonest and usually the most harmless disease of
eyes is properly fixing the torch, its reflection from the the lid is a stye. The lid is involved in herpes zoster
corneal mirrors will be the same, and more or less central ophthalmicus, where the virus affects the VIIth cranial
on each cornea. Are the reflections from your torch nerve, often associated with HIV infection. Cutaneous
equally centred on the pupils? leishmaniasis causes the lid to scar and produce an
everted eyelid (ectropion). Loiasis is found in equatorial
The cover test: Ask the patient to look straight ahead at rain forests, where the vigorously mobile loa loa worm is
some target in the distance. Cover the left eye with a piece found under the conjunctiva, causing an acute
of paper. If the right eye moves, in or out, to fix on the inflammatory swelling.
distant target, it was previously squinting. If it does not
move, it was looking straight at the target. THE LIDS
Now put the paper in front of the right eye. If the left eye If a patient has a red swelling on the lid margin,
moves as you remove the paper, it was previously with an eyelash coming out of it, this is a stye
squinting in or out. If it does not move, there is no (hordeolum). It is a staphylococcal infection of an eyelash
manifest squint, and both eyes look straight. follicle. Pull the eyelash out of the swelling,
using an analgesic. Only use antibiotics in recurrent styes,
MANAGEMENT is limited. or if infection is spreading beyond the lid
If an adult has a squint and double vision, this suggests (cavernous sinus thrombosis is a rare complication, 6.6).
a serious recent disease of the extraocular muscles or their Warm soaks (28.3) are useful.
nerves, such as diabetic neuropathy, myasthenia gravis,
or raised intracranial pressure. He needs a full medical
and neurological examination.
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28.11 Proptosis (Exophthalmos) Proptosis can occur slowly over years, or rapidly over
days. Its causes vary geographically, and with the age of
If there is a space occupying lesion in the orbit, it pushes the patient. The more common causes are listed first;
the eye forwards. Proptosis is always serious, and it can the later ones are mostly very rare.
be difficult to diagnose, but is uncommon. Some of its N.B. Thyrotoxicosis may cause unilateral proptosis,
causes need medication (orbital cellulitis: IV antibiotics so check for weight loss, & tachycardia.
and Burkitt's lymphoma: cytotoxics).
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28.12 Tarsal (Meibomian) cysts (Chalazions) CAUTION! Take care to curette away any pockets of
granulation tissue, which may be hidden by a flap of
Meibomian glands secrete oil at each blinking of the conjunctiva, or have herniated themselves through the
eyelid; this prevents evaporation of the fluid film on the tarsal plate into the orbicularis muscle. If you do not do
eye. Cysts may form in these glands on the conjunctival this, it may recur.
side of the tarsus (or eyelid). They present as a swelling in Remove the clamp and pinch the lid until it stops
either lid, which may become chronically or acutely bleeding. If this is troublesome, wash it with warm saline.
infected. Small asymptomatic ones need no treatment, Place chloramphenicol ointment in the conjunctival sac
and may resolve spontaneously. Incise an acute infection tid for 1wk.
and curette a chronic one. These cysts are common
everywhere, so that treating them is a common outpatient .
eye operation. Sometimes, they present as granulomas. If the material you incise is hard, and not gelatinous,
suspect a carcinoma.
Send it for histological
examination.
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Make sure that no black choroid remains to avoid the risk INDICATIONS.
of sympathetic ophthalmitis. Close Tenon’s fascia and (1);A malignant intraocular tumour (retinoblastoma or
conjunctiva with 6/0 nylon. melanoma) is an absolute indication.
(2) A blind, persistently painful eye, which is not infected
If you are operating for acute infection, leave it open to (evisceration is an alternative).
drain. (3) A penetrating wound, especially in the circumcorneal
region, complicated by iridocyclitis, and entanglement of
If there is a chance of getting an artificial eye, the iris, lens capsule, and vitreous. If you leave an eye like
insert a plastic conformer shell. this, sympathetic ophthalmitis may follow in the other eye.
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Make the globe prolapse forwards out of the orbit by Separate the palpebral ligaments, the trochlea (the pulley
closing the arms of the speculum behind it, and pushing structure for the tendon of the superior oblique), and the
them backwards. If the eye is so enlarged, that it will not inferior oblique muscles from the bone with the
fit between the blades of the speculum, pull it forwards by periosteum. Use curved scissors to cut the structures
holding the stump of the medial rectus muscle with a entering through the orbital fissures. Pull the contents of
haemostat (28-20D). Pass a pair of curved scissors, the orbit forwards, and cut the tissues at its apex with
with their blades closed, down the medial side of the strong scissors as far back as you can.
orbit, feel for the optic nerve behind the eye, open the
scissors, and cut it (28-20E). Bleeding may be profuse. Remove the contents of the
orbit quickly, and then control bleeding.
If you are excising it for a malignant tumour,
cut it as far posteriorly as you can, because it may have Turn the skin at the edges of the orbit back into it.
been infiltrated by tumour. Pull the eye forwards, and cut Graft its raw surfaces with split skin, either now or as a
any tissue that remains attached to it (28-20F). secondary procedure in 10-14days. Gently pack the orbit.
Put a hot wet pack into the orbit, and press on it until If you are not grafting it, dress it with disinfectant such as
bleeding stops. acriflavine wool, and apply a firm bandage.
If you are going to put in an implant, it will probably be DIFFICULTIES WITH DESTRUCTIVE METHODS FOR
a simple glass globe. Place it in the muscle cone, THE EYE
and Tenon's capsule, and suture the conjunctiva over it.
If the patient refuses to have a painful eye enucleated
If there is no possibility of an implant, or eviscerated, consider injecting absolute alcohol behind
close the conjunctiva and Tenon's capsule separately with it to destroy its sensory nerves. You can use any strength
5/0 absorbable (28-20G). Irrigate the socket with 0·5% of alcohol, provided it is more than 50%, but you may
chloramphenicol. need to repeat the injection if pain returns. Permanent
relief is uncertain.
EXENTERATION OF THE ORBIT (GRADE 3.4)
Retrobulbar alcohol is very painful for about 30secs,
INDICATIONS. so use a retrobulbar block of lidocaine 1ml. Remove the
A malignant tumour of the orbit, often an advanced syringe and needle. When the block is effective,
conjunctival carcinoma (28.15) or a retinoblastoma, put another syringe on the needle and inject 2mL of
which has penetrated the globe and caused proptosis. alcohol. The orbit will become severely oedematous for
10days. Add chloramphenicol eye drops qid for 1wk.
ANAESTHESIA.
Use ketamine or GA. Have blood for transfusion
available.
29.15 Conjunctival carcinoma
METHOD.
The conjunctiva is a thin transparent mucous membrane
If the lids have been involved by tumour, suture their which covers the inner aspects of the eyelids and is
margins together with 3/0 silk. Use a #15 scalpel blade to reflected over the anterior part of the eyeball and ends at
cut round the margins of the orbit. If the lids are not the limbus. Conjunctival epithelium is non-keratinized.
involved, incise closer to the scleral margins, so as to save It is continuous with the cornea at the limbus and the skin
all, or some, of the skin from the lids to line the empty at the lid margins.
orbit.
Control bleeding from the upper inner margin of the orbit Squamous carcinoma of the conjunctiva used to occur
with diathermy, adrenaline solution or hydrogen peroxide. mostly in the elderly but now is commoner among young
Incise the periosteum round the margin of the orbit, HIV+ve patients, in whom it acts much more
and reflect it as far posteriorly as you can. It is firmly aggressively. It may arise on its own or from a
adherent at the bony suture lines of the skull. pre-existing lesion like a pterygium (28.18). When small,
it appears as a whitish lesion surrounded by a hyperaemic
CAUTION! area, whose surface is irregular with small nodular parts.
(1) The bone on the medial wall of the orbit is very thin, Initially it is mobile but as it invades, it becomes fixed.
so elevate the periosteum here with special care.
(2) The tumour may have eaten through the wall of the Advanced cases are easy to diagnose, and may be
orbit, into the brain. If so, you may find it difficult to be associated with metastases to pre-auricular and
sure of the anatomy. submandibular lymph nodes.
The periosteum should strip easily until you reach the
orbital fissures, and the nasolacrimal duct (6-4). Cut this.
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MANAGEMENT If the tumour has extended through the globe, but not
through the wall of the orbit, you should remove the
Small lesions you can completely excise; this is advisable globe and refer for radiotherapy, but the prognosis is so
as it can then provide histological confirmation as well as poor that a long journey to a referral hospital is not
information on the invasiveness of the tumour. worthwhile. Consider chemotherapy.
Large lesions need an exenteration (28.14) with removal If there is proptosis and a fungating mass, exenteration
of regional lymph nodes. Radiotherapy is useful, but of the orbit (28.14) will remove the mass, but is unlikely
chemotherapy needs the help of an expert, especially if to prolong life.
HIV disease is present.
CHEMOTHERAPY.
In 35% of cases the following regime causes a partial
response, and in 65% it prevents progression for a while.
28.16 Retinoblastoma Use vincristine 1·4mg/m², doxorubicin 50mg/m² and
cyclophosphamide 1g/m². Administer all drugs IV once
every 21days.
This uncommon, malignant, radiosensitive tumour of the
embryonic cells of the retina usually presents in children
<2yrs. It is bilateral in 25% of cases, and occurs in 28.17 The eyes in leprosy
2 forms, familial and sporadic. At first, the tumour
enlarges within the eye; later it grows through the sclera,
or chambers of the eye, to perforate the cornea. It can also Leprosy causes:
spread through the optic nerve (where it may cause (1) Paralysis of the facial nerve, affecting the orbicularis
glaucoma) to the subarachnoid space. Familial cases are muscle so that the eye does not close (lagophthalmos).
inherited as autosomal dominants. Healthy patients with (2);Loss of sensation in the ophthalmic division of the Vth
one affected child have only a 5% risk of producing a cranial nerve, which makes the cornea anaesthetic.
second one. If a child survives, there is a high risk of (3);An acute iritis (uncommon), which is usually
transmitting the disease to his offspring. associated with a type II reaction and is less common if
the patient is taking clofazimine.
The earliest sign is a squint or a fixed dilated pupil with a (4);A chronic iritis (common) causing atrophy of the
white reflection ('cat's eye'), and greyish white tumour dilator pupillae and a small unreactive pupil.
visible with an ophthalmoscope. Presentation is often late,
with a large globe, and tumour penetrating the sclera or The combination of these lesions can have a devastating
cornea. effect on the sight. An anaesthetic cornea prevents a
patient noticing that there is something in the eye, or that
DIFFERENTIAL DIAGNOSIS varies with the stage of it is dry. The blink reflex disappears, so that, even if there
presentation, and is easy after glaucoma and intraocular is still enough power in the VIIth cranial nerve to blink,
extension have occurred. Before this, the diagnosis can be it does not wash and wet the conjunctiva automatically.
difficult, when all you can see is a white mass in an As a result, the cornea may be unprotected, especially
infant's vitreous. Dilate the pupils, and examine both the during sleep, so that it may develop exposure keratitis,
fundi under LA. Enquire for a family history. and ulcerate. If the centre of the cornea becomes opaque,
sight is damaged. So warn of the danger of an anaesthetic
Early: cornea, and examine the eyes regularly.
(1) Traumatic perforation of the globe.
(2) Traditional medicine in the eye. To decide if the cornea has been damaged, look for
(3);Retrolental fibroplasia, (history of prematurity at superficial scars, and use fluorescein drops, or papers,
birth). to search for central staining. If the cornea is anaesthetic,
the eye is at great risk. If there is lagophthalmos,
Late: but the cornea is not anaesthetic, he may have enough
(1),A corneal ulcer leading to perforation, an anterior sensation to complain of discomfort or burning.
staphyloma (due to bulging of a weak cornea, 28.3).
(2) Panophthalmitis. To find out if there is significant lagophthalmos, examine
(3) Congenital glaucoma (28.6). the closed eyes. If the cornea is completely covered, all is
well. But if any part of it remains exposed, you should do
MANAGEMENT depends on the stage of presentation. something to protect eyesight. Several operations are
If early with the tumour confined to the globe, possible. Tarsorrhaphy aims to reduce, or remove entirely,
try to refer for radiotherapy, which cures 85% of cases. the gap between the closed eyelids. It has cosmetic
Otherwise, enucleate the globe (28.14). disadvantages, but it does save sight, and it is not
difficult, so you should be able to do it if you care for
leprosy patients. A more effective procedure is transfer of
the temporalis muscle.
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AURAL SYRINGE, Bacon's, for one-hand use. This has a rubber bulb,
a tube, and a valve. It delivers a steadier stream of fluid than a metal
syringe, and can be used with one hand. If you don't have an ear syringe,
29 The ear, nose and use an ordinary 20ml syringe with an eccentric nozzle. If you wish,
you can fix a small plastic cannula to its tip, and cut it short to prevent it
being pushed in too far.
throat FORCEPS of different sizes for use in the ear canal, nasal cavity and
mouth.
NASAL SPECULUM such as the Thudichum’s, Mark Hovell
modification, size 7. Use this for examining the nose. Dangle one on the
distal IP joint of your flexed index finger, and control it by holding the
29.1.Introduction limbs together between your middle & ring fingers.
Ear, nose and throat (ENT) disease is common in primary SUCTION motor or foot-driven and suction nozzles.
MIRRORS for examining the throat and larynx: laryngeal mirrors.
care. It is said that 1:3 of all patients coming to primary N.B. dental mirrors are usually concave (not flat like laryngeal mirrors)
care are coming because of an ENT problem. and therefore impossible to focus on the larynx.
Patients come with a sore throat, poor hearing, noises in SNARE for removing nasal polyps.
their ears, bleeding from the nose, blocked nose and many TONGUE DEPRESSORS: wooden (preferably) or metal; the handle of an
ordinary table spoon will do (sterilised after each use).
other symptoms. In some ways, ENT symptoms are often ELECTRO-CAUTERY.
neglected in primary care because they are often thought RIBBON GAUZE 1cm width for packing the nose; 05cm width for
not to be so important: they do not usually kill people but packing the ear.
they do make life unpleasant and uncomfortable, and these FOLEY CATHETER Ch12,14, or 16 for posterior epistaxis.
PASTES FOR DRESSINGS: (1) BIPP (bismuth iodoform paraffin paste)
areas of the body can be difficult to examine. Sometimes gauze, for packing the ear. (2) Simple Vaseline for lubricating ribbon
there is indeed something serious, such as a cancer or a gauze for the nose.
blocked airway, so it is important to be able to perform an SILVER NITRATE CAUTERY STICKS.
ENT examination and to recognise common and serious SALINE FOR IRRIGATING THE NOSE to keep it clean of pus and crusts
OLIVE OIL is useful for softening wax.
conditions. To see the eardrum, or the larynx or the inside
of the nose, it is necessary to have equipment.
This equipment does not have to be sophisticated and
expensive. A torch, even a simple one, can allow you to
look at the throat, up the first part of the nose and into the
ear canal. However, to see the whole of the inside of the
nasal cavities, to see the eardrums and to see the back of
the tongue and voice box, you need to have some
equipment such an otoscope, a head light and a mirror.
You also need forceps and a suction machine for
treatment.
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People with moderate hearing loss have difficulty In conductive hearing loss, there is failure of transmission
hearing normal conversation. of sound to the cochlea.
People with profound hearing loss are unable to hear In sensori-neural hearing loss, there is disease of the
shouted speech when standing just 1m away. cochlea or of the auditory nerve.
Try to find out the incidence of deafness in your district,
and the common causes for it. CONDUCTIVE HEARING LOSS can be due to:
(1) failure of development of the external ear
Chronic ear infection leads to hearing loss, as can (2).the ear canal being full of wax (this is unusual unless
meningitis, measles and mumps. Other common causes people use ear buds, which pushes the wax into the ear,
included exposure to excessive noise, head and ear injury, rather than helping it to come out)
ageing and the use of ototoxic drugs (especially (3).infection of the ear canal (otitis externa) leading to
gentamicin, streptomycin and some cytotoxic drugs). blockage of the canal by swelling and infective debris
Congenital hearing loss can occur with maternal rubella, (4).problems with the eardrum, especially with a
syphilis, and HIV disease; low birth weight and birth perforation (hole) in the eardrum
asphyxia, and neonatal jaundice as well as drugs are other (5).damage or stiffness to one or more of the 3 ossicles,
common causes. usually because of chronic infection, cholesteatoma
or injury, sometimes by congenital or hereditary illnesses
The ear is made up of the: (6).fluid or ‘glue’ in the middle ear (secretory otitis media
(1) outer ear: external auditory meatus, pinna, ear canal, or middle ear effusion) or pus in the middle ear
(2) middle ear: tympanic membrane (eardrum), (suppurative otitis media)
three small bones (ossicles: malleus, incus & stapes),
(3) inner ear: labyrinth (3 semicircular canals, vestibule SENSORINEURAL HEARING LOSS can be due to:
& cochlea with the VIIIth cranial (auditory, acoustic or (1).Damage to the cochlea, due to infection
vestibulo-cochlear) nerve. (viral infection such as mumps, herpes simplex, herpes
zoster, measles, meningitis), injury (fracture of base of
Hearing involves sound coming to the ear, being directed skull), loud noise and ageing.
down the ear canal, with the sound vibrations being (2).Damage to the auditory nerve, due to infection
transmitted to the eardrum and then through the ossicles to (more common) or tumour (rare)
the cochlea. In the cochlea, the mechanical sound
vibrations are transformed into electrical impulses which N.B. CENTRAL HEARING LOSS, where there is a
are transmitted along the auditory nerve to the brain stem problem in the cerebral cortex, is rare.
and then to the cerebral cortex and consciousness.
Conductive hearing loss is potentially curable e.g. by
removal of wax, drainage of middle ear
fluid, repair of damaged eardrum or ear
bones, treatment of otitis externa, or otitis
media.
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(5);Examine if the eardrum moves inwards momentarily To measure hearing, stand behind, and slightly to the side
when the patient swallows, or outwards if he carries out a of the patient, to the side that you are testing. If you are
Valsalva manoeuvre (holding the nose and blowing the testing hearing in the left ear, stand behind and to the left
cheeks out): this proves the Eustachian tube (29-5) is not side of the patient. Your opposite, right, hand is
blocked. outstretched, and touching the right ear of the patient.
N.B. The light reflex is always in the anterior inferior With the index finger of the right hand on the patient’s
quadrant; its absence does not necessarily signify right ear, the right hand touching the back of the skull,
pathology. and with the right arm straight, you are now about one
metre behind and to the side of the patient.
CLINICAL TESTING OF HEARING With the right index finger, generally stroke the ear.
Try this on your own ear, and you will hear a noise.
EXAMINATION (adults). This noise helps to ‘mask’ the hearing in the ear that you
Always do the next 2 tests as a pair; separately they will are not testing. Now whisper a number and see if the
not give you the information you need. patient can repeat that number. If the patient can hear the
number whispered at one metre away, then the hearing is
RINNE'S TEST. normal or close to normal. Then swap sides and hands,
Strike a tuning fork gently against your knee or elbow and stand behind and to the other side of the patient.
(not against a hard surface, or unwanted overtones will be
produced). Place the foot of the vibrating fork firmly on Another simple method is to ask a patient if he can hear
the patient's head, just above and behind the ear to be the ticking of a wrist-watch held up to the ear.
tested; apply sufficient pressure so that you need your Alternatively, rub the index finger and the thumb together.
other hand to support the other side of the head. This produces a slight noise.
Wait till he no longer hears the sound and then
immediately place the fork, still vibrating, beside the ear CLINICAL TESTING OF HEARING IN CHILDREN
canal. Normally he should still hear the fork vibrating, In a child <3yrs neither a tuning fork nor an audiometer
(+ve Rinne test). If he does not hear the sound any more, are useful. Unless you have special equipment you have to
(-ve Rinne test), his bone conduction is better than air use:
conduction, and there is a problem with sound conduction (1);the parents' account of an abnormal behaviour
of at least 20dB (middle ear disease). response, or the failure to make proper speech sounds. Or,
CAUTION! Beware if there is severe sensori-neural (2);the distraction test, which is effective in most young
deafness in one ear, this may give a misleading -ve Rinne children.
test because the sound is conducted through the head and
heard in the other ear. Weber's test will distinguish this. THE DISTRACTION TEST is a valid screening method.
Find a sensitive and understanding assistant, and practise
WEBER'S TEST. making the test noises, which are the syllables of the word
Strike the tuning fork against your knee, place its foot on ''shoe'', spoken separately as two tests, a high-pitched
the middle of the forehead, and ask which ear hears the ''Shsh…..'' and a low, sung ''Ooo…..''. Make them softly,
sound loudest. If there is conductive deafness in one ear just loud enough for your assistant to hear.
(a -ve Rinne's test), because bone conduction is heard Sit the child on the mother's knee facing your assistant
better than air conduction, the tuning fork is heard better in (29-1). Meanwhile, remain out of sight behind the mother.
that ear. If there is sensori-neural deafness, the sound will Ask your assistant to gain the child's attention a little,
be loudest in the better functioning cochlea. by moving a toy up and down in a vertical line, while
making the test sound. Then, ask him to hide the toy and
Do not be fooled that speech defects arise from break eye contact. At this exact moment, make a ''Sh…..''
‘tongue tie’ (31.9)! sound about 60cm from the child's ear, and level with it,
while you remain out of the sight. A normal child
CLINICAL TESTING OF ADULT HEARING LEVEL immediately turns towards the source of the sound.
Reward the child with some encouragement. Now test the
The Rinne and Weber test help tell you whether a hearing other ear with an ''Ooo….'' sound, before returning to the
loss is conductive or sensori-neural, but do not indicate first ear with an ''Ooo….'' sound, and then the second ear
what the level of hearing is. with a ''Sh….'' sound. To avoid false results, be sure to test
the ears alternately.
Hearing is measured in decibels (dB). The more decibels a
sound is, the louder it is. A whisper is around 30dB, If there is no response, try louder sounds. Then try a
the spoken voice around 60dB and a shout 90dB. visual or tactile stimulus. If there is still no response,
Jet engines are in the region of 120dB. Being able to hear suspect cerebral disability, or some non-audiological
levels ≤30dB is generally satisfactory. The human ear problem. If there is now some response, repeat the sound
should be able to hear a mosquito flying in a room 3m stimuli at 2 or 3m, first in a louder voice, and then in a
away. normal one.
N.B. The scale is logarithmic: 31dB is ten times as loud
as 30dB.
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CAUTION! These tests should tell you on which side to B. MIDDLE EAR
find the lesion. 1. A hole in the eardrum (a perforated tympanic
(1) This is a very reliable test, if you do it carefully. membrane). The hole may be small or so large that it is
Otherwise, you can easily get false results. easy to miss (you will look straight at the inner wall of the
(2) Before the test itself, practise both the manner of middle ear, and not see any eardrum: 29-3B,C,D).
attracting the child's attention, and the sound to be made. Hearing loss in ears with perforated eardrums is usually
(3) Timing is critical. due to infection producing damaged, scarred and immobile
(4) Make sure the mother does not give away any clues, ear ossicles. So always treat discharging ears promptly
consciously or unconsciously. with antibiotics, but if discharge from the ear continues
(5) You will get a misleading +ve if you show yourself, despite antibiotics, then it is likely that the patient has
or make visible the test object either directly, or reflected chronic middle ear disease that needs surgery. If an ear
in a window, or some reflective object, or give some with a hole in the eardrum keeps getting infected, again
tactile clue. You will get a misleading -ve if the child gets surgery can be useful by repairing (and closing) the hole.
bored, tired, or distracted by other things. If this happens,
don't persist; try again later. 2. Fluid or ‘glue’ in the middle ear. This is due either to
a recent ear infection or to a blocked Eustachian tube
MANAGEMENT OF CONDUCTIVE DEAFNESS (29-5). Recognising middle ear fluid can be difficult but
A…OUTER EAR (EXTERNAL CANAL) the eardrum may look opaque (29-3G-K); you can
1. Wax. It is important to understand that most wax is sometimes see an air-fluid level behind the eardrum,
healthy and finds it own way out of the ear canal. or you notice that the eardrum does not move on
Leave most wax alone. Wax can cause deafness, however, swallowing or on the Valsalva manoeuvre. In most cases
when it gets impacted into the ear canal. The most the fluid absorbs by itself, though this can take many
common reason for this is the use of cotton buds, which months. Alternatively, a myringotomy (29-3L), making a
pushes the wax into the canal (rather than removing it). hole in the eardrum, will release the fluid. Be careful to do
You can remove wax carefully by using a thin hooked this anterio-inferiorly, because you can easily damage the
metal wire (but be careful not to damage the ear), ossicles of the ear.
by cotton wool wrapped around a thin wooden stick, Fluid and ‘glue’ in the middle ear is usually the result of a
by suction (but this requires a micro-sucker) or by problem in the nose: enlarged adenoids in children,
syringing. Sometimes the wax can be too hard to remove, rhinosinusitis, or sometimes (in adults, and even young
in which case ask the patient to put 3-4 drops of vegetable people), a nasopharyngeal cancer. If due to rhinosinusitis,
oil (thick olive oil is best) in the ear tds for 1wk. treating this will allow middle ear fluid to resolve.
N.B. It is legitimate to remove wax which is hiding an
eardrum you need to inspect. 3. Chronic middle ear disease. This is disease of the
middle ear which may be due to long term tympanic
Syringing the ear. Make sure that there is no infection in perforation, scarred ear ossicles or a cholesteatoma.
the ear, and no perforation in the eardrum. Take a 20ml This is a white, skin-like debris that grows into, fills and
syringe filled with warm water, and gently flush out the destroys the middle ear (29-3N), sometimes spreading out
ear canal, aiming the end of the syringe up or down but not to damage the facial nerve and erode into the inner ear and
directly at the eardrum. even into the brain. Though not a malignant condition,
N.B. Never point a needle into the ear canal! it acts locally like one and so is dangerous, destroying
hearing and may be fatal. This needs skilled surgery
2. Otitis externa (29.3). Infection in the ear canal can requiring operating microscopes and micro-drills.
cause its wall to become swollen and filled with debris. Chronic middle ear disease is an important cause of
It may then be necessary gently to re-open the canal by deafness, important because all too often it results from
daily application of antibiotic and acetic acid. Use steroids acute (and simple) ear disease not being treated
only for psoriasis. Occasionally the canal needs clearing, if adequately. Chronic middle ear disease will be prevented
the eardrum is intact. More rarely necrotizing infection only if you can train up otologists to do audiological
ensues which needs radical debridement. Otitis externa testing but much can be done by treating infected ears
pain can be severe indeed. early with antibiotics.
3. Foreign body. This does not usually cause deafness 4. Otosclerosis results when the ear ossicles do not
unless associated with a blocked canal, infection or has vibrate, because they are stuck together by bone. It causes
caused damage to the eardrum and ossicles. a conductive hearing loss but when you look at the ear and
eardrum, everything looks normal. Treatment is by a
4. A tumour (rare). hearing aid. Surgical correction needs a real expert,
and failure will result in a ‘dead ear’, i.e. an ear with no
hearing at all.
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5. Trauma. Conductive hearing loss can result from a If a baby is born deaf, this will usually be suspected by
tympanic perforation caused by trauma, either a sudden the family. A mother who says that her baby is deaf is
loud noise, e.g. a gunshot close-by (acoustic trauma), or by usually right. Don't ignore her. The baby’s intelligence
sudden change in air pressure, e.g. a slap on the ear with will probably be normal, and an ‘island’ of residual
the palm of the hand (barotrauma) or by a penetrating hearing may remain. The parents and older siblings must
injury. make the most of this. Instruct them like this: 'Let him
N.B. When you see a perforated eardrum resulting from watch you speaking. Use speech and signs together,
trauma, it is best to leave it completely alone and not even because you will not know which the child will later find
prescribe any antibiotics; almost all heal naturally and easiest’. Speak slowly and clearly, and indicate familiar
spontaneously. objects as you name them. If necessary, repeat the word
close to the ear. Show you are pleased, whenever the child
MANAGEMENT OF SENSORI-NEURAL DEAFNESS tries to use a word, however indistinctly. Include the child
1.;Congenital cochlear hearing loss, due to mumps, in as much play, and as many activities, as you can. As
measles, rubella and other virus diseases, or due to always, ‘success builds on success’.
inherited genetic abnormalities.
CAUTION! Children who are born deaf cannot learn to
2.;Bacterial meningitis can be complicated by speak unless they have special teaching, from their
sensorineural deafness due to infection passing from the parents, or someone else, from as early in life as possible.
meninges to the inner ear.
5.;Sudden inflammation within the cochlea or along the Otitis externa exists in 4 types:
auditory nerve (known as vestibulo-neuronitis, (1);A furuncle (an infected hair follicle), usually
or auditory neuronitis), sometimes due to herpes simplex staphylococcal, near the entrance of the external auditory
or herpes zoster infection. canal (29-2). This is very painful, because the skin here is
tightly bound down to the perichondrium of the elastic
6.;Excessive loud noise due to industrial noise, the noise cartilage of the ear. It occurs here because there are no hair
associated with construction and road building, and noise follicles to become infected in the deeper bony part of the
from too loud music (‘disco deafness’). Exposure to loud canal.
noise destroys the tiny cochlear hair cells whose (2);A diffuse inflammation of the whole ear canal
movement transmits a signal to the brain. Many rock band resembling eczema. The common causes are:
players are badly deaf over 4kHz. (a) excessive self-cleaning of the ear,
(b) excessive humidity,
7. Ageing. As we age, just as muscles get weaker and hair (c) associated general skin infection,
turns grey, so hearing can deteriorate though it seems that (d) eczema or psoriasis
this deterioration is worse in the loud urban and industrial This may produce swelling and blockage by debris of the
environments of modern life. This type of deafness is ear canal, and rarely necrosis.
called presbyacusis (‘hearing of old age’). Hearing is lost (3);A vesicular eruption of herpes zoster of the canal and
first and foremost in the high frequency range. pinna, sometimes associated with a facial palsy, dizziness
or hearing loss, owing to involvement of the VII th & VIIIth
Apart from speech training and lip reading, hearing aids cranial nerves (the Ramsay Hunt syndrome), often related
are usually the only help available in sensori-neural to HIV disease.
hearing loss, but are important. They amplify sound but (4);In an area endemic with leishmaniasis, a well-
children with small ear canals may feel pain at volumes as demarcated ulcer from which may cause tissue destruction.
low as 10dB. Better hearing aids can amplify only a
selected range of frequencies to avoid increasing the DIAGNOSIS.
background noise that often makes hearing more difficult. There is pain on moving the pinna or pressing the tragus.
A child should not be forced to wear hearing aids if There is a purulent discharge from the ear canal, which
managing without, although beware that he may then risk may be blocked. Sometimes there can be an associated
harm because he misses environmental cues. Aid in the swollen, tender lymph node behind the ear.
management of all forms of deafness. Maintenance and Don't confuse this with the tender bone of mastoiditis.
repair of hearing aids is a skill which needs training and
equipment. Many hearing aids simply do not work because
there is no battery; others because they are not adapted.
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If the perforation extends to the edge of the eardrum, If there is bilateral discharge from the ears, treat the
and particularly if it involves the pars flaccida (29-3N), side with pain first.
it is peripheral and dangerous, because it implies bone If there is fever, antibiotics alone will cure none of the
destruction. A cholesteatoma is common. complications, but always start them.
If there is a tender swelling over the mastoid, Acute mastoiditis is typically a disease of children,
this is ACUTE-ON-CHRONIC MASTOIDITIS and may complicate neglected acute or chronic otitis
media. It is rare where primary care is good.
If there is EARACHE, this is ominous. Pus is gathering In babies, it occasionally presents as a swelling over the
under pressure somewhere, and, unless it is released, mastoid process.
it may track internally, with serious results.
If acute mastoiditis complicates acute otitis media
If there is severe vertigo & loss of balance, perhaps (uncommon), the child continues to have fever, and the ear
with vomiting, this is LABYRINTHITIS. Symptoms are continues to discharge pus in increasing quantity through a
worse on moving the head. There is usually also increased perforation in the eardrum.
hearing loss. Look for a fine horizontal nystagmus, and see
if this is made worse when you close the ear canal with If acute mastoiditis complicates chronic otitis media,
your finger, and gently press it. Use ampicillin in high there is:
doses, with chloramphenicol IV and metronidazole PR. (1);A dull nagging pain; this may either be new,
There is a danger of meningitis if infection does not settle. or an increase in chronic pain.
Try then to drain the mastoid cortex. (2);Increasing discharge; if the discharge is chronic
anyway, it is usually difficult to quantify.
If there is severe illness, headache, vomiting, fever, (3) Increasing deafness: again the change may be subtle.
with neck stiffness, photophobia & restlessness, (4) Tenderness over the process.
this is MENINGITIS. A +ve Kernig's & Brudzinski sign (5);Oedema of the skin over the mastoid process, owing to
will be present. Confirm the diagnosis by lumbar puncture. underlying infection, giving it a 'velvety feel'.
Examine the CSF by Gram's method, and culture it, (6);Swelling in the postero-superior wall of the meatus.
before immediately starting antibiotics. (7);Anterior rotation of the pinna, so the ear sticks out
Use ampicillin in high doses, with chloramphenicol IV and more on the affected side than normal. This is a very
metronidazole PR. When the meningitis has settled, characteristic sign, and should make you suspect the
arrange a mastoidotomy. diagnosis; it can however also be caused by a swollen
postauricular lymph node, by a meatal pustule,
If there is hemiparesis, cerebellar signs, dysphasia or or by cellulitis of the scalp.
depressed level of consciousness, the condition is serious,
because the infection has spread to the brain. The presence If pus has gathered under the periosteum, simply open
of pyramidal signs (spasticity and upgoing toes) suggests a this and drain the pus, or later it may be necessary to open
poor prognosis. Start ampicillin in high doses with the mastoid cortex to allow the pus to drain.
chloramphenicol IV and metronidazole PR, prior to The more radical operation of mastoidectomy, to remove
drainage of a brain abscess, possibly extradural (6.5). all the cortex overlying the mastoid antrum, and saucerize
Check the HIV status. the opening, is a highly complex operation because of the
close proximity of important structures with the danger of
serious damage to hearing, the facial nerve and the brain.
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Suggesting a pustule (furuncle) in the external auditory If syringing fails (rare), use GA. Ketamine is ideal.
meatus (29.3, rare in a child): swelling in the outer Extracting a foreign body is seldom urgent, so you have
cartilaginous part of the external auditory meatus, and the time to prepare. Lay the patient down, and use a headlamp
mastoid is not tender. Hearing becomes normal by pulling or, better, an auroscope with an open lens, and aural
the pinna upwards and backwards. There is pain on pulling speculum. Rest your hand on the patient’s head.
the ear and on chewing, a history of other abscesses, and a Try gentle suction with a piece of soft rubber tubing on the
small thick discharge. The eardrum looks normal, end of the sucker. If this too fails, try using suction with
although you may have difficulty seeing it. Radiographs the syringe.
show a normal mastoid.
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Use an aural hook, a cerumen or crochet hook, or a paper MOHAMMED (10yrs), the son of a local VIP was admitted with a
ball-bearing in the ear. The consultant ENT surgeon was on leave,
clip bent as shown (29-5), held in mosquito forceps (3-3).
and so a junior took over the case. It seemed a pity to give the child a GA,
Put the hook into the auditory canal, so that it lies against and as he seemed co-operative, he decided to remove the ball-bearing
the wall. Then, manoeuvre the hook past the foreign body, with a wax hook. Unfortunately, after two unsuccessful attempts,
twist it, so that it now lies behind the foreign body, during which the ball-bearing was driven deeper in, some bleeding began,
which rather obscured the view, but the ball-bearing was eventually
and allows you to pull it out.
removed. However, in the blood clot were found the remains of the
malleus, the incus, and the stapes.
LESSONS (1) If you are inexperienced, simpler methods may be safer,
even if they are less dramatic. Syringing is not sophisticated, but it is
'brilliant' compared with inadvertent stapedectomy. (2) The less
experienced you are, the more necessary is it to remove a foreign body
under general anaesthesia. A struggling child is no subject for delicate
surgery. (3) Don’t try removing a round metal object with a hook!
Using a magnet may have worked!
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29.7 Epistaxis (Nose bleeding) If he cannot sit up, lay him on his side. Get suction ready.
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Put this into one nostril, and pull it out of the mouth, If you have properly packed the nose and it continues
leaving the string in place. to bleed whenever the packs are removed, the ultimate
measure is to tie the anterior ethmoidal arteries in the
Do the same thing on the other side. Tie the oral ends of medial wall of the orbit.
the strings to the pack, and tie a 3rd piece of string to it. If the bleeding is arterial and not arising from Little’s
Pull the pack up into the back of the nose, and press it into area, it arises from the sphenopalatine artery (29-6G),
place with your finger in the throat. Make sure that it has a branch of the maxillary which arises from the external
passed behind the soft palate, and that this has not folded carotid. Clipping the internal maxillary artery behind the
upwards. Then pack the anterior nasal cavity, as before. posterior wall of the maxillary sinus is an alternative,
Tie the nasal ends of the string over some gauze. but unless you have experience in dissection, leave these
Let the 3rd string protrude from the corner of the mouth, this operation for experts.
and tape it to the cheek. Or keep it in place with a plastic
umbilical cord clamp.
CAUTION!
(1) Insert packs with great gentleness: you can easily cause
more bleeding as you insert them.
(2) Withdraw the packs, or the Foley catheter, slowly after
48hrs.
Don't leave any pack or catheter, either anterior or
posterior, in the nose for longer than this, or you will
increase the risk of suppuration, especially in the sinuses.
The only possible exception is a pack impregnated with
BIPP (4.11), which you can leave for 1wk. If you are using
a Foley, deflate it a little first to see if bleeding is
controlled.
(3) Remove a pack slowly, bit by bit.
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Tilt the table 10º head up to minimize venous bleeding, Chronic sinusitis may follow acute sinusitis, or as a result
but not more, because this increases the risk of air of nasal polyps, which prevent the sinuses draining.
embolism. Turn the patient's head to the opposite side, Pain is not a major feature, but there may be a dull ache in
and extend it slightly. Make an oblique incision from just the face, usually later in the day. Bending the head forward
below and in front of the mastoid process, almost to the can be uncomfortable. Distinguish this from hypertension.
thyroid cartilage.
Divide the platysma and deep fascia in the line of the TREATMENT OF ACUTE RHINOSINUSITIS
incision, and dissect flaps upwards and downwards. No treatment may be necessary. Most cases of upper
Free the anterior border of the sternomastoid and retract it respiratory infection are viral and resolve spontaneously
posteriorly. You will see the common facial vein. after 2-3wks, and require only analgesia.
Divide this between ligatures. Carefully retract the internal
jugular vein backwards, in order to see the common If there is fever for more than a few days, or if there is
carotid artery bifurcating to form the internal and external severe facial pain, then consider:
carotid arteries. (1) broad spectrum oral antibiotics,
(2) nasal decongestants; but do not use these for >5 days.
If you have difficulty in deciding which artery is which, If you do, the nasal mucosa becomes accustomed to them
find some branches of the external carotid and follow them and when you stop them, there is rebound effect,
backwards to the main stem (the internal carotid artery which results in swelling of the nasal lining resulting in a
has no branches in the neck). Pass an aneurysm needle blocked nose!
round it, tie it with zero non-absorbable, but don't divide it.
Tie it as close to its origin as you can. TREATMENT OF CHRONIC SINUSITIS
CAUTION! Chronic rhinosinusitis is defined as disease lasting for
(1) Tie the external carotid just proximal to the origin of >6wks. Examine the nose to look for nasal polyps,
the lingual artery. a deviated nasal septum or, rarely, a tumour. Use:
(2);Avoid the hypoglossal nerve, which crosses the (1) broad-spectrum antibiotics for 2-3wks,
external and internal carotid vessels and then runs (2) saline nasal douching: washing the nose out with salt
anteriorly to lie on the hyoglossus muscle in company with water (this can be made at home using 1l of clean water
the lingual vein. with 3 teaspoons of salt) and either sniffed up from the
(3);Avoid irritating the carotid sinus and body in the palm of the hand or sprayed into the nose using a 20ml
bifurcation of the internal and external carotid vessels, syringe,
because this may trigger profound bradycardia. (3) steroid nasal sprays: these sometimes help, since they
dampen down the swelling and inflammation in the nose.
DIFFICULTIES WITH RHINOSINUSITIS
If swelling around the eyes develops with fever,
29.8 Rhino-sinusitis this is ORBITAL CELLULITIS (6.6, 28.11).
This is serious: start IV cloxacillin or chloramphenicol,
The paranasal sinuses lead off the nose, so that disease in and add nasal decongestant drops (ephedrine 0·5%).
them usually follows disease in the nose itself. Sinusitis CAUTION! Chronic use of vaso-constrictive or
has some common features, regardless of which particular cocaine nasal sprays can lead to septal perforation.
sinus is infected. The common presenting symptoms in the Watch for development of a subperiosteal abscess,
nose are: which needs draining.
(1) discharge,
(2) obstruction of the nasal airway, If there is localized pain above the eye, suspect
(3) facial discomfort or pain. FRONTAL SINUSITIS. Later, gross orbital swelling,
proptosis, and diplopia may develop. If large doses of IV
Acute sinusitis often follows a viral upper respiratory ampicillin, chloramphenicol & metronidazole do not
infection, and usually involves one of the sinuses only. control symptoms rapidly, you may have to drain the
It may follow a dental infection. frontal sinus. Frontal sinusitis is always secondary to
maxillary sinusitis and obstruction of the fronto-nasal duct,
Presentation is with fever, copious purulent discharge, and: so be sure to wash out the maxillary sinus also. Infection
(1).pain, or a sense of pressure in the cheek may spread to the frontal bone, causing FRONTAL
(sometimes wrongly thought to be 'toothache'), OSTEITIS. Sometimes the pus may break through the
(2).obstruction of the nasal airway, often without the anterior skull wall of the frontal sinus and under the skin,
discharge of mucus or pus, leading to swelling of the tissues of the forehead and an
(3) swelling of the face (this is much more likely to be due abscess under the skin. This is known as a ‘Pott’s puffy
to a dental abscess, 6.9). Tenderness over an infected sinus tumour’. It requires incision and drainage of both the
is not a useful sign. subcutaneous abscess and of the frontal sinus. Infection
may also lead to meningitis or a frontal extradural or
intracerebral abscess.
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A. DRAINING THE FRONTAL SINUS (GRADE 1.5) If the ostium is sufficiently blocked to prevent the water
Infiltrate with 2% lidocaine mixed with 1:100,000 draining (rare), insert a second trochar to let it drain.
adrenaline and incise 1cm lateral to the midline along a CAUTION!
line level with the upper limit of the orbit. Use a dental (1);Don't go right through the maxillary sinus into the
drill to cut a hole in the floor of the frontal sinus, and cheek. You should be able to wiggle the tip of the trocar
insert a cannula attached to a syringe half-filled with slightly when it is inside the sinus.
saline. (2);Keep the syringe full of saline. Don’t blow air in if the
Aspirate: you should see air bubbling out together with ostium is blocked; this may push air into cerebral veins and
some purulent fluid. Insert a small drain. The best type is a prove fatal!
3mm endotracheal tube through which you have passed a
Ch8 paediatric Foley catheter. This arrangement allows
you to syringe out the sinus through the Foley catheter 29.9 Nasal obstruction
(29-8D) and the fluid can drain along its side out of the
outside tube. Also, wash out the maxillary sinus through a
cannula inserted through the inferior meatus. Typical signs are snoring, nasal obstructed speech,
Definitive surgery with removal of the anterior wall of the rhinorrhoea and secondary sore throats.
frontal sinus and its entire lining (7.13) may be necessary N.B. Look out for secretory otitis media (29.4)!
later. Nasal obstruction can be due to:
CAUTION! Do not do this if the air cavity of the frontal (1);Swollen nasal turbinates (29-12) due to allergic
sinus is situated much higher than the level of the orbit. rhinitis. The patient often has asthma as well.
N.B. Remember to wash out the maxillary sinus of all The turbinates tend to be swollen and pale.
patients with frontal sinus infections, because this is often (2);Swollen nasal turbinates due to occupational exposure
the primary source of infection. to wood dust, latex, animals, grains or mould.
The nose often feels dry and looks crusted.
If there is increasing pain in the cheek against a (3);Swollen nasal turbinates due to idiopathic rhinitis.
background history of rhinosinusitis, suspect maxillary The turbinates look swollen and reddish.
sinusitis. If there is chronic repeated infection or a fluid (4);Deviated nasal septum: the nasal septum is not in the
level on a radiograph (29-8C), this needs draining. midline and is bent or twisted. There may also be an
external deformity of the nose. This may be idiopathic or
B. DRAINING THE MAXILLARY SINUS (ANTRAL traumatic.
WASHOUT) (GRADE 1.4) (5) Nasal polyps (29.10)
(6) Rhinosinusitis (29.8)
Obtain good LA, especially under where the trocar will (7) Nasal tumours, rare but should not be missed.
penetrate; wait at least 10mins. (8);Septal haematoma. Following injury to the nose,
You may need add sedation with ketamine also. the nasal septum may swell up due to haemorrhage under
the perichondrium. The swelling is soft. Infection can then
(1);Infiltrate the anterior end of the inferior turbinate lead to a septal abscess.
(concha: 29-12) upwards & backwards with lidocaine 2% Do not operate for NASAL OBSTRUCTION unless you
mixed with 1:100,000 adrenaline, applied on gauze, or as a have some experience; then only when simple methods
spray. fail; otherwise the outcome may be of no benefit.
(2);Twist cotton wool on to the serrated end of a probe.
Load this with cocaine paste, or soak it in 4% lidocaine. A. ELECTROCAUTERY FOR SWOLLEN NASAL
Gently paint under the inferior turbinate. TURBINATES. (GRADE 1.3)
(3) Use a long thin needle to inject lidocaine into it. Take care not cauterise both the turbinate and the nasal
septum which could then result in adhesions.
Take a 2mm antral trochar and slide it along the nasal Also be careful not to cauterise too deep or too far
cavity, under the inferior turbinate and along the wall of posterior since by doing so there is a risk of serious
the maxillary sinus, until it rests at a natural depression on bleeding. If there is excessive bleeding, pack the nose as
the wall of the maxillary sinus. Now angle the trochar so for epistaxis (29.7).
that it is facing the tragus of the external ear and then with B. SEPTOPLASTY
controlled movement, push the trochar through the wall of Correcting a deviated septum is delicate surgery that
the maxillary sinus. As soon you feel the trochar give into requires training and experience: it is easy to cause
the sinus, stop advancing it and check that it moves gently collapse of the nose or a hole in the nasal septum.
within the sinus. Attach a 20ml syringe, containing 10ml C..DRAINAGE OF NASAL SEPTAL HAEMATOMA
of saline, to the trochar and aspirate. You should aspirate (GRADE 1.3)
either air or pus. Either indicates that you are in the sinus. Do this in order to avoid collapse of the nose due to
If pus is obtained, aspirate all the pus, and then gently pressure-induced necrosis. You can use LA. Incise through
flush the sinus with warm saline until there is free flow of the mucosa over the septal swelling and release the blood
saline into the nasal cavity. clot. Pack the nose to push the perichondrium back to
touch and adhere to the cartilage. Remove the pack after
3days.
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Foreign bodies in the nose are not uncommon in children. Acute tonsillitis is common, especially in children <10yrs,
The child is usually brought to clinic with unilateral nasal and is usually due to streptococcus. It responds to
discharge, not nasal obstruction. In fact, it is wise to mouth gargles, and penicillin. More serious cases are
consider all unilateral nasal discharge in children as due to caused by the Epstein-Barr virus in glandular fever
a foreign body until this has been ruled out by careful (with lymphadenopathy), and corynebacterium in
examination under GA. The discharge associated with a diphtheria (grey membrane on the tonsils). In scarlet fever,
nasal foreign body is often foul-smelling. the streptococcus produces a toxin resulting in a high
fever, rash and prostration.
REMOVING A FOREIGN BODY FROM THE NOSE
It is rare that a child will let you remove a foreign body Infection from tonsillitis may spread to the ear (otitis
from the nose without general anaesthetic and a foreign media: 29.4), around the tonsil (quinsy: 6.7), to the lungs
body (unless a small watch battery which will release (pneumonia), and in the blood-stream (rheumatic fever).
alkali into the nose) is not an emergency operation. It may also result in an allergic glomerulonephritis.
Clear the nose and try to see the foreign body. Try to get
the child to blow or sneeze the foreign body out. Close the Acute tonsillitis does occur in adults, and is much more
other nostril and tickle the nose to make him sneeze. common in HIV disease; it may then not respond to simple
CAUTION! If you suspect a foreign body, assume it is penicillin therapy.
there, until you are absolutely certain it isn’t.
Sometimes the attacks of tonsillitis are frequent and
ANAESTHESIA. LA is suitable, if you can see the foreign debilitating; also the tonsils themselves may enlarge
body, it is not too far back, and the patient is reasonably significantly, especially in general lymphadenopathy from
co-operative. IV ketamine is especially useful in children. other causes (17.1), e.g. HIV disease, tuberculosis,
If you use GA, insist on endotracheal intubation and pack lymphoma and Kaposi sarcoma.
the pharynx to prevent inhalation of the foreign body.
Very occasionally, in small children, large tonsils may
EQUIPMENT. You will need a good light, suction, angled forceps, almost meet in the midline and make eating difficult,
and some kind of hook, such as a Eustachian catheter, a bent probe,
as well as causing dyspnoea at rest, mouth breathing,
or a bent paper clip held in a haemostat. Put a large speculum on an
otoscope, and remove its back lens. otitis media, snoring at night, and even sleep apnoea.
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(5);As you pass through the nasal cavity, take note of the
anatomy of the nose: the inferior and middle nasal
turbinates and the nasal septum (often bent). Take note of
any polyps (not uncommon) or cancers (rare).
Benign nasal polyps are pale, oedematous, smooth and
bilateral. Cancers are red, friable, irregular or bleed and
almost always unilateral.
(7) Ask the patient to breathe through the nose. This opens
up the passage from the nasopharynx to the oropharynx
and, by manoeuvering the tip of the scope downwards, you
will be able to enter the oropharynx. You can now see the
back of the tongue, the larynx and the hypopharynx from
above (29-13). Often there is some mucus or saliva on the
tip of the scope preventing a view. If so, angle the tip of
the scope against the back wall of the oropharynx and ask
the patient to swallow. This usually ‘cleans’ the end of the
scope. Often you have to keep repeating this instruction,
till eventually you get a good view.
Fig. 29-11 NASO-PHARYNGO-LARYNGOSCOPES: (8) Look carefully at the base of the tongue, the epiglottis,
A, flexible fibreoptic B, rigid.
the vocal cords and the pyriform fossae (29-14).
Ask the patient to stick his tongue out in order better to see
USING A FLEXIBLE FIBREOPTIC
the base of the tongue and the vallecula (the space between
NASOPHARYNGO-LARYNGOSCOPE
the epiglottis and the base of the tongue).
The flexible fibreoptic nasopharyngolaryngoscope (usually
(9) Ask the patient to take a deep breath in, so as to see the
abbreviated to FO endoscope) is some 30cm long with a
vocal cords move outwards and then ask him to say, “eee”
handle and controls that allow you to focus the image and
or to count to 5 to see the vocal cords come together
move the tip of the scope up or down. Connect it by a
(29-14).
cable to a light source or to a battery pack.
(10) Remove the scope and then pass it into the opposite
(1);Check that the scope is clean, that the light source is
nasal cavity to examine that nasal cavity; there is no need
working and that the image is focused.
to pass it further on the second side.
(2) Explain to the patient what you are going to do.
Decide whether he requires LA spray to the nose and/or
(11) Check the patient is breathing well and has no stridor.
throat. Most patients do not, but if a patient is anxious or
has a narrow nose, then local spray of lignocaine or
(12);Clean and sterilize the scope in preparation for the
co-phenylcaine can help.
next patient.
(3);Stand in front of the patient; examine one nostril and
then the other with the scope, and decide which nostril is
wider and will allow easier passage of the tube to the back
of the nose.
He should be sitting, preferably on a chair with a headrest,
so that the head remains steady in one position.
Get a nurse to steady his head.
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DIRECT LARYNGOSCOPY Have the laryngoscope ready in your hand, and when you
are sure the patient is anaesthetized, pass the laryngoscope
INDICATIONS. into the mouth, avoiding using the teeth as a fulcrum.
(1) Examination when you intend taking a biopsy. Press the laryngoscope against the back of the tongue until
(2) Assessing if a laryngeal tumour is operable. the epiglottis comes into view. With a curved
laryngoscope blade, pick up the epiglottis with the point of
N.B. Remember flexible bronchoscopy includes direct the instrument, revealing the base of the arytenoids.
laryngoscopy! Push the laryngoscope forwards with its handle:
this flattens the tongue and brings the cords into view.
METHOD. Examine the oropharynx including the back of the tongue,
You need good communication with your anaesthetist for and the hypopharynx including the pyriform fossa.
this. Position the patient, with the neck flexed and head Carefully examine the supraglottis, including the epiglottis
slightly extended on a pillow. Get an assistant to hold his and aryepiglottic folds. Pass the rigid scope into the
right palm against the patient’s head, and hold the thumb larynx and examine the false cords, true cords and
against the underside of the mandible. This gives vertical subglottis. Biopsy any abnormalities, but do not disturb
and lateral control. minor abnormalities of the vocal cords as they are delicate
structures and big biopsies of small
lesions will make the voice worse.
When you have finished, allow the
anaesthetist to ventilate the patient with
oxygen to prevent bronchospasm.
INDIRECT LARYNGOSCOPY
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Normal cords are white. Laryngitis makes them red, 29.14 Bronchoscopy: inhaled foreign bodies
and chronic laryngitis also makes them swell. If you see a
lump, it is probably a polyp. A ragged ulcer is likely to be
a carcinoma. Note the movement of both the cords by If the neck is flexed, and extended sufficiently, the mouth
asking the patient say, ''eee”. To examine the nasopharynx, can align with the trachea or oesophagus, so that you can
depress the tongue with some soft instrument, and place a pass a rigid tube. This is the 'sword-swallowing position',
smaller (14mm) rhinoscopic mirror in the pharynx, so that and is the basis of rigid bronchoscopy (29-16) and
your line of sight passes up behind the soft palate. oesophagoscopy. In theory, these are simple procedures;
the traditional type of bronchoscope is merely a long tube
SOME CONDITIONS VISIBLE IN THE NOSE with a light at one end. In practice, however, removing a
Benign oedematous nasal polyps: in some populations foreign body with one requires much skill. Anaesthesia is
very common. These are bilateral and pale, often filling difficult, and the skill of your anaesthetist is the main
the nasal cavities (29.10). determinant of success. You need a range of instruments to
cover all sizes of patient, and also a variety of forceps.
Nasal septal perforation: usually at the front of the nasal There are many opportunities for disaster, particularly
septum and secondary to trauma (picking of the nose with obstructing the airway, or tearing the lower trachea and
finger tips) but can be due to cancer, syphilis, leprosy, bronchi especially if the patient is not properly sedated,
connective tissue diseases. cocaine & chronic use of so causing mediastinal emphysema and mediastinitis.
ephedrine nose drops. If you have other instruments with fibreoptic illumination,
make sure that your bronchoscope is compatible with that
Nasal carcinoma: if a polyp bleeds or is irregular, suspect system. You will need good suction.
cancer (29.16). This may arise from leather tanning,
lacquer paint, soldering, or welding fumes, and nickel or If you have a fibreoptic flexible bronchoscope, you can
chromium exposure. use this under LA quite readily. It is much, much safer!
Foreign bodies: determine if they are solid or not, Bronchoscopy is useful for:
and whether you can easily grasp them (29.11). (1);Sucking out a patient's stomach contents from the
trachea, if there he has been unfortunate enough to aspirate
SOME CONDITIONS VISIBLE IN THE PHARYNX: during a GA. Make this your first priority, especially if
Adenoids: midline, usually seen in the young. you are new to bronchoscopy.
(2);Sucking out the secretions which have gathered in the
Naso- or hypo-pharyngeal carcinoma: asymmetric, bronchi of a desperately sick patient postoperatively
granular or ulcerating lesions (29.16). (11.11).
(3);Removing foreign bodies, especially peanuts inhaled
Carcinoma of the base of tongue: an ulcer or an irregular by children. This is more difficult than the other
bleeding, exophytic mass. indications, so if you are new to bronchoscopy,
don't start with this, if you can avoid doing so.
SOME CONDITIONS VISIBLE IN THE LARYNX: (4);Diagnosing carcinoma of the trachea, carina and upper
Supraglottitis: swelling of the epiglottis. bronchi, and other diseases of the larger airways.
Laryngitis: swollen, red vocal cords, usually symmetrical. Inhaled foreign bodies in the larynx and tracheobronchial
oedematous vocal cords (29-15D7) tree, particularly peanuts or watermelon seeds,
are common. If a child is lucky, the first immediate bout of
Laryngeal papillomatosis: laryngeal warts, sometimes coughing expels the nut.
very large (29-15D8).
Otherwise, wheezing and coughing usually stop without
Laryngeal carcinoma: an early cancer is a small white expelling it. This may be followed by a latent interval,
plaque (leukoplakia) but as it grows, it can become during which there are no signs, especially if the nut has
thickened, ulcerating and a large mass that eventually gone far down the bronchial tree. This latent interval is
blocks the airway (29-15D6, 29.17). then followed by fever, a cough, and the symptoms of
chest infection. Antibiotics may relieve the symptoms
Vocal cord paralysis: the vocal cord does not move temporarily, but they always return when treatment stops.
outwards on inspiration (29-15D3), and does not move A misdiagnosis of TB is common.
inwards on speaking or saying “eee” (29-15D4).
If coughing, or the 'upside down thump' or Heimlich
Foreign bodies, e.g. dentures, a pen top, or a peanut. manoeuvre described below, fail to remove a foreign body,
it has to be removed through a bronchoscope. Even if you
Ascaris worms: these may occasionally be aspirated when can successfully pass one, removing a foreign body is
there is intestinal obstruction and profuse vomiting of a difficult, and sometimes impossible. Leaving it inside,
bolus of worms (12.5). however, results in suppuration and chronic disability,
or death.
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The anaesthetist and the surgeon share the patient. If you cannot grasp the foreign body, try to pass down a
The anaesthetist must be in charge, and decides when he Fogarty balloon catheter beyond it, and inflate the balloon
must give oxygen. below the foreign body, as in an embolectomy.
CAUTION! It is usually best then to withdraw the bronchoscope and
The chest must expand during ventilation. If it does not, the foreign body together. If there is much pus, suck that
because you have passed the bronchoscope into the out too.
oesophagus, remove it, let the anaesthetist intubate the
child, wait and then try to bronchoscope him again. CAUTION!
(1) Hold the bronchoscope lightly in your fingers, so that if
INDICATION the patient moves, it will move with him, instead of
(1);Aspiration of stomach contents injuring the respiratory tract.
(2);Retention of secretions (2);Take care not to damage the teeth.
(3);Removing a foreign body (3) Remove it promptly if the patient struggles.
(4) Biopsy of a bronchial lesion (4);If you fail, and the anaesthetist says, “That's enough”,
(5);Diagnosis of tuberculosis don’t persist in your probably futile endeavours!
If you have a flexible bronchoscope, pass this through one If the patient is suffocating and blue from the
nostril (which you have anaesthetized with lidocaine spray procedure, wait and try again later. If he is suffocating
or pack), and then keeping in the midline, through the because of the foreign body, you will have to persist.
vocal cords.
If a foreign body breaks into pieces, bring it up bit by
CAUTION! bit. If it slips off while you are withdrawing it through the
(1) Make sure you are not going down the oesophagus cords, try again. If necessary, squirt a little saline down the
(you must recognize the cords on entry). bronchoscope with a syringe, and use suction.
(2) Very little movement should be possible between the
sides of the trachea and the bronchoscope. So hold its If the foreign body rolls up and down the trachea,
handle in your right hand. Hold its shaft between the index but you cannot get it past the cords, tip the table steeply
and middle fingers of your left hand. Rest your left thumb head down, and manipulate it past them with the piece of
on the upper front teeth, and keep the lower lip out of the hooked wire that you have prepared for this eventuality.
way with a gauze swab, held in your ring finger.
If you hold the bronchoscope against the teeth like this, If the foreign body is up a side-bronchus,
it and the head will turn as one and less damage is likely. you will only reach it with a flexible scope, or if it shifts
with vigorous physiotherapy.
Look for the foreign body in the bronchi: the common site
is just distal to the carina in the right main bronchus. If you are looking for a carcinoma, look for
This is shorter, more vertical and wider than the left. abnormalities of the wall, and biopsy any growth.
Most foreign bodies enter the right side. It will be easier to remove a piece from the carina.
Suck out the blood afterwards.
If the carina is normal, pass the bronchoscope down one or
other bronchus, preferably the normal one first. STORAGE
When you withdraw from the right main bronchus and Hang flexible endoscopes vertically in a lockable cupboard
enter the left one, you will have to move the head to the with good ventilation; they should not be stored curled up
right as you do so. in their transportation case. Biopsy forceps wires easily
get tangled, and caught in doors; make sure they hang
With luck you will see the foreign body, and perhaps the nicely on separate hooks.
bronchi to particular lobes. Try to bring the foreign body
out on the end of the sucker. If this fails, grasp it with the
forceps.
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INCISION
Make a transverse incision 4cm long 2cm below
the border of the cricoid cartilage (29-19A).
Cut through the subcutaneous fat, and the cervical
fascia (29-19C).
N.B. In an emergency, lie a small child on your
lap with the head held hanging, and make a vertical
incision midway between the cricoid and the
suprasternal notch.
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N.B. It might be unwise to excise a flap in a child; If the tracheostomy has an inner tube, remove it
a simple vertical incision of adequate length may be regularly for cleaning (at least every 4hrs for the first few
better, but re-insertion of the tube can be difficult. days). Arrange vigorous chest physiotherapy.
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If there is a suspicious node in the neck and you can see TREATMENT.
no obvious primary (unusual), take specimens from The role of surgery is limited to biopsy. If there is a
several suspicious-looking areas in the nasopharynx. lymphoma, treat for it (17.6). If there is a carcinoma,
try to refer for chemo-radiotherapy.
RADIOGRAPHS may show involvement of the base of Treatment of nasopharyngeal cancer is highly specialised
the skull. and needs to be given in centres with appropriate
experience and facilities.
PROGNOSIS.
Local control is possible in 60-90% of cases.
5-yr survivals range from 30% (nasopharyngeal
carcinomas) to 60% (lymphomas). Prognosis is dependent
upon facilities for chemoradiotherapy.
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If a patient of any age has the rapid onset of hoarseness If a child, particularly, has progressive dysphagia,
and stridor, worse on inspiration, suspect ACUTE continual drooling from the mouth, stridor, cough, a
LARYNGITIS (not uncommon). Steam and antibiotics red swollen epiglottis, and is ill and febrile,
will usually achieve a cure. Tracheostomy may suspect ACUTE EPIGLOTTITIS (not uncommon),
occasionally be necessary, but avoid it if possible, which is much more serious than acute laryngitis.
especially in a young child. If he is old enough to speak, he may have the characteristic
'hot potato' speech, which is different from the hoarseness
If there is a membrane in the throat, there is likely to be of laryngitis. Use chloramphenicol or ampicillin IV.
a streptococcal infection (common), or DIPHTHERIA Be prepared to intubate him, followed if necessary by
(uncommon). tracheostomy. If he is not rapidly and correctly treated,
the chances of death are considerable.
If a patient of any age has slow progressive hoarseness,
leading to stridor which is worse on expiration, suspect If a child develops stridor with tonsillitis,
a papilloma of the larynx, or a carcinoma in older smokers suspect a peritonsillar abscess (6.7)
(both not uncommon, 29.17). Tracheostomy and
endoscopic removal may be necessary. Biopsy an adult's If a child develops stridor after ingesting an impacted
lesion, and look for malignant change. fishbone, suspect a retropharyngeal abscess (6.8)
Recurrence is common in children, where the disease is
related to aspiration of virus from genital condylomata. If a child (usually) has hoarseness and variable
Symptoms may be confused with asthma, and deaths have progressive stridor of rapid onset after fever, with
occurred from asphyxia. severe dysphagia and a bleeding mouth and nose (rare),
suspect GANGRENOUS PHARYNGITIS. Use IV
If a patient has stridor and increasing dyspnoea antibiotics and oxygen. Feed him through a small
following extubation after having been previously nasogastric tube, and aspirate the pharynx periodically to
intubated, suspect a tracheal stenosis. You may be able to remove blood and slough. Mortality is high.
dilate this endoscopically, but it usually needs excision.
If a child has had stridor and dyspnoea on exertion
If a patient of any age has sudden stridor, particularly since birth, perhaps with hoarseness which is
on inspiration, after ingesting food, suspect a foreign progressive with growth, suspect a LARYNGEAL WEB,
body (not uncommon: 29.14). a rare membrane across the laryngeal lumen close to the
level of the vocal cords. Symptoms depend on the
If a patient of any age has sudden stridor, worse on degree of stenosis. Tracheostomy may be necessary.
expiration, following food, medicine or a sting, suspect Expert surgery can give good results.
ANGIONEUROTIC OEDEMA, causing soft tissue neck
& laryngeal swelling). If there is stridor, use 1ml If an infant or young child has sudden, spasmodic
adrenaline (1:1000) IM. Otherwise, use an antihistamine or stridor, usually at night, which ends spontaneously
200mg hydrocortisone IV. Tracheostomy may be with another deep inspiratory effort and collapse,
necessary. The prognosis with treatment is good. Rarely, suspect LARYNGISMUS AND TETANY (rare).
if there is no response, infuse 2 units of FFP, which He is normal between attacks. Use parathyroid hormone
contains the missing C1-esterase inhibitor. Advise patients and calcium between attacks, and the prognosis will be
about avoidance of the particular allergen, if known. good.
Try to provide an ‘epinephrine-pen’ (auto-injector of
adrenaline) for emergency home administration. If a baby has stridor soon after birth, worse on any
exertion or crying, but looks well and the cry is normal,
If a patient of any age has sudden severe stridor, suspect LARYNGOMALACIA (rare). Endoscopy shows a
usually without much hoarseness, suspect markedly folded epiglottis, with its aryepiglottic folds
LARYNGEAL PARALYSIS due to infection, trauma, sucked in towards the larynx during inspiration to cause
poliomyelitis, or nutritional deficiencies. stridor. Reassure the parents that he will probably recover
If he has had a thyroid operation, suspect recurrent spontaneously between 3-5yrs.
laryngeal nerve damage. Unilateral vocal cord palsy
produces a characteristic prolonged wheezy cough.
Re-intubation or a tracheostomy (29.15) may be necessary.
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If there is a piece of food in the larynx with persistent Passing a rigid oesophagoscope is easier than passing a
choking and inability to talk, try Heimlich's manoeuvre rigid bronchoscope. An oesophagoscope looks like a
immediately: stand behind the patient, put your fist under bronchoscope except that it has no side tube for oxygen,
the xiphoid and give a short sharp upward thrust, whilst and no ventilation holes at its distal end, because the
compressing the chest with your arms. This will exert a patient does not need to breathe through it.
sudden pressure on the lungs, and may expel the food
bolus with a rush of air, with immediate relief. If this fails, Fortunately, most ingested foreign bodies pass through the
or the victim is too obese, sit him propped upon cushions oesophagus unless they are sharp or too large, but if they
on a chair with its backrest resting against the chest, stick, they have to be removed.
and push him down forcefully against the back of the chair
held rigid by others. Most (90%) stick in the upper 5cm of the oesophagus,
N.B. Do not try a Heimlich manoeuvre on a small child. just below the cricopharyngeus (30-1A) before the
oesophagus enters the thorax. This is fortunate, because
If the presentation is early with ‘something in the this is the easiest place from which to remove them.
throat' without severe dyspnoea, take a careful history. They are commonly coins, buttons, safety pins, or bones.
Where and how severe is the pain? Feel the neck.
Is there surgical emphysema? Take radiographs, The patient may have almost no symptoms, or he may be
especially a lateral view. Look for air in the tissues. distressed, refuse food, drool saliva, choke, gag, or cough
If a large fish bone has stuck, you may see it, but you will (typically in paroxysms). If he is a child, he may merely
not see a small one. Do not confuse the hyoid bone 'fail to thrive'. If he is older, he may complain of pain,
(27-19F) for a foreign body! If there is no convincing or the sensation of a foreign body behind the sternum.
evidence that it has lodged in the pharynx, and pain is
mild, it probably only scratched the throat and passed on. If the foreign body is large enough to compress the
Treat expectantly. Encourage eating of dry bread. trachea, he may have stridor, or episodes of cyanosis and
A small sharp object may readily pass through the entire recurrent pneumonitis (unusual).
alimentary tract without causing harm.
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If a foreign body gets stuck at the gastro-oesophageal If the patient is very young, or mentally incompetent,
junction, suspect achalasia (30.6). there may be no history that he has swallowed anything.
Symptoms may have lasted hours or years. The diagnosis
is usually obvious, but a foreign body which is missed,
can cause persistent dysphagia and loss of weight, so that
you may suspect a carcinoma or oesophageal candidiasis.
A TRUE STORY. The examining surgeon at a nurse's training school
(St Francis Hospital, Katete, Zambia in its early days): “What instrument
would you use for oesophagoscopy?” Enrolled nurse:
“A sigmoidoscope”. When it was explained that this was wrong,
she repeated (correctly) that this was indeed the instrument that she had
seen used at her rural hospital! LESSON: If necessary, improvise.
EQUIPMENT needed
OESOPHAGOSCOPE, (a) infant, (b) child, (c) adult, with forceps and
suckers that are long enough to go through them. If you do not have an
oesophagoscope, you may be able to use a bronchoscope to remove coins
from the oesophagus, or dilate a carcinoma before passing a Celestin tube
(30-2E). The more protruding beak of a bronchoscope is, however,
more likely to perforate the oesophagus.
BOUGIES, oesophageal, neoprene, standard set, alternate sizes only.
The old fashioned gum elastic ones are satisfactory.
THE SECRET OF
RIGID OESOPHAGOSCOPY IS TO
FLEX THE NECK AND EXTEND THE HEAD
INDICATIONS.
(1) Removal of foreign bodies.
(2) Dilation for a benign or malignant stricture.
N.B. For diagnosis, flexible oesophagogastroscopy is
much better and safer (13.2) because it does not need GA,
and has much less risk of injury to the oesophagus.
RADIOGRAPHS.
Many, but not all, foreign bodies are radio-opaque,
but chicken and fish bones for example may be hard to
see. Obtain a lateral view as well as the PA.
In the oesophagus coins lie in the coronal plane, so that
you see their full diameter in a PA film. In the respiratory
tract they lie sagittally, so that you see them from the side.
A barium swallow may be useful, but it makes
oesophagoscopy soon afterwards more difficult;
diatrizioate meglumine ('gastrografin') is better.
CAUTION!
(1) Not all foreign bodies are visible on a radiograph.
(2).If there is a swallowed foreign body that may cause
Fig. 30-1 CORRECT POSITION OF THE HEAD FOR RIGID trouble, get a radiograph of the whole abdomen and the
OESOPHAGOSCOPY. A, the difficult part is passing the cricoid
cartilage (1) and cricopharyngeus muscle (2). This will be easier if you
pelvis also.
keep the handle of the instrument up, so that it slides over this (It’s obviously no use performing an oesophagoscopy for
muscle. B, keep the head on a pillow with the neck flexed and the something that is already in the stomach!)
head extended in the 'sniffing position'. This position will allow you N.B. Ultrasound may help deciding if an object is in the
to pass the oesophagoscope as far as the deepest part of the thoracic
kyphosis. C, introduce the oesophagoscope obliquely and move it
oesophagus or bronchus.
vertically, as it reaches the pharynx. D, if you need to examine the
lowest part of the oesophagus (less often necessary), straighten or PREPARATION.
slightly extend the neck, until he is in the sword-swallowing position. Keep the patient's head on a pillow throughout.
E, a rigid bronchoscope is circular, and has air holes.
F, an oesophagoscope is oval, and has none.
This will flex the neck. Then extend the head on the neck
Adapted from Dudley HAF (ed) Hamilton Bailey's Emergency Surgery, to achieve the 'sniffing position'.
Wright 11th ed 1977 p. 249,251 Figs 22.1,3 with kind permission.
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If the foreign body is not sharp, pass a lubricated Foley REMOVING A FOREIGN BODY
catheter first using a laryngoscope into the oesophagus METHOD.
past the foreign body under ketamine anaesthesia; First try laryngoscopy. You may be able to feel the foreign
inflate the catheter balloon with enough water to occlude body with a probe, and remove it with a long clamp.
the oesophagus, and gently pull it out. The foreign body If laryngoscopy and simpler methods fail, pass the
will come out with it, so you must grasp it quickly with oesophagoscope.
Magill forceps lest it falls down the bronchus instead! As soon as you can see the foreign body clearly (usually a
Make sure the neck is extended and the patient is coin, which will reflect the light and shine brightly as a
‘head down’. transverse line), pass the biopsy forceps and grasp it
N.B. Do not inflate the balloon with air: the tension in firmly.
the balloon will not be enough to extract the foreign body. If it moves distally, withdraw the forceps, pass the
If the Foley catheter is too big, use, if you can, a Fogarty oesophagoscope a little further, and try to grasp it again.
balloon embolectomy catheter. This manoeuvre is much When you have grasped it, bring it and the
safer than using the oesophagoscope if you are oesophagoscope out together.
inexperienced.
CAUTION!
The same position will allow you to pass the (1) The great danger is perforating the oesophagus:
oesophagoscope into the deepest part of the thoracic (a) usually at the level of the cricopharyngeus which
kyphosis. The most common reason for failure is keeps the entry closed, or
insufficient flexion of the neck, and extension of the head. (b) lower down where the foreign body impacts: beware
The patient needs a GA: ask the anaesthetist to place his the aorta lies at this level!
endo-tracheal tube on the left side of the mouth. (2) Safety pins, bones, and lumps of food, such as meat,
Have an efficient suction machine and tubes ready. should, if possible, be removed by an expert: they are
particularly difficult, and dangerous. You should try to
If you need to view the very lowest part of the oesophagus turn round a sharp object and pull it out with the point held
(unusual), straighten, or slightly extend, the neck, so that distally, if you can do this safely.
the pharynx and the oesophagus are in a straight line to let (3) If you cannot see the lumen of the oesophagus beyond,
the oesophagoscope pass (the 'sword-swallowing do not advance the oesophagoscope!
position'). Otherwise, keep it flexed. If your table does not
have a headpiece that drops down, ask an assistant to hold DIFFICULTIES WITH OESOPHAGOSCOPY FOR
the head over the end of the table to control its movement REMOVING A FOREIGN BODY
(30-1D): this is not easy, and is potentially dangerous!
If you do not have an oesophagoscope,
Beware of the lady with the elaborate towering hairstyle: you may be able to use a sigmoidoscope. Obviously you
it will be safer to undo this, or just cut it off, must clean it and soak it in disinfectant before use!
than fail to extend her head. After you have identified the cricopharyngeus,
use the obturator to negotiate it.
Make sure suction is available and the light is working
properly. Have biopsy forceps and foreign body graspers If a foreign body is too large to remove whole,
ready; check that these are long enough to pass through the as with an impacted denture, you may be able to break it
oesophagoscope! and remove the pieces.
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Arrange an immediate drainage (if the tear is in the Persuade the patient to swallow a piece of fine string
cervical oesophagus, 30-5) or thoracotomy. Delay is likely attached to a toffee, coated with honey. Keep the other end
to be fatal. of the string outside the mouth; the string inside the
oesophagus will maintain a lumen, however small, and
If an empyema develops, evacuate all fluid and air, insert may help with retrograde dilation later, by acting as a
intercostal drains, keep nil by mouth, and consider a guide along which you can direct a bougie.
feeding jejunostomy (11.7): a gastrostomy is less effective
because the feed can reflux into the oesophagus). If injury to the oesophagus is likely to be severe
(you can sometimes tell early by the bleaching caused in
If the above symptoms are delayed, there is the mouth and pharynx), do not hesitate to construct a
fever and the chest radiograph is normal, feeding gastrostomy (13.9), which you can use for
suspect MEDIASTINITIS. Antibiotic treatment is more retrograde dilation.
likely to succeed. Fashion a temporary oesophagostomy
tube drainage in the neck (30-5) and a gastrostomy (13.9) RETROGRADE OESOPHAGEAL DILATION
to rest the oesophagus. A feeding jejunostomy (11.7)
in addition will allow you better to feed the patient.
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A barium swallow may give similar appearances to CAUTION! If the bougie suddenly seems to encounter no
achalasia (30.6), and so you need endoscopy to resistance at all, you have perforated the oesophagus.
differentiate between the two, and to dilate a stricture. Strictures at the lower oesophagus are particularly
This sort is, inevitably, at the lower third of the vulnerable because the oesophagus makes a slight curve
oesophagus, where dilation is especially hazardous. when entering the stomach.
If there is profound wasting, and a barium swallow If you fail to pass the bougie, abandon the procedure and
shows shouldering at the stricture, this is a malignant try again at the next opportunity: you will be surprised
stricture (30.5). how often it goes easily then!
If there are signs of HIV disease, and especially oral If the stricture remains impassable, try to arrange an
candidiasis, there is likely to be oesophageal candidiasis oesophagectomy with remaining stomach or colonic
(30.4), which may be so thick as to block the oesophagus. replacement; this is formidable surgery unlikely to be
Treat this with azole antifungal agents and fizzy readily available. In the meantime, provide nutrition via a
carbonated drinks. gastrostomy (13.9) or jejunostomy (11.7).
If there is regurgitation and retrosternal pain, without If there is severe chest pain, odynophagia even for
much weight loss, and a barium swallow shows a saliva, and shock, you have perforated the oesophagus
mega-oesophagus in a 25-35yr old, this is achalasia (30.7).
(primary, or related to Chagas disease: 30.6)
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BARIUM SWALLOW will show a distinctive narrowing, Push both gently over the bougie down the oesophagus.
with shouldering of the edges (apple-core lesion, 38.1) When the tube reaches the tumour, you may feel some
resistance. Now push more firmly with a gentle twisting
OPERABILITY. action. You will feel the P-L tube passing through the
The few cases suitable for oesophagectomy must have: stricture, until you feel its cup being stopped by the upper
(1) A lesion <5cm long on Barium swallow end of the stricture. Watch the cm scale on the
(microscopically, the tumour may extend double this oesophagoscope, as it passes the teeth, so that the tube
length in each direction), which narrows the oesophagus rests not >1cm than the distance to the tumour measured
by <50% and shows no axial deviation. previously.
(2) No mediastinal widening (no enlarged nodes).
(3) No deformity of the trachea, carina, or left main Remove the bougie, untwist the oesophagoscope slightly
bronchus on bronchoscopy. to disengage it from the cup of the P-L tube.
(4) No evidence of a tracheo-oesophageal fistula. Look down the oesophagoscope to see that the tube is in
(5) No pneumonia, chronic bronchitis, TB, or HIV disease. place. Suck out blood and tumour debris.
(6) No significant weight loss (>10%). Remove the oesophagoscope under direct vision.
(7) No cardiac disease. The P-L tube is unsuitable for very high lesions (<15cm
(8) Good general health, and young age. from the incisor teeth), and low lesions (>35cm from the
Do not refer cases which do not meet these criteria. incisor teeth), because of the problem of acid reflux.
CAUTION! You should not be tempted to create a The mortality of insertion is c.10%.
feeding gastrostomy, which will only prolong the patient's N.B. There are similar, safer and more reliable and
agony, and will not solve the distressing problem of the lasting expandable stents which can be inserted in the
inability to swallow saliva. same way, with the appropriate introducer; these are now
not so expensive.
STENTING FOR CARCINOMA OF THE OESOPHAGUS
(GRADE 3.2) If you use a Celestin-type (retrograde) tube, pull it down
through an open gastrotomy (30-2C). Occasionally the
INDICATIONS. stricture cannot be dilated from above, but it might be
Inability to swallow. Even if there is total obstruction, possible from below. However, the mortality of this
you may still be able to pass a tube. procedure is significantly higher (20%).
CAUTION! POSTOPERATIVELY
(1) The earlier the presentation, the easier it will be to pass Continue IV fluids till oral intake is satisfactory: unless
the tube. Do not wait until dysphagia is complete: there are problems with the procedure, swallowing is
you may not be able to dilate the stricture. usually possible immediately. Advise the patient, in his
(2) There is no substitute for being taught this procedure enthusiasm to resume eating, to chew his food well.
by an expert. Remember to advise laxatives, as the liquidized food taken
(3) Do not attempt this if the patient has recently had subsequently will tend to constipation. It is best to avoid
radiotherapy: the oesophagus becomes very friable and stringy vegetables.
perforation is then a very great risk. Wait for 4wks;
even then the danger is great. DIFFICULTIES WITH OESOPHAGEAL TUBES
If you make a false passage or tear the stricture,
Check the position and length of the tumour on the barium mediastinitis will follow and usually be rapidly fatal
radiograph, and also note any deviation or fistulae present, within 24hrs. Life without a tube is so intolerable that you
which may make placing the tube difficult. will have to take this risk. Surgical intervention is very
N.B. Using a flexible endoscope (13.2) and placing a unlikely to be successful.
stent is much easier and safer for the patient.
If the bougie passes, but the tube will not pass, you may
Using the rigid oesophagoscope, aim to place a P-L, need considerable force, even after what seems like good
similar or improvised tube (30-3B,C) antegrade through dilation. Only one diameter (10mm) of P-L tube is made,
the dilated oesophageal stricture; choose a tube of the right and it does not pass every stricture. You can make a
length (11cm, 15cm or 19cm). Make sure the stricture is home-made tube (30-3B,C). Take a soft plastic
dilated to an adequate width to accommodate the tube. endotracheal tube of suitable size, cut off the tip with half
Leave the dilating bougie in situ, and make sure a strong the balloon. Wind thick silk or nylon under the balloon
monofilament thread (fishing wire) is attached to it, remnant to make a bulge. Cut the tube long enough for the
so you can pull it out easily if necessary. Lubricate the stricture, and bevel the other end by cutting it obliquely, to
tube well inside and out, and slide it over the end of the make it easier to pass.
bougie. Guide the tube into the patient's mouth and With the oesophagoscope in place, pass the improvised
pharynx with your left hand, and engage the tube with long forceps under direct vision until its bulbous
oesophagoscope in the cupped upper end of the tube. end is snug up to the top of the carcinoma. It will be
possible to take thick liquids at least.
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Or, get a long piece of wire from your workshop which You can recognize 3 stages of the disease process:
will just pass down the whole length of a Ch18 nasogastric (1) incipient where the dilation of the oesophagus has not
tube. Lubricate it well and pass it through the tube. yet started and Barium swallow appearances mimic a
Pass this wire stylet and tube through the oesophagoscope, benign oesophageal stricture,
through the stricture and into the stomach. Remove the (2) non-advanced where dilation is <7cm diameter,
stylet and oesophagoscope. Pass a long nasotracheal tube (3) advanced where there is gross dilation >7cm and atony
down the nose, recover its distal end from the throat, of the oesophagus.
and bring it out of the mouth. Push the end of the
nasogastric tube through the nasotracheal tube out If you can get it, endoscopic injection of 1ml of 20IU
through the nose. Remove the nasotracheal tube. botulinum toxin in each 4 quadrants at the lower
Tape the nasogastric tube to the cheek. Bandage the oesophageal sphincter gives improvement in >50% of
elbows in extension with rolled newspaper to prevent patients.
removal of the tube on recovery from GA.
INVESTIGATION.
N.B. In order of increasing efficacity are: nasogastric, Barium swallow radiography gives a characteristic picture
improvised, Celestin, P-L tubes, but by far the best is a of tapering of the oesophagus in:
self-dilating stent. (1) oesophageal dilation
CAUTION! Do not try to pass the wire stylet down on (2) mega-oesophagus
its own. (3) often with food remnants causing ‘filling defects’.
Oesophagoscopy demonstrates no evidence of an
If you push the whole tube past the stricture (unusual), obstructive lesion.
you may be able to pull it back with strong forceps. If this
fails, leave it: it will pass per rectum! EQUIPMENT.
You should use balloon dilation for the incipient stage.
If the patient regurgitates the tube, this is a nuisance, In an endemic area, you should obtain the instrument
but not a disaster. If possible, replace it by a flanged tube designed by Pinotti from São Paulo: this is a plastic
(30-3E,F). The shorter the tube, the better it works, but the catheter with a 10cm long heavy metal tip and a
more easily it slips out. If it is too short, the tumour may cylindrical balloon attached to the body of the catheter
grow over the end and obstruct it. Flanged tubes are more (30-2).
likely to stay in place. N.B. This is not the same as a Sengstaken tube (13-14)
A tube may displace if the patient vomits after the initial
procedure, so keep him sedated with an anti-emetic. BALLOON DILATION OF INCIPIENT MEGA-OESOPHAGUS
(GRADE 2.4)
If the tube blocks, try fizzy carbonated drinks to unblock
foodstuffs, which are usually the cause; if this fails, INDICATION. Incipient mega-oesophagus.
perform an OGD or oesophagoscopy (13.2, 30.2). Fast the patient for 12hrs. Sit him upright and spray the
oropharynx with 4% lidocaine. Introduce the instrument
orally and wait till the patient feels the mercury tip has
entered the stomach (30-4A). Inject 50ml water into the
30.6 Achalasia balloon (30-4B) and gently pull it up against the cardia
(30-4C), so that it is anchored there. Then gradually inject
a further 50-250ml water until the patient feels pain
Sometimes, in a patient of 25-35yrs, there is dysphagia, (30-4D), keeping it inflated for 5mins.
regurgitation and retrosternal pain; a Barium swallow will
initially show tapering of the distal oesophagus, which Then empty the balloon until only 50ml are left,
looks like a benign stricture; later the proximal oesophagus thus leaving the balloon in position. Inflate the balloon
enlarges and ultimately may become enormous. twice more at intervals of 30mins, and then remove it.
There is however, no blockage: the defect is in the
function of the myenteric Meissner & Auerbach plexuses DIFFICULTIES WITH BALLOON DILATION
at the gastro-oesophageal junction. If there is bloody vomiting after dilation, suspect a
mucosal tear. This should heal spontaneously (30.7);
This may be primary, or arise as a result of infestation by if not re-inflate the balloon with half the volume of water
Trypanosoma cruzi in Central South America to compress the oesophageal mucosa for 5mins,
(Chagas disease). In this case, other organs are commonly deflate and observe.
also affected: the heart in >30%, the pylorus is in 20%,
the colon in 15% and the gallbladder in 7%. Squamous If there is persistent retrosternal pain and dysphagia,
carcinoma of the lower oesophagus develops in c.5% of suspect an oesophageal perforation. This should not occur
Chagas mega-oesophagus. if you stop distending the balloon when the patient feels
pain. Confirm the perforation with a ‘gastrografin’
swallow. If present, an urgent laparotomy to close the
perforation is necessary (30.7): delay will be fatal.
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MANAGEMENT OF MEGA-OESOPHAGUS
The non-advanced mega-oesophagus <7cm diameter needs
an oesophageal myotomy (Heller’s operation) with a
partial gastric fundoplication (39-6B), to prevent
postoperative acid reflux.
The advanced atonic mega-oesophagus >7cm diameter
needs an oesophagectomy.
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EQUIPMENT needed
CHAIR, operating dental. A dental
chair is expensive. If you do not
have one you may be able to adapt a
strong chair, and fit it with a rest to
support the patient's head, when it is
pushed firmly backwards, especially
when you extract upper teeth.
DENTAL MIRROR, serrated handle
with #4 size plane head (31-1A).
DENTAL PROBE, single-ended
(31-1B).
DENTAL DRESSING TWEEZERS,
Guttman, (31-1C).
‘PLASTIC INSTRUMENT' (31-1D).
This is for inserting filling material
into a cavity.
SPATULA, metal, for mixing filling
material (31-1E).
SCALER, dental, Cumine (31-1F).
DENTAL MATERIALS, clove oil for
dental use. Zinc oxide powder.
When mixed together on a glass slab
with the spatula listed above,
these make an effective analgesic
and a mildly antiseptic dressing for
Fig. 31-2 DETAILS OF TEETH.
a dental cavity.
A, healthy tooth; internal structures: (1) fissure. (2) enamel.
SUCTION MACHINE. This is essential,
(3) dentine. (4) pulp. (5) gum (gingiva). (6) cementum. (7) periodontal
to prevent aspiration of liquids, pus or blood.
fibres. (8) alveolar bone. (9) root canal. (10) blood & nerve supply at
root apex.
External features: (11) white, shiny enamel: (a crown is fixed onto
31.2 Gum disease this). (12) no space between tooth & gum. (13) Firm, pale gums.
(14) bone supporting tooth.
B. diseased tooth; stages of periodontal disease: (15) plaque
(bacteria) forms and infects gum. (16) gum recedes and forms a
The gums of healthy teeth cover their necks and those of pocket for food & bacteria to collect. (17) gum becomes inflamed
adjacent teeth (31-3G). If gums are diseased by (gingivitis), bleeding often. (18) periodontal fibres destroyed; abscess
periodontitis, they recede and expose the necks of the teeth develops. (19) bone destroyed (periodontitis) and tooth becomes loose
(31-3H, I), which ultimately become loose and fall out. & may fall out. Stages of dental decay: (20) bacteria in plaque
convert sugar to acid. (21) acid destroys enamel (caries).
Besides causing sore, bleeding gums, periodontal disease (22) decay spreads to dentine, which becomes sensitive to heat &
causes more lost teeth in many communities even than cold, and infection spreads to pulp cavity. (23) pulp infection spreads
caries. It may be caused by actinomycosis. down root canal. (24) peri-apical root canal abscess develops.
After Ahmed MAM, Abdel-Latif, MMM in Textbook of Tropical Surgery,
ed Kamel R, Lumley J, Westminster 2004 p.320 Fig 82.1
Periodontal disease is the result of a vicious circle.
Food tends to accumulate between a tooth and its gum,
You may not find yourself scaling many teeth yourself,
and cause the gum to slowly recede. This makes the pocket
but there must be someone in your hospital who could do
larger, so that food accumulates even more easily. In more
severe cases the diseased gums swell, bleed easily this, and you should be able to teach how to do it properly.
(gingivitis), and discharge pus (pyorrhoea), often with
PREVENTIVE DENTISTRY
severe foetor (31-2). Gingivitis is common in early
CLEANING TEETH Explain that this should always start
pregnancy (<12wks), and scurvy (vitamin C deficiency),
with the toothbrush (or toothstick, 31-3B,C) on the gums,
and may result in severe necrotizing ulceration with HIV
disease. moving it up over the lower teeth, and down over the
Ingestion of food increases mouth acidity, which attacks upper ones, at least 10 times, for at least 2mins. This is not
the enamel lining of the teeth. Saliva exists to buffer and easy behind the lower front teeth, and needs much
practice. After this, it is important to rinse out the mouth.
wash away acid, but if there is excessive sucrose and little
If there is no toothpaste, you can use common salt,
fluoride, an exopolymer of extracellular polysaccharide
or nothing: brushing is more important than paste.
matrices in a viscous hydrated phase builds up as a very
sticky biofilm. This is known as plaque, under which the Do not discourage the use of sticks or sugar cane!
tooth continues to disintegrate.
SCALING TEETH
INDICATIONS.
The prevention of gum disease, and most of its treatment,
Use the spoon end of a scaler (31-3F) to remove deep
is improved oral hygiene: better tooth-brushing
hardened plaque (31-3J). This starts just below the gum.
(31-3D,E), increase of fibre and reduction of sugar content
in the diet, and when necessary, scaling to remove Removal may be difficult, because the plaque may stick so
hardened plaque that has accumulated in the crevices firmly to the teeth that scraping it off can cause mild pain
(31-3J). and bleeding. Use the point of the scaler to remove plaque
from between the teeth. Rinse the mouth out thoroughly,
and then demonstrate how to clean the teeth properly.
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Ideally, forceps should avoid the crown, and fit the whole
surface of the neck and root of a tooth. The blades must be
sharp, so that they can easily slide between a tooth and its
gum. If necessary, sharpen them on the outside of their
tips.
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EXTRACTING TEETH If there is severe periodontal disease and the teeth are
firm, but have swollen gums round them, leave them until
INDICATIONS. other remedies have failed; you may still be able to save
(1) A painful, severely carious tooth. them.
(2) A periapical abscess (31-2B). But if one or more of the teeth are loose in their sockets,
(3) A periodontal abscess. and the gums are red and swollen, and bleed easily on light
(4) Severe periodontal disease. pressure, remove them.
CHILDREN'S TEETH.
Under 12yrs, be very careful when you remove a
deciduous (primary, or ‘milk’) tooth, lest you remove or
damage the permanent tooth underneath.
WHICH TOOTH?
If there is toothache, it is usually clear which tooth is
responsible. Occasionally, however, when pain is referred,
it is not clear even which jaw is affected. So, do not
necessarily remove the tooth which appears to be at fault.
The offending tooth may:
(1) have a large hole in it. (If you cannot immediately see
any carious areas, use a dental mirror to look on the
adjacent surfaces of the teeth.)
(2) be broken, black, or brown.
(3) look grey under its enamel.
(4) be loose with severe periodontal disease around it.
(5) be tender on gentle tapping.
Tap each tooth in turn with the handle of a dental mirror.
The most sensitive one is likely to be the cause of the
toothache.
N.B. Toothache may come from an infected maxillary
sinus, or the temporo-mandibular joint!
RADIOGRAPHS.
If a tooth is displaced or impacted (31-4), get a radiograph.
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EXTRACTION OF A LOWER TOOTH (GRADE 1.2) To extract lower left premolars, turn the head towards
Use right-angled forceps and press downwards. you and use gentle rotating movements.
If you are extracting a lower front tooth or a lower left To extract lower right premolars, move to the right,
molar or premolar, sit the patient upright in the chair, or even stand behind the right shoulder.
and low enough for the mouth to be level with your elbow.
If he is too tall, stand on something. Grip the tooth socket To extract a lower right molar, stand behind the right
between the index and middle fingers of your left hand, shoulder, and use a side-to-side rocking action (31-6E).
and put your thumb under the mandible (31-5A).
If you have difficulty extracting the lower 3rd molar,
If you are extracting a lower right premolar or molar this may be because its roots are deformed, and need to be
tooth, stand behind the patient (31-5B). dissected out with bone chisels (31.4).
If you are left-handed, stand behind the patient whilst EXTRACTION OF AN UPPER TOOTH (GRADE 1.2)
extracting all lower left premolar and molar teeth. Tilt the head backwards. If your chair does not have a head
For all others, stand in front, but on the left side. rest, support the patient’s head against a wall, or ask your
assistant to support it. Stand upright and to the right in
front of the patient. For all upper teeth, put the finger and
thumb of your left hand on either side of the gums.
CAUTION!
(1) Make sure that the long axis of the tooth forceps blades
is in the long axis of the tooth.
(2) Do not grasp the tooth and the gum together.
(3) Carious teeth are brittle and will break if you put too
much sideways pressure on them: do not use the forceps as
a 'nut cracker'.
(4) Do not start extracting movements when you have only
grasped the crown of the tooth.
(5);When you rock a tooth, feel if it is responding to
reasonable pressure; if it does not respond and seems very
firmly fixed, abandon the attempt.
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CAUTION!
(1) Hold the elevator with your index finger near its tip to
stop it slipping.
(2) The upper premolar and molars roots are very close to
the maxillary sinus, so you can easily push a root into it.
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If a fistula presents after 24hrs, the edges of the wound If there is persistent haemorrhage, suture the gums.
will probably be infected, so do not suture it. Advise oral Use a half-circle cutting needle and 3/0 black waxed
intake of a sloppy diet. Allow the area to heal, excise the non-absorbable suture. Pass 3 such sutures through the
fistulous tract, and close the fistula with a buccal flap. You gum one side of the tooth socket, and out on the other side.
can remove most teeth or roots from the sinus through the Place a plug of haemostatic gauze over the bleeding socket
original defect enlarged if necessary. (31-7A), and tie this in position. If you do not have
haemostatic gauze, use cotton wool; but be sure to remove
If you lose a tooth while you are extracting it, the pack after 48hrs. Alternatively, bring the edges of the
immediately bring the head forwards, and ask the patient gum together by chipping away bone from the crests of the
to cough it out. If you don’t find it, X-ray the socket and socket. This will put the gum under tension, and make it
the chest. If it has been inhaled, try to remove it by less likely to bleed. Be careful not to suture foreign
bronchoscopy (29.14) as soon as possible, before a lung material under the gingiva!
abscess develops. CAUTION! Do not be content with inadequate
suturing; it will only cause more problems later.
If you break or dislocate the mandible, you will need to
fix it internally and reduce it. INFECTION AFTER TOOTH EXTRACTION
Diagnose infection when there is:
If you injure the tongue, and the wound is small, (1);Pain & bleeding. Irrigate the socket, remove clot and
it needs no treatment except mouth washes. If it is larger, food debris, pack it with haemostatic gauze, and suture this
pull it forwards, inject some lidocaine with adrenalin and in place. Place a firm gauze pack on top and ask the patient
repair it with absorbable sutures. to bite on this. Use metronidazole. Do not allow rinsing of
the mouth, which may restart the bleeding; instead, clean it
If there is an extra tooth, it is usually conical, with wet gauze.
and may present almost anywhere on the jaw, and even in (2);An acutely painful empty socket, without any clot in
a nostril. Removing it may call for skill and ingenuity. it. This is a DRY SOCKET. It is a local osteitis of
If necessary use a dental elevator to clear away the soft condensed bone. The danger is that osteomyelitis may
tissues of the gum before you apply forceps. follow. Irrigate it with warm water and remove any food
and degenerating blood clot. Under LA, scratch around
inside the dry socket to make it bleed. Try to excise any
sharp bone spurs. If it bleeds and a clot forms, it will
probably heal. A dry socket is very painful, so make sure
you provide adequate analgesia.
(3);Fever and a very painful socket, a mandible which
is exquisitely tender, and perhaps numbness of the lips
(owing to involvement of the mental nerve). This is acute
OSTEOMYELITIS (7.15).
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If the 2nd molar is normal, and the impacted 3rd molar At this stage, there is a sore mouth, a swollen, tender,
is at a nearly normal angle, use bone forceps or dental painful lip or cheek, profuse salivation, and an extremely
forceps to nibble away the jaw behind it. foul smell, with purulent discharge from the mouth or
nose. Within the next 2-3days, a bluish-black area of
If the 3rd molar is completely horizontal, split it with a discoloration appears externally on the lips, or cheek.
chisel, and then extract it in 2 parts, with any convenient The gangrenous area is cone-shaped, so that much more
forceps. tissue is destroyed inside the mouth, than the external
wound might indicate. After separation of the slough,
the exposed bone and teeth rapidly sequestrate.
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Avoid petroleum jelly gauze (which acts like a foreign A dental cyst forms round the apex of a chronically
body), especially when it has been impregnated with infected, and usually non-vital, tooth, commonly in an
antibiotics. older patient. Chronic infection causes the epithelial
remnants in the periodontal membrane to grow, and
In a fit patient, cut away any separating dead tissue, become cystic. Dental cysts are usually quite small,
and remove any loose teeth or sequestra (dead bone). and are commonly symptomless. Occasionally, they grow
When quite large sequestra are ready to separate, you may large enough to expand the alveolus in which they arise.
be able to remove them under ketamine. In the maxilla they may extend into the sinus, or the nasal
fossae. The fluid they contain is usually clear,
In an unfit patient, allow the dead tissues to separate but may contain cholesterol crystals. They may be hard,
spontaneously. Sequestra occasionally drop out. tense, or fluctuant. If the bone over a cyst is thin it may
More often, they have to be removed after 3-4wks, crackle like an eggshell when you press it. Radiographs
when the patient’s condition has improved enough for show a clearly defined, well corticated, unilocular
surgery to be safe. radiolucency, unless the cyst is infected, which causes it to
CAUTION! There is no place for radical surgery at this lose its cortex.
stage, except to control bleeding (rare).
A dentigerous cyst usually arises in a young adult from
Try to organize reconstruction at 3-6 months,
the follicle of a normal unerupted, or erupting, permanent
before marked trismus develops. This will allow the scars
to mature, the local tissues to become supple and soft, tooth. It expands the lateral aspect of the jaw while the
and the child’s health to improve. Meanwhile, maintain stronger medial side resists deformation. The tooth which
forms the cyst usually fails to erupt, and you can see that it
good nutrition and oral hygiene.
is missing from its normal place in the mouth.
These children have major psychological difficulties of Radiographs show a well corticated unilocular
adjustment; do all you can to help them. radiolucency containing the unerupted tooth. If this tooth
is normally placed, opening the cyst may allow it to erupt.
Often, it is so misplaced that it cannot erupt, and needs
enucleation.
31.6 Jaw swellings
An odontogenic keratocyst (rare, developmental) is filled
Lesions which make the jaws swell, apart from trauma, with keratinized epithelial squames. These make the
are: contents creamy, so that it looks like pus, and can only be
(1);Infection: an alveolar abscess (6.9), a dental sinus, distinguished from pus microscopically. Do not confuse
actinomycosis and osteomyelitis (7.14). this cyst with an abscess; there are no signs of infection.
(2) Various types of dental cyst. Radiographs show a well corticated uni- or multi-loculated
(3);Tumours: Burkitt's lymphoma (17.6), ameloblastoma, radiolucency. These cysts are particularly likely to recur
carcinoma, salivary tumours (17.7), and giant cell tumours after they have been removed (20-60%), so need radical
(31-13D). surgery.
(4) A complex group of fibro-osseous lesions.
Developmental cysts (rare) are not associated with teeth.
Actinomycosis classically follows oral surgery, or may The commonest one is a nasopalatine cyst, which develops
complicate poor dental hygiene; infection arising from from epithelial remnants in the nasopalatine canal,
Actinomyces israelii spreads across tissue planes and immediately behind the upper front teeth. If it is causing
results in a woody hard swelling around the mandible, problems it should be enucleated. If this is impractical you
resulting in sinuses discharging yellow ‘sulphur-like’ may have to open it out, taking care not to injure the
granules. incisor teeth and their supplying vessels.
N.B. These are not sulphur at all, just yellow in colour;
they stain blue under microscopy. TREATMENT OF JAWBONE CYSTS
Osteomyelitis results, and infection may spread to the base
of the skull giving rise to cranial nerve lesions. Simple methods are to:
There is no lymphadenopathy early on as the bacillus is (1);Marsupialize a cyst, by removing the mucosa over it,
too large to pass in the lymphatics; lymphadenopathy together with the immediately underlying bony wall and
implies secondary infection. lining, washing it out, and then suturing the lining of its
floor to the surrounding mucoperiosteum. This relieves
You should drain pus, excise fistulae and remove necrotic tension, stops further expansion, allows drainage, and lets
tissue; however the definitive treatment is till acute the space the cyst occupied slowly fill up from the bottom.
infection has settled and then oral penicillin for 2-6 (2) Lay a cyst open.
months. In case of penicillin allergy, you can use (3);Decompress a dentigerous cyst, by opening it,
erythromycin or doxycycline. and allowing the tooth in it to erupt.
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INDICATIONS.
(1) An easier alternative to enucleation for a
larger dental cyst.
(2) A dentigerous cyst.
(3),An elderly patient, in whom there is a risk
of pathological fracture.
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INCISION. Clear the bony covering of the cyst, fracture its eggshell
You can approach all cysts from inside the mouth, surface, and remove a piece of bone from its most
unless you need also to resect the jaw. prominent part. Nibble away more bone, and push the cyst
Approach the cyst from the side of the jaw on which the off the bony wall of the cavity in which it lies.
swelling is greatest. If it is equal on both sides, approach it If it is a dentigerous cyst, its lining will be held round the
from the buccal side. Reflect a large mucoperiosteal flap tooth it contains.
(31-12B). Remove bone over the same site (31-12D). You need an expert to excise a piece of jaw with a tumour.
Remove the superficial part of the lining (31-12E), so as to This may be:
expose the cavity widely, and render the deeper part of its (1);A giant cell tumour which is only locally invasive,
lining continuous with the oral mucosa. Wash out the cyst, but may grow very large if it is not treated (37-4).
and examine its lining for signs of neoplastic changes. (2);An ameloblastoma (adamantinoma), which arises
If there is more than a little tissue in it, suspect that it inside the jaw from the enamel organ of a tooth,
might be an ameloblastoma. Send any material you and slowly destroys the surrounding bone. It may be solid
remove for histology. or cystic, it is locally invasive like a basal cell carcinoma,
and does not metastasize. You are unlikely to miss an
If you are marsupializing a dentigerous cyst, be sure to ameloblastoma if you remember that: (a) the radiolucent
remove all the epithelium, or it may grow again. lesions it produces are commonly multilocular (the cysts
To do this, remove all the soft tissues on the outside of the described below are mostly unilocular), (b) the solid tissue
bony cyst wall. Remove the tooth at the same time. from around any 'cyst' should be sent for histology, which
Leave it open to granulate. is the only certain way of making the diagnosis (the cysts
described below are filled with liquid). An ameloblastoma
If a dental cyst is related to a permanent tooth, requires radical removal.
the tooth is likely to be non-viable. It might be saved by (3);An odontogenic keratocyst, an ossifying fibroma,
root canal treatment, but you will probably have to remove a carcinoma, or a fibrosarcoma.
it. If it is related to a deciduous tooth (unusual), remove
the tooth.
INDICATIONS.
An infected or 'messy' cyst, with a lining which you cannot
completely remove, or a flap which you have to sacrifice.
METHOD.
Remove the tooth associated with a dental cyst,
unless it can be root-treated. Open the cyst, remove as
much of its lining as you can, and then pack it with BIPP
impregnated gauze. Reduce the bulk of this over 4wks, to
allow the cavity to granulate slowly from its base.
ENUCLEATING A CYST
More advanced methods include enucleating a cyst by
reflecting a periosteal flap, opening it, removing all its
lining, and then replacing the flap. This is more difficult
than the preceding methods. GA with tracheal intubation is
essential.
Approach a cyst in the upper jaw through the outer aspect
of the socket. Approach a cyst in the lower jaw through an Fig. 31-13 BENIGN TUMOURS OF THE ORAL CAVITY.
incision 1cm below the lower border of the mandible, A, a fibroma. B, a pregnancy epulis (a benign gingival growth, 31.9).
C, a haemangioma of the tongue. D, a giant cell tumour.
or inside the mouth, through the labial side of the socket. E, a hard papilloma (31.9). Adapted from drawings by Frank Netter,
Infiltrate the tissues with adrenaline in saline (3.1). with the kind permission of CIBA-GEIGY Ltd, Basle Switzerland.
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31.7 Cleft lip & palate MILLARD CLEFT LIP REPAIR (GRADE 2.5)
Mark the points 2 to 4 on the child (31-14A), and infiltrate
with lidocaine/adrenaline solution (3.1).
Cleft lip Incise through full thickness of the lip at points 4f and 5g
This may be variable in extent, and often associated with so their thicknesses are equal, and along the dotted lines 4h
cleft of the tooth socket, or palate. It is usually unilateral, and 5e, these also being equal. Make a curved extension
but may be bilateral. Defects of the midline or oblique 4a and an equal curve laterally dc under the ala nasae.
facial clefts are more complicated and of different Preserve a small ‘C’ flap so that cd′e5 fits into 4′ab4.
embryology. This allows for closure of the nostril. Close the flaps with
The Millard rotation advancement repair is the most buried knots using 4/0 absorbable suture so that points
popular; you should only attempt correction if the baby is 45 and fg align. Suture the skin with 5/0 nylon, and paint
in good nutritional state, and preferably >9 months old. the wounds with chloramphenicol ointment qid.
Make sure you have a fine marking pen and indelible ink If you leave one length long, you can use this as a stay
or dye. Do not attempt this operation if your experience is suture for easy retraction whilst you complete the
limited and your supply of fine sutures limited: getting a remaining sutures. Restrain the child from tampering with
good cosmetic result on a re-do is very difficult. the wound by wrapping his hands up; make sure he is fed a
sloppy diet with a spoon and uses mouthwash after eating.
Remove the sutures after 4days, preferably
under ketamine.
Cleft palate
If milk comes from a baby's nose as he sucks,
suspect that there is a cleft palate.
This is often, but not always associated with a
cleft lip. It may be unilateral or bilateral.
Cleft palates are much more difficult to repair
than cleft lips. You should not operate before
c.12-18 months, before the child tries to speak,
and when he should be fit enough for a major
operation, if he has been adequately fed.
Breast-feeding is a major problem, except for
minor clefts of the soft palate only, which need
no treatment. Try a cup and spoon.
Alternatively make a feeding spout to fit a
Fig. 31-14 MILLARD CLEFT LIP REPAIR. standard feeding bottle (31-15). If this fails, he
A, 3 is the centre of the lip (Cupid’s bow); 2 is the peak of Cupid’s will have to be fed through a nasogastric tube, until he is
bow on the normal side; 4 is the projected point equivalent to the stronger, when cup and spoon feeding may be possible.
point 2 on the affected side, so that 23=34; 5 is the start of the A special plate, supported by 2 wire arms on the cheek,
mucosal thickening of the cleft side, so that 5g=4f; h is the medial
extremity of the open nasal sill on the cleft side, and e the lateral can be constructed in the first few days of life, to bridge
extremity. The lip vermillion does not usually reach these points. the gap in the cleft palate.
B, intra-operative view: divide the upturned cleft lip across 4f and 5g
such these are equal. Cut 4h so 4h=5e; cut a curved extension 4a SPATULATE FEEDING SPOUT
where a is the medial border of the nasal sill on the unaffected side;
this effectively removes the abnormal lip tissue (and makes the defect Fig. 31-15 SPATULATE
look bigger and worse!). Cut a C flap to allow plastic nostril closure: FEEDING SPOUT. Attach this
cut cd=a4. Extend an incision along the nasal sill ab=de to make the to a feeding bottle and squeeze it
C flap fit nicely. C, end-result: points fg, 45, be, ad′, hd, 4′c are all to deliver a bolus into the spout.
joined together. The Z-plasty closing the upper lip is optional: omit it After Jones PG, Woodward AA.
if you are unfamiliar with it or you do not have very fine instruments. Clinical Paediatric Surgery,
After Kirk RM, Williamson RCN. General Surgical Operations Churchill Blackwell 3rd ed 1986 p.210
Livingstone 2nd ed 1987 p.563 Fig 31.26 Fig 24.4
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Good dental care is essential. These children are prone to Precancerous lesions occur as:
recurrent ear, nose and throat infections, and particularly (1) leucoplakia (white patches: dyskeratosis),
get ‘glue ears’ (29.2,4). (2);erythroplakia (leucoplakia interspersed with reddish
Experts can do the surgery in theatres with basic facilities: spots),
if a programme for cleft repairs can be set up in your (3) submucous fibrosis,
district, this is the best chance for your patients. (4) chronic dental ulcers.
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If there is a lesion <1cm on the lips or tongue, excise it Paracoccidiomycosis (blastomycosis) is frequent in parts
with a margin of at least 1cm. All other patients need of Central and South America, particularly Brazil.
chemotherapy, followed by radiotherapy and/or surgery. It occurs between the ages of 20-40yrs. The fungus is
Verrucous carcinoma is best treated by surgery only, inhaled from vegetables or the soil, and implanted through
because radiotherapy causes it to become a rapidly breaks in the skin or mucosa, resulting in haemorrhagic
growing anaplastic lesion. papules which soon ulcerate. Regional lymphadenopathy
is common, and the intestines may also be involved.
If there is cancer of the mouth, and you can feel nodes Use ketoconazole 200-600mg od if you can make a
in the neck on presentation, consider your options diagnosis early.
carefully. Patients with a potentially curable lesion with The problem with the disease is gradual destruction of the
mobile nodes and no distant metastases, may have a 25% mouth and nose, requiring plastic reconstruction as for
chance of cure with skilled surgery. If nodes appear cancrum oris (31.5)
months or years after the primary has been treated, and are
still mobile, radical dissection has a 30-50% chance of LUMPS ARISING FROM THE ALVEOLUS
cure. Node biopsy may be useful. The nodes may be
enlarged by infection. If in doubt, try antibiotics for a few If there is a firm lump on the gum, it is probably a
days, and see if they become smaller. Adequate surgical FIBROUS EPULIS (common, especially in pregnancy).
excision may mean using an extensive delto-pectoral or Very few of these lesions are fast-growing, and if a lump
forehead rotation flap. is soft, bluish, and grows rapidly it may be a sarcoma
(very unusual). Excise it and send it for histology. If it is
CHEMOTHERAPY is not curative, but there is a 20% very extensive, try to refer to an expert periodontologist
response rate to x2wkly IV methotrexate at 40mg/m2, (if you can find one!) or a maxillofacial surgeon. It may be
with little further benefit from multi-dose regimes, or more one of a wide range of obscure, rare, fibro-osseous lesions.
expensive drugs.
If there is a soft swelling on the gum, between two
teeth, or on the palate, and associated with chronic
infection, it is probably a PYOGENIC GRANULOMA.
31.9 Other dental & oral problems It is related to HIV disease, when it is often very vascular,
and may simulate a malignancy. Pyogenic granulomas are
common inside the mouth, and can also occur on the
The range of possible oral pathology is large; some of the tongue. If a patient is pregnant, leave the lesion and do
more important lesions are tumours. not try to excise it. Otherwise, excise it using infiltration
with adrenaline, and provided the infection is eradicated, it
MOUTH ULCERS will not return. Send any material you obtain for histology.
Make sure there is no underlying osteomyelitis (7.14).
If a patient has a recent, shallow, painful ulcer in the
mouth, it is likely to be an APTHOUS ULCER, or a If a child has a loose tooth with a swelling of the jaw,
recurrent HERPETIC ULCER (both very common). suspect that this is BURKITT'S LYMPHOMA (17.6) if it
The distinction between them is not important, since there is common in your area. Typically, the teeth are displaced.
is little you can do about either of them, and they will
resolve spontaneously. Advise mouth washes, and try folic LUMPS ARISING ELSEWHERE IN THE MOUTH
acid 5mg weekly, both as prevention and treatment. If there is a pedunculated swelling on the cheek
These ulcers are common in people taking the (or tongue), it is probably a FIBRO-EPITHELIAL
anti-malarial prophylaxis, proguanil. POLYP or a fibroma (31-13A). This is commonly
associated with repetitive irritating trauma, particularly
If there is a irregular ulcer of the gums, cheek or the that from an ill-fitting denture. Excise it and it will not
floor of the mouth, suspect that this is a CARCINOMA recur, provided the trauma is removed.
(uncommon), especially if it has a raised edge. Send tissue
for histology and arrange deep radiotherapy, or radical If there is a papilloma (wart) inside the mouth (31-13E)
surgery. it may be viral (verruca vulgaris or condylomata
associated with HIV disease), and there may be similar
Mucocutaneous leishmaniasis (34.7) is endemic in lesions on the hands and genitalia. If necessary, excise the
Bolivia, Brazil and Peru, and is transmitted by the sandfly oral lesion.
from other infected humans, dogs or rodents.
Itchy papules arise at the mucocutaneous junction of the If there is an expanding tumour of the mandible,
lips and nose, and ulcerate. With spread by lymph and with a radiograph showing large loculi and a honeycomb
blood, tissue destruction may become extensive, requiring appearance, suspect that this is an AMELOBLASTOMA
plastic reconstruction. (31.6).
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TONGUE-TIE (Ankyloglossia)
In neonates the lingual fraenum seems short and attached
to the tip of the tongue; appearances change in the next
1-2yrs and the tongue is actually perfectly mobile
protruding easily over the lower incisor teeth.
Fig. 31-17 CYSTS IN THE MOUTH.
A, ranula. B, sublingual dermoid cyst. C, mucocele of the lip. D, Poor speech is almost invariably due to hearing deficiency
secondarily infected nasopalatine cyst. or brain damage. True tongue-tie is very rare and causes
Adapted from drawings by Frank Netter, with the kind permission of the tongue to indent deeply in the midline on protrusion,
CIBA-GEIGY Ltd, Basle Switzerland
and requires a Z-plasty correction: this is a procedure that
requires proper GA, mouth packing, light and good
CYSTS OF THE MOUTH
equipment!
If there is a bluish, translucent, raised vesicle 0·2-2cm
diameter, it is probably a MUCOUS RETENTION CYST
THE MOUTH IN FACIAL PALSY
(31-17C). These cysts may arise from the mucous glands
anywhere inside the mouth, including the tongue,
If a patient cannot close the mouth because the facial
but are most common inside the lower lips. They may arise
nerve is paralysed, because of leprosy, a stroke, or parotid
in a few days, persist for months, periodically discharge
disease or surgery, the gums may dry and he may dribble
their contents, and then recur. Try to excise the lesion;
food and drink and become socially outcast. His teeth will
if you merely incise it, it is likely to recur.
also be more susceptible to caries.
If a child has a circumscribed, fluctuant, often bluish
One solution is a plantaris or fascia lata tendon transfer to
swelling of the alveolar ridge, over the site of an
support the lip, by slinging it from the zygoma or
erupting tooth, it is probably an eruption cyst.
temporalis fascia on both sides. Although this is a static
This is common, usually symptomless, and bursts
sling, it will keep the mouth closed, improve its
spontaneously to allow the tooth underneath to erupt.
appearance, and stop the dribbling. If there is no
If it does not, under ketamine, grasp it with toothed
lagophthalmos (lid-lag: 28.17) try to arrange a temporal
forceps, and excise it. A little dark blood will escape,
muscle transfer to reactivate the mouth.
and the underlying tooth will erupt within the next few
months.
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INDICATIONS.
(1);Joints in which active and passive movements or
traction have failed, or are not possible because the
deformity is too great.
(2) Hip contractures of <45º
(3) Knee contractures of <30º.
(4) Ankle contractures of <20º.
HIP.
Flex the opposite hip to eliminate a lumbar lordosis Fig. 32-2 MANIPULATING CONTRACTURES.
When you manipulate a joint under anaesthesia, always exert
(bent back). Press the upper ⅓ of the thigh backwards, to pressure close to a joint, or you may break a bone or displace the
bring the leg down on the table in slight abduction. epiphyses. A, when you manipulate the hip, flex the opposite hip,
This will also stretch the adductors, which will probably be and grasp the thigh. Push it down in extension and slight abduction.
tight. B, do not push down on the knee! C, exert pressure near the knee, and
not as in D! For an equinus deformity of the ankle (E), grasp it near
Laying the patient prone is a very useful nursing procedure the ankle, and dorsiflex it. (F, and G), not as in H! For a varus
for preventing and treating flexion contractures of the hip. deformity of the foot (I), evert it and dorsiflex it for at least 5mins.
If tolerated, use the prone position with a pillow under the (J). Manipulate an adduction deformity of the forefoot firmly and
lower thigh. This uncomfortable position is more gently over a wedge (K,L). Kindly contributed by Ronald Huckstep.
acceptable if the head faces towards the middle of the
ward, rather than the wall. CASTING FOR CONTRACTURES.
Apply a well-padded plaster cast, close to but not at the
KNEE. extreme range of movement of the joint. If you do,
Hold the knee close to the joint; otherwise you may break pressure on its cartilage may cause necrosis and
the tibia or the femur, displace the epiphyses, or sublux the osteoarthritis later. So let it relax a little, before you apply
tibia on the femur. the cast. A few weeks later, if necessary, manipulate the
CAUTION! Do not try to release contractures of the joint again, and replace the cast with another one, in which
knee too forcibly; you may injure the popliteal nerve, the joint is nearer to the limit of its normal range of
or damage the joint. movement.
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Suppress these reactions with prednisolone 40mg od Teach the exercises for the patient to do himself at home:
(or 60mg od in severe cases) for 2wks, or as long as there but if you plan reconstructive surgery, he may need more
is activity. Then as soon as the acute stage has subsided, intensive activity.
reduce the dosage by 5mg monthly, even if there is no sign
of nerve-function returning. The total duration of treatment
takes 6 months but may be more in BL patients.
32.3 Tuberculous bones and joints
Type II 'erythema nodosum leprosum' (ENL) reactions
occur in LL and BL patients. During 2-3hrs a crop of When TB involves the skeleton, it is the involvement of
painful erythematous papules develop, typically on the the joints that matters most: the spine, hips, knees, feet,
extensor surfaces of the limbs, but in severe attacks over elbows, wrists, and shoulders, in this order of frequency,
much of the body except the scalp. The skin may be and occasionally other joints also. Bacilli reach the joints
thickened, especially over the backs of the hands and on usually from some focus elsewhere. So look for lesions in
the legs, where contractures may form. There is a high the lungs, and for signs of TB in other parts of the body,
fever, malaise, headache, and anorexia with uveitis, especially lymph nodes (17.4).
swollen joints and testicles. Meanwhile, the nerves are
painful, and become steadily paralysed. Unfortunately, The patient is usually a young adult, or a child >6yrs,
they are less likely to recover than after a Type I reaction. although children as young as 1yr and older people can
ENL frequently recurs, even up to 7yrs. Suppress a severe also be infected, especially with HIV disease. One or more
reaction with prednisolone 60mg od, reduced rapidly of the joints has become progressively painful and stiff
within 2-4wks. Treat mild reactions with aspirin. during the previous few weeks. If the leg is involved, the
Use thalidomide 10mg/kg for recurrent reactions, reducing first complaint is a limp. The infected joint fills with fluid,
to 100mg od (but remember this drug is teratogenic!). and the muscles round it waste. There is usually only mild
Use clofazimine 300mg od for maintenance once the acute to moderate pain, except on forced movement.
phase has settled, reducing by 100mg every 2 months. Tuberculous arthritis is 'cold', which means that the skin
over the infected joint is the same temperature as the
Continue antileprotic drugs in both types of reaction. normal skin. (The joint is not 'hot', as it is in septic
The nerves may start to recover within 3wks, or they may arthritis). Sometimes there are systemic symptoms, such as
not improve for 3 months, or a year, or longer. mild fever, night sweats, or loss of weight or appetite.
Meanwhile, manage them as described below. Pain and fever may be quite marked. There may also be
signs of tuberculosis in the chest, or a family history of it.
PHYSIOTHERAPY IN LEPROSY
A limb which is paralysed by leprosy needs physiotherapy In a synovial joint (or diathrosis, where the fibrous joint
to strengthen its muscles and prevent contractures, capsule is continuous with the periosteum), the disease
especially if paralysis is recent, actively progressing, starts within the synovium and spreads slowly over the
or possibly only temporary, as in either type of leprosy cartilage; it then extends through the cartilage into the
reaction. As long as there are signs of weakness, someone, underlying bone, which decalcifies. In the spine, disease
or preferably the patient himself, must put all the paralysed starts in a disc. If you start treatment before the cartilage is
joints through their full range of movement each day, destroyed, the joint will recover fully, or nearly so. If you
even if they cannot be actively maintained in their start later, the articular cartilage will be destroyed, so that
positions of function. even if the disease is arrested, the joint will develop a
fibrous ankylosis (except in the spine, when ankylosis is
Protect the paralysed muscles by splinting the joints in always bony, 32.1). Sometimes, cold abscesses form,
their positions of function during sleep, and never allow a become secondarily infected, and may track for a
muscle to be overstretched. Make sure active exercises considerable distance to produce a sinus far from the
continue in order to retain mobility in all the joints. original lesion. If a tuberculous joint is secondarily
Even if all the intrinsic muscles of the hand are paralysed, infected, the ankylosis that results is always bony.
it will still be more functional if its joints are kept mobile The diseased limb develops a flexion contracture, and its
with daily exercises. Start this protection the first day you joints may subluxate or dislocate, especially the hip, knee,
diagnose a reaction. shoulder, or elbow.
You can treat tuberculous joints successfully and cheaply;
When there are signs of recovery, as shown by pain if you make the diagnose in the first few weeks.
decreasing, nerves becoming softer, and sensation and But even if treatment starts late, when joint surfaces have
motor function returning, the patient must increase the already been destroyed, you can expect a fairly good
range of active movement and strengthen the muscles with result, if you can prevent deformities and contractures.
carefully graded active exercises; and practise any skilled
coordinated movements that he will need later when he There are no certain diagnostic signs, so the secret is
returns to normal life. Start exercises as soon as the acute always to be suspicious. Whenever you see any chronic
symptoms of neuritis have subsided. Begin by doing each bone or joint disease, ask yourself whether this could be
exercise 5 times, increasing to a maximum of 30 times, TB. Taking an aspirate or biopsy of a node or the
repeated 3-5 times daily. synovium will confirm the diagnosis in about 50% of
cases.
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If you cannot send tissue for biopsy, you will probably Both tuberculous and septic arthritis eventually involve
have to rely on the characteristic radiographic changes. pelvic bone. If it is already involved when you first see the
Even so, your error rate is likely to be small. Try to: patient, this suggests tuberculosis.
(1) Use the drugs needed in adequate doses for an adequate
period: much the most important. Suggesting trauma: a history of injury, a haemarthrosis:
(2) Rest the joint; if the arm is involved, you can usually the radiograph may be normal, or showing widening of the
treat it in a sling, but if there is tuberculosis affecting the joint.
leg, you will need to provide in-patient care.
(3) If there is disease of the hip or knee, apply traction. Suggesting other forms of arthritis: a history of
This will overcome spasm, prevent the softened bone from dysentery, brucellosis, or gonorrhoea.
collapsing, and keep the inflamed joint surfaces apart.
You may have to refer to experts to remove or drain a Suggesting HIV-disease or rheumatoid arthritis:
tuberculous lesion, or promote ankylosis. presenting in a single joint; looks like tuberculosis, but
tests are often non-specific. Other joints may flare up later.
TUBERCULOUS ARTHRITIS If possible, take a biospy, aspirate fluid for a PCR test.
Remember that TB is commoner than mono-articular
RADIOGRAPHS. Look for: rheumatic disease in most parts of the world.
(1);Generalized rarefaction: the whole joint is less dense
than it should be. The earliest stage is a lack of definition; Suggesting Perthes disease (32.14), or a slipped
the joint is not as sharp as it should be. epiphysis: the patient is a child and the hip is involved.
(2);Localized areas of erosion or decreased density, Look for unavoidable passive external rotation of the hip
caused by caseous lesions in the bone. when the patient tries to flex it (Drehmann’s sign: 7-17)
(3) Abnormally narrow or wide joint space.
(4) Irregular joint space, in late cases. Suggesting osteoarthrosis: in the old, or with a previous
CAUTION! Joint destruction in TB is always more injury; look for osteophytes, areas of increased density
severe than the radiographic appearances suggest. (eburnation), and sometimes associated cysts (especially in
Remember to X-ray the lungs. the hip).
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Look in the throat for a retropharyngeal abscess (6.8). Suggesting Burkitt's lymphoma: a child in endemic
RADIOGRAPHS are critical (32-5). Remember to get areas where this is the commonest cause of paraplegia
chest films too. Look for: (17.6).
(1) Narrowing or obliteration of a joint space, involving at
least 2 vertebral bodies and the disc between them Suggesting metastatic disease: involvement of the bodies
(this is the typical late picture). Sometimes several of the vertebrae without involvement of their discs.
vertebrae disappear into the space normally occupied by The serum alkaline phosphatase is raised. If the primary is
only 1 or 2. So count the vertebral spines, because these in the prostate, the acid phosphatase and PSA will be
may be all that is left when the vertebral bodies have been raised also.
destroyed.
(2),Look for forward collapse of the spine. Suggesting a senile kyphosis: an old woman with
(3),You may also see the shadow produced by a osteoporosis of all, or most, of the spine, and normal discs,
paravertebral abscess in the thoracic region (this strongly which bulge into the softened vertebrae. The kyphus is
suggests tuberculosis, but it can be produced by gradual. Treatment is difficult (32.6).
staphylococcal and other forms of bacterial osteitis),
and calcification in the psoas sheath, showing that a psoas
abscess is forming. Evidence of a paravertebral abscess TREATMENT.
increases the probability of tuberculosis being the cause, Start TB treatment (5.7). Screen for HIV disease.
but is not necessary for diagnosing it. If walking is possible, encourage this. Warn that treatment
(4),Osteophytes and bridging (rare). If you do see must continue, and that it will take some months to have
bridging, it is more likely to be due to late staphylococcal much effect. During this time, the kyphoscoliosis getting
infection. worse, before it stabilizes. Do all you can to trace
defaulters by keeping good records.
SPECIAL TESTS.
ESR may be very high. A falling ESR is a useful DIFFICULTIES WITH A TUBERCULOUS SPINE.
indication of response to treatment, but is less important If the cervical spine is involved, treat with an orthopaedic
than an improvement in the clinical condition, as indicated collar, or failing this, a plaster corset and TB treatment.
by decreasing pain and tenderness. Aspirate accessible The spinal canal is larger in the neck than in the thoracic
abscesses with a 14G needle and look for AAFB’s. region, so the spinal cord is less likely to be compressed.
Suggesting poliomyelitis: weak, wasted, flaccid legs. If a patient with spinal tuberculosis complains of
If polio involves the spine, it is almost sure to involve the clumsiness, weakness, or incoordination of the legs,
legs too. You will see scoliosis rather than kyphosis. paraplegia is imminent. Later, the voluntary power of the
legs is reduced, their muscle tone is increased, and the
Suggesting idiopathic scoliosis: the curve is smooth, plantar responses become extensor. Later still, there are
with no gibbus, or muscle-wasting. Apart from the curved flexor spasms, and finally contractures.
shape of the spine, there are no other signs;
the radiographs are normal, and no vertebrae are Paraplegia is the major complication of spinal tuberculosis.
destroyed. The disease starts in childhood. In early cases it is due to an inflammatory oedema
round a paraspinal abscess, and later to compression.
Suggesting a congenital lateral hemivertebra causing Paraplegia may be the presenting symptom, and is usually
scoliosis or dorsal hemivertebra causing kyphosis treatable. In most cases it is motor only (unless it comes on
(usually mild): half of one of the vertebrae is missing. very rapidly), because the abscess presses on the anterior
On a radiograph this is almost triangular, its edges are columns (grey matter, or motor neurones) of the cord
smooth and well formed, and there are no signs of disc rather than on the posterior columns (white matter, or
destruction in the vertebra above or below. This kind of sensory neurones). Although tuberculous osteitis affects
deformity does not progress with age, and needs no the various regions of the spine in the following order of
treatment. decreasing frequency: low thoracic, lumbar, upper
thoracic, and cervical, you will see tuberculous paraplegia
Suggesting kyphoscoliosis due to lung disease: most commonly in the thoracic region, sometimes in the
a previous history of empyema, other causes of lung cervical region, and seldom in the lumbar region. This is
fibrosis, or pneumonectomy. When the lung collapses, a because the spinal canal is wide there, and the cauda
collapsed thoracic cage may result. The spine itself needs equina, a loose bundle of nerves & nerve roots from L2-S5
no treatment. and nerves is less readily affected than the solid cord by
TB.
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Clear the attached rib of muscle laterally to 8cm from the DIFFICULTIES WITH COSTOTRANSVERSECTOMY
midline and then cut the periosteum of a rib longitudinally If you damage the pleura, insert an intercostal drain
on its back, and strip it from the bone with a curved (9.1).
periosteal elevator all round, keeping close to the bone.
This will help to separate it from the tissue covering the
underlying pleura, and protect the intercostal vessels and
nerve. 32.6 Back pain & lumbar disc lesions
Then cut the rib with rib cutters (or carefully with bone Backache is a very common symptom. Your task,
cutters), at the lateral extremity of the incision. as often, is to sort out those patients who need specific and
Avoid damaging the pleura. sometimes urgent treatment, from those whom you can
Then grasp the outer end of the rib, and by a twisting only help symptomatically.
movement remove it with the severed part of the Most common causes are:
transverse process at its base. (1) vertebral disc prolapsed
(2) osteoarthritis and senile osteoporosis in the very old
Now look for the paraspinal abscess. Insert your index
finger along the side of the vertebral bodies, and separate Causes not to miss are, particularly in children:
the tissues gently. You may need some sharp dissection (3) pyomyositis (7.1),
with scissors; if so keep very close to the bone. (4) osteomyelitis (7.15),
This will lead you to the abscess, and not the pleura! (5) septic or tuberculous arthritis (7.16, 32.4).
Tuberculous pus is watery, with debris in it. Pus from
osteitis is yellow and creamy. Drain and culture what you Other causes include:
find. Pass your finger round the anterior surface of each (6) malignant deposits in the spine,
vertebra, up and down to ensure thorough drainage. (7) back injuries including ligamentous sprains,
(8) spondylosis, spondylolysthesis and ankylosing
N.B. Do not perform a laminectomy (i.e. dividing the spondylitis.
posterior arch of the vertebra) as this may cause the spine
to subluxate. Do not forget:
(9) pancreatitis (15.11),
If you find no pus, check the radiograph, you may have (10) pyelonephritis,
chosen the wrong level. If so, re-examine the radiographs (11) retroperitoneal abscesses (6.15),
and remove a further transverse process and its related rib (12) a leaking aortic aneurysm (35.8)!
and feel again.
Lumbar disc lesions are due to the protrusion of the
If you still find no abscess, take some tissue from the disc nucleus pulposus of an intervertebral disc through a
space for histology. The best place to biopsy is felt more weakened area in its annulus fibrosus. This is the ring of
easily than seen. Use cervical biopsy forceps, or dissecting firm fibrous tissue that holds the softer nucleus pulposus in
forceps and a #15 blade mounted on a long handle. place. Prolapsed tissue from the nucleus pulposus may
press on a nerve root, and cause pain down the leg
CLOSURE. Preferably use suction drainage (4.9). (32-7B,E). Almost all lumbar disc lesions occur in the
There is no need for an intercostal drain, unless you spaces L4/5 or L5/S1. Pressure on the S1 root causes pain
damage the pleura. Approximate the muscles to the spine down the back of the thigh, calf, and outer side of the foot
by sewing the spinal muscles to the supraspinous ligament (32-7D). Pressure on the L5 root causes pain on the lateral
with absorbable sutures. Close the skin with continuous aspect of the thigh and leg, and the dorsum of the foot
2/0 monofilament. Apply a dressing. (32-7C).
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A protrusion from the L5/S1 disc usually presses on the S1 In lumbar disc lesions, the lumbar spine is flattened,
root (not on L5), but a protrusion from the L4/5 disc may with loss of its normal lumbar lordosis, and slight
press on the S1, or on the L5 root. Occasionally, when the scoliosis. There may be tenderness over the interspinous
protrusion is central, other roots are involved, and these ligaments, at the site of the lesion, or on gently tapping the
may cause urinary problems. spinous processes. Movement of the lumbar spine is
usually severely restricted. Forward flexion is always
Disc protrusions are more likely to occur in a back which restricted, and is accompanied by spasm. Lateral flexion
has been weakened by a sedentary occupation, and may may be free, in one or both directions.
follow sudden flexion of the spine, or bumping in a Lay the patient flat and raise the leg by the ankle.
sedentary position, as with truck drivers and their Straight leg raising is limited and flexing the ankle makes
passengers in the back on bad roads. it worse. The ankle jerk (S1) may be diminished or absent.
The patient is usually a younger to middle aged adult, There may be also diminished sensation in the relevant
who presents with sudden severe pain in the front of dermatomes.
the thigh, the back of the thigh (sciatic pain, You can usually diagnose a disc lesion clinically.
which is present in most patients), the calf, or the foot. Most disc lesions are benign and self-limiting, and can be
Movement, coughing, or sneezing all make the pain worse. managed non-operatively, although they often recur.
The dorsum of the foot may be numb, and its dorsiflexors
weak, occasionally on both sides. PLAIN RADIOGRAPHS rarely show confirmatory signs.
Look for mild scoliosis, loss of the normal lumbar lordosis
and narrowing of the disc space. Radiographs must be well
centred to show this. If you take films obliquely, any disc
space will look narrow. Perform a MYELOGRAM (38.1h)
if sciatica is getting worse despite treatment, or if there is
an acute cord compression, or deteriorating paraparesis.
Obtain a chest radiograph especially in a smoker (looking
for cancer) or if TB is likely.
DIFFERENTIAL DIAGNOSES
Suggesting metastatic disease: an older patient with
persistent spinal pain, both when active and at rest.
The radiographs of the spine may be normal initially.
Typically, there is a patchy osteoporosis of the bodies,
and/or the arches, of the vertebrae (some metastases are
sclerotic, especially those from the prostate). There may be
a pathological fracture, especially of a vertebral body.
The discs are spared. Look for the primary in the prostate
(27.22), the breast (24.4), the bronchus (29.19), the thyroid
(25.6), and the kidney (27.35), and for signs of multiple
myeloma (32.20).
Suggesting an acute infective cause: pyomyositis (7.1),
or osteitis of the spine (7.15): an acute onset with fever
in a child or young adult, who is obviously very ill.
Suggesting tuberculosis (32.4): a slow onset with loss of
weight, malaise, mild fever, and a gibbus.
CAUTION!
Fig. 32-7 BACK PAIN.
A, normal disc. B, ruptured annular ligament, with the nucleus (1);Young children do not have disc lesions, so assume
pulposus protruding. C, L5 lesion causes loss of sensation on the that all back pain in a young child is serious, until you
dorsomedial aspect of the foot, and weakness of the dorsiflexors of have proved it is not.
the ankle, with sparing of the ankle jerk. D, S1 lesion causes loss of (2) Back pain and fever are a serious combination.
sensation on the lateral border of the foot, weakness of plantar
flexors, and a diminished ankle jerk. E, prolapsed disc pressing on (3) Think of TB.
the large S1 nerve root; F, central protrusion risks involving S2, S3,
S4 and S5 which control bladder function, G, if the disc protrudes TREATMENT.
medial to the nerve root, the patient tilts his spine towards the Insist on bed rest in the most comfortable position, which
painful side to relive pressure on the nerve root, whilst H, if the disc
protrudes lateral to the nerve (at a lower level) , he tilts away from is usually with the hips and knees flexed. Do not put
the painful side. After Apley AG, Solomon L. Apley’s System of pillows under the knees; they will immobilize the legs and
Orthopaedics and Fractures. Butterworth 6th ed 1982 Figs 18.20,21,23. promote deep vein thrombosis. Put boards under the
mattress. Provide analgesia (if necessary, pethidine or
EXAMINATION. (32-8). morphine with NSAIDs for the first few days), and do not
Remember to examine, for metastases, the prostate rectally let him get up, even to go to the toilet. Make sure you turn
in a man, and the breasts in a woman. a patient 2hrly if he cannot do so himself: do this with
Measure the length of both legs: in many cases they are 3 assistants, rolling him keeping the spine from bending.
different, and a simple shoe raise will solve the problem. There is no evidence that steroids help in the long term.
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Many patients improve without traction. If not, tie a band CONTRAINDICATIONS FOR SURGERY
round the pelvis, and apply a total of 7-10kg to both sides (1);Be careful if the patient’s neurological deficit does not
for a maximum of 3-5days. Raise the foot of the bed to correspond with the radiological findings; operation then,
apply counter traction. Alternatively, apply 4-5kg of at the wrong site, obviously will fail to cure the problem!
traction to each leg with adhesive strapping. (2),Make sure the neurological deficit is of spinal,
Start active and passive movements of the legs, as soon as not peripheral, origin, e.g. arising from a neuropathy
the acute pain is over. When the pain is sufficiently (e.g. diabetic or HIV), or nerve injury (for example,
improved, start back extension exercises. If symptoms from IM injections).
improve, continue bed rest for 2-3wks. Then allow
mobilization to the toilet, keeping the back straight. DIFFICULTIES WITH BACK PAIN
Do not allow bending down: insist on crouching with the If an older patient has pain on sitting or standing,
hips and knees flexed, keeping the back straight, to pick or following manual activities, he is probably suffering
something from the ground. from OSTEOARTHRITIS. Exclude other diseases.
Keep the spine as mobile as possible with exercises.
INDICATIONS FOR SURGERY. Encourage weight loss in obesity.
(1);Neurological deficit: if there is perineal numbness,
loss of an anal reflex or incontinence of urine or faeces, If an old patient, especially female, has a marked
surgery is urgent, otherwise incontinence may become kyphosis, think of SENILE OSTEOPOROSIS, with a
permanent. Sensory loss in the S1, L5 or L4 regions generalized loss of matrix and calcium, especially from the
usually means surgery is needed sooner rather than later. bodies of the vertebrae. The discs expand and compress
(2);Significant weakness of the dorsiflexors (L5) the weak vertebral bodies. Painful pathological fractures
or plantarflexors (S1). are common, and there may be root pain.
(3) Failure of the pain to improve, despite 3-4wks in bed. Treat symptomatically with analgesics, and encourage
mobility, if necessary with the aid of a stick.
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Keep the major joints mobile, and if they do become fixed, Polio can weaken both groups mildly or severely,
try to ensure that this happens in the position of function equally or unequally. When, as is usual, the muscle groups
(7-16). are involved unequally, it is commonly the extensors
which are most affected.
When this happens, the stronger flexors pull the limb into
a flexion contracture. If all the muscles of the limb are
weak, there is a flail limb.
In a child, growth will cause further deformity. All this can
happen in varying degrees to the hips, the knees, or the
ankles, on one or both sides, to cause many patterns of
paralysis. The arms are less commonly affected, and are
usually less of a disability.
Make sure you have ruled out other causes of paralysis,
especially HIV disease.
Remember similar deformities may result from cerebral
palsy. If you can correct physical deformities, mental
deficiency will be much easier to handle.
Many children of the world have paid a high price for THE HIP IN CHRONIC POLIO
acquiring their natural immunity. Poliomyelitis is still
found in Pakistan, Afghanistan, Madagascar, Myanmar If an adult or child has an isolated flexion contracture
and Central and West Africa, as well as war zones of the hip of <30º due to weakness of its extensors and
(Ukraine, Syria & Iraq). In certain countries, there is an adductors, he is probably walking adequately, and needs
active effort to stop immunization, so this disease may no treatment, provided there is no other serious
soon acquire a re-birth. Some cases of vaccine-derived contractures. The stability of the hip may even be
polio have occurred in areas of inadequate vaccination and improved and shortening compensated by a small
low immunity. The strategy to prevent this is to launch a adduction and flexion contracture.
high-quality high-coverage immunization.
The polio virus destroys the anterior horn cells of the If an adult or child has an isolated flexion contracture
spinal cord. This causes a flaccid lower motor paralysis, of >30º, consider releasing it.
without impairing sensation.
The flexor and extensor muscles of a normal limb are If there is a flail hip due to paralysis of all its muscles,
arranged so that they oppose one another's action. provide a pair of crutches.
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Fig. 32-10 CHRONIC POLIO. A, A patient with a weak hip or knee If there is a valgus deformity of the knee, usually
may be able to walk by putting his hand on the thigh, or associated with a flexion contracture, a surgical release
B, by locking the hip in hyperextension, using the extensors of the
hip. C, if the whole leg is weak, a stick will be necessary. D, if there is and a calliper are necessary. If necessary, bend the calliper,
severe contractures of both knees, crawling on the ground may be the or fit it with a valgus knee strap, to prevent it rubbing
only way to get around. E, an adult 'crawler' seated. Note the large against the knee.
callosities on the knees. Kindly contributed by Ronald Huckstep.
If a small child has a severe valgus deformity of the
If there is a hip dislocation or subluxation in a flail hip, knee, an osteotomy, or stapling of the medial epiphysis,
reduce the dislocation, and apply an abduction plaster by an expert, is necessary.
spica. Provide crutches. Occasionally, an osteotomy,
an arthrodesis, or a psoas transfer is necessary. If there is lateral rotation of the tibia on the femur,
Reducing a dislocated hip can be difficult. or lateral subluxation of the knee, there is usually also a
It readily redislocates because there are no functioning flexion contracture of the knee. Try to correct rotation and
muscles left around the hip to hold it in place. subluxation at the same time as the flexion contracture.
If the dislocation is recurrent, leave it alone. More often, a late deformity is structural, and cannot be
corrected by simple tenotomies. If rotation and subluxation
are the only deformities, they are usually asymptomatic,
and do not require specific treatment.
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If there is a calcaneus deformity of the ankle, (3),Appliances of an intermediate type are more durable.
due to weakness of the calf muscles, a lace-up boot may be They are cheaper than appliances of type (4),
all that is necessary. Otherwise, fit a below-knee calliper and are technologically appropriate. An example is a
with a front stop. modified Bata shoe with a metal tube to support the end of
the iron bar (32-13B). If these shoes have an open toe, they
If there is a valgus deformity of the ankle, will fit feet of various sizes, but are less durable in wet
usually associated with some degree of equinus, correcting weather. The leprosy shoes (32-22,23) are of this kind.
the equinus deformity and fitting a calliper will probably (4),The expensive high-technology appliances that are
be enough. Otherwise a transfer of the peroneal tendons, standard in the industrial world. These need imported
and perhaps a triple arthrodesis will be necessary (32-26F). materials, particularly duralumin and special plastics,
and can only be made and repaired by a skilled technician.
If there is a varus deformity of the ankle, Unfortunately, many prosthetists consider it a matter of
due to weakness of the evertors of the foot fit him with a professional pride to make only the most sophisticated
below-knee calliper if the deformity is mild. Otherwise a appliances of this type, which patients cannot afford.
soft tissue correction, or a triple arthrodesis will be Resist their efforts, and encourage them to make
necessary (32-26F). appropriate appliances in sufficient quantity.
If there is an adduction deformity of the forefoot, If you cannot get ready-made appliances from an
try several manipulations (32.1). Surgical correction will orthopaedic service, ask your hospital workshop to make
probably be necessary. those of types (2) or (3). All large or medium-sized
hospitals, doing much surgery, need a workshop making a
If there is a cavus foot (32-20A), a tenotomy, tendon wide range of appliances of level (3). You will need
transfer, or arthrodesis of the toes is necessary. above- and below-knee callipers, fitted when necessary
with backstops or frontstops (32-13A). The callipers differ
N.B. Apparent shortening is due to tilting of the pelvis, only in length, in the diameter of the ring, and in the
as the result of an adduction or abduction deformity of the presence of a knee piece in an above-knee calliper.
hip. True shortening is a real shortening of the leg, Calipers of types (2) and (3) have irons each side of the
and in polio is due to the failure of a paralysed leg to grow. leg. Although the single outside or inside irons of the
If necessary, correct an abduction contracture of the hip, callipers of type (4) look more elegant, they are weaker,
a flexion contracture of the knee, or an equinus contracture they are more difficult to make and adjust, and they are
of the ankle. If the shortening makes walking difficult usually less effective than double ones.
(usually >4cm), raise the short leg with a clog or with
boots. If necessary, fit callipers. Use callipers to prevent deformities in a weak limb, and to
straighten and support a child's leg after you have
DIFFICULTIES WITH CHRONIC POLIO corrected the contracture. There are few indications for
If the femur or tibia fractures, fit a cast, fitting callipers on an uncorrected contracture. Fit them as
and use the opportunity to correct any deformity, soon as walking starts, and replace them with a larger size
and maintain walking. The knee and ankle are unlikely to with increasing growth. Encourage all children, who have
be functional, so stiffness will not be a problem. muscle weaknesses which might lead to deformities,
An internal fixation is indicated to maintain alignment. to wear callipers until they have stopped growing, even if
they can walk without them. The indications for fitting an
APPLIANCES FOR POLIO
adult with a crutch, or a calliper, are the same as in a child,
When you have released the contracture, the muscles of except the deformities are static.
the leg will still be weak, so you will probably have to
provide a brace, or a crutch, or both. A weak hip needs
crutches, a weak knee needs a long calliper (32-13A),
and a weak ankle needs a short one. If you cannot provide
callipers, do not try to release the contractures!
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TENOTOMY
INDICATIONS.
(1) An isolated hip contracture of >30º at any age.
(2) A child with an isolated flexion contracture of the knee
of >30º.
(3);An adult with an isolated flexion contracture of the
knee of <90º.
(4);Combined hip and knee contractures of >30º,
provided there are no contraindications. If you have many
patients, start by operating on the younger ones with lesser
deformities first.
Fig. 32-14 ILIOTIBIAL BAND TENOTOMY.
A, position of the incisions. B, structures to be cut.
CONTRAINDICATIONS to any release operation are: Kindly contributed by Ronald Huckstep.
(1);Weak arms. The patient will need crutches, so he must
have 2 arms, especially if both legs and the trunk are weak. 1st incision.
There are exceptions to this rule, and a really determined Make this on the outer side of the thigh, about 2cm above
adult, or child, sometimes manages surprisingly well with the knee. You can usually feel the tensor fascia lata as a
limited weakness in one or both arms, provided the trunk tight band. Push the knife horizontally into the outer side
is strong. of the thigh, just behind the tight band, until it just touches
(2);A patient with mild contractures, who is walking the lateral side of the femur.
reasonably well, is probably best left as he is. Rotate its blade, so that its cutting edge is upwards; then
This includes: cut all the subcutaneous structures anterior to the blade,
(a) a contracture of the hip alone of ≤30º, especially if it and lateral to the femur. Provided you make the incision in
also has a mild abduction deformity, which may increase the right place, and only cut anteriorly, you will not cut
its stability and compensate for shortening. anything important. Do not cut posteriorly, or you may cut
(b) an isolated knee contracture in a child: treat with the popliteal artery, or the lateral popliteal nerve.
manipulations under GA every 2wks.
(3);An adult who is earning his living as a 'crawler', 2nd & 3rd incisions.
and is happy to go on doing so. Make these ⅓ and ⅔ of the way down the outer side of the
(4) Do not operate on any patient unless you can provide thigh. Feel for the tensor fascia lata, and push the knife in
him with callipers (32-13). along its posterior border down to the bone, exactly as for
CAUTION! Scar tissue is not stable for at least the first incision. Then rotate the knife 90º and cut
6months, so when you correct contractures, you must find anteriorly and laterally to the outer side of the shaft of the
some way of maintaining the position of the limb for at femur.
least 6months, or longer, if there is still muscle imbalance, If you cannot feel the tensor fascia lata, insert the knife
or much scar tissue. where you think it should be and cut exactly the same way.
There are other tight structures to be cut, including the
ILIOTIBIAL BAND TENOTOMY (GRADE 1.3) vastus lateralis.
Use a narrow tenotomy knife, or an old cataract knife, 4th incision is the one which releases the hip.
or a #11 scalpel blade altered (32-17), so that only its tip is Make it 2cm below the anterior superior iliac spine.
sharp. Operate under full sterile precautions, and prepare CAUTION!
both legs, even if you are only going to operate on one of (1) Do not damage the femoral vessels and nerve. Do not
them. Squeeze all blood out of the incisions periodically push the knife further medially than a point 2 cm lateral to
during the operation, and at the end. The hip incision may the mid-inguinal point (where you can feel the artery).
bleed considerably. (2) Feel for the inguinal ligament, and take care not to
divide that.
Release the hip and knee before you release the ankle. Push the knife in subcutaneously, below the anterior
The structures you are going to divide must be tense, superior iliac spine, from a lateral to a medial direction,
as you divide them, so keep the hip in as much extension so that its flat surface is in the plane of the skin just caudal
and adduction as you can, while you cut. Feel the tight to the anterior superior iliac spine. Stop 2cm lateral to the
structures through the skin, to make sure that you have left mid-inguinal point. Then rotate it 90º, so that its edge faces
no tight bands undivided. backwards, and cut all the tight subcutaneous structures.
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If the contracture is severe, cut all tight structures lateral CAUTION! Be sure that it is the biceps tendon,
to the branches of the femoral nerve. Cut right down to the and only the biceps tendon. Be careful you have not caught
front of the trochanter of the femur. the lateral popliteal nerve with it: they both look very
When you have cut the tight structures anteriorly, similar. Look for muscle fibres being inserted into the
twist the knife so that it cuts laterally, and cut all the tight tendon before you cut it. Be sure the nerve has not stuck
structures on the anterolateral side of the hip. to the back of the tendon.
CAUTION! Put your finger into the wound, and feel for any other tight
(1) When the tip of the knife is deep, angle it caudally, structures which need cutting. You may need to cut the
so that its blade is parallel with the inguinal ligament, posterior part of the iliotibial band, and the lateral
and will not cut it. intermuscular septum. Sometimes, the anterior part of the
(2) Do not cut further back than the coronal plane of the deep fascia lata also needs cutting.
anterior part of the hip joint. Leave the abductors posterior Apply skin traction, or a well-padded cast.
to this, to give lateral stability to the hip.
(3) Keep the hip in as much adduction and extension CASTING AND MANIPULATION. If the contracture of
as you can, while you divide the tight structures. the knee is <45º, apply a well-padded cast with the knee
Feel them through the skin during the operation, just short of the full extension to which it is capable.
and do not leave any tight deforming bands behind. It must not be under any tension, or it will be painful.
If the contracture is >45º, apply a pulley support keeping
OPEN BICEPS FEMORIS TENOTOMY (GRADE 1.3) the knee elevated, with skin traction to the distal leg
(Russell traction).
INDICATIONS. This is only indicated if the knee
contracture is >30º but <90º. The method which follows is CAUTION!
a very limited open tenotomy suitable for a patient: NEVER put a knee into a cast under tension, or wedge a
(1) who needs a bit more extension, so that he can be put cast to correct a knee contracture, or its articular cartilage
into skin traction, may necrose, and early painful osteoarthritis may follow,
(2);whose biceps femoris tendon is tight, but not the in what was previously a painless mobile joint.
semitendinosus and semimembranosus tendons, which are Check the hip incision again (if you have released the hip
attached medially. Feel the tendons when the knee is at the same time), as soon as you have applied the cast,
extended to its limit. If all the tendons are tight and need and squeeze out any clot which has formed, under full
surgical release, get expert help. sterile precautions. Pad the incision and apply light
adhesive strapping.
Every 2wks, remove the cast, and manipulate the hip and
knee, until the knee is in at least 5º of hyperextension,
and there is <10º of flexion deformity ('fixed flexion')
in the hip. Manipulate it (32.1), and spend 5-10mins on
each joint. Be sure to flex the knee fully, and to rotate the
tibia medially and laterally, to maintain these very
important movements. Correct or avoid backward
subluxation of the knee. If necessary, correct the lateral
rotation of the tibia on the femur.
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BUCKLE KNEE EXTENSION DEVICE Fig. 32-17 CLOSED ACHILLES TENOTOMY. A, if you do not have
a tenotomy knife, make one by grinding away a #11 blade.
B, the 2 incisions: make only tiny incisions in the skin. Insert the
knife with its blade in the plane of the fibres, and then twist it before
you cut. Make the 1st cut from the medial side above the malleolus,
and the 2nd posteriorly cutting medially. C, put the foot into a cast in
gentle dorsiflexion. N.B. The fibres of the Achilles tendon twist from
medial to lateral as they descend. Kindly contributed by John Stewart.
METHOD.
Fig. 32-16 BUCKLE CORRECTION FOR KNEE FLEXION Do not use GA. Apply a below-knee cast, while the knee is
DEFORMITY. flexed to 90º, to allow you to achieve more dorsiflexion of
the ankle. You may not be able to get the foot into the
neutral position on the first occasion. When the cast is dry,
apply a walking heel, and allow mobilization.
32.9 Equinus deformity of the ankle Encourage progressive knee extension. Once the patient is
walking with the knee fully extended, repeat the procedure
and apply a further cast, until the foot will reach the
This is the most common deformity in a child, and is neutral position with the leg extended.
fortunately the easiest to correct. Provided there is no
severe valgus or varus deformity (32.1), you can correct a CLOSED ACHILLES TENOTOMY (GRADE 1.3)
milder equinus deformity with serial casts, each of which INDICATIONS.
will release the deformity a little more. If you are Where serial casting is inadequate, with also a minor varus
inexperienced, you will find serial casts very useful. or valgus deformity, provided it is not so severe that it will
prevent you fitting callipers.
If a child has a more severe deformity, he needs the
Achilles tendon lengthened. You can perform this by an CONTRA-INDICATIONS.
open or closed method. The closed operation is simpler, In a child, tenotomy is contraindicated if:
and there is less risk of infection, or keloid formation. (1),The equinus ankle is helping to compensate for a short
The advantage of the open method is that it is possible to leg, or to stabilize an unstable knee, and so enabling
divide the posterior capsule of the ankle joint, if this is satisfactorily walking.
necessary, as it may be in polio. (2) He will never walk because his arms are weak.
The risk in both methods is that you may cut the posterior (3),The deformity is minimal, and he is managing well
tibial nerve and vessels, and cause gangrene of the toes, with a shoe or boot, with or without a calliper.
but this should never happen, if you are careful. (4) The feet are infected; if so, delay the operation.
(5) There is a severe valgus or varus deformity which will
make fitting a calliper impossible.
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METHOD.
N.B. For club foot, use the method described in 32.10. DIFFICULTIES WITH CLOSED TENOTOMY.
Use a small tenotomy knife, or the improvised one If you have cut the whole Achilles tendon, do not be
(32-17). Use full sterile precautions, scrub up, alarmed. It will almost always heal satisfactorily in the
gown yourself, use gloves, and apply a tourniquet (3.4). lengthened position. Do not try to repair it at this stage.
1st incision: cut through the posterior ⅔ of the Achilles If the deformity recurs, it probably did so because the
tendon, above the level of the malleoli. Do this by pushing patient did not wear a calliper, or wore one without a
the knife into the tendon from the medial side, in the line backstop (32-13B). If he fails to wear one initially,
of its fibres, at the junction of the anterior third and the the deformity is sure to recur. He may be able to do
posterior two-thirds. Rotate the knife 90º, and then cut without a calliper 6-12months later. Follow up carefully,
posteriorly, until you feel the knife cutting very easily, so that you can decide about this.
which shows that you have now cut the posterior part of
the tendon. If you fracture the lower tibia because you have
2nd incision, push the knife into the tendon in the line of its manipulated it too vigorously, fit a cast.
fibres, at the junction of its lateral ⅓ and medial ⅔,
just above its insertion on the calcaneum. Then, rotate the OPEN ACHILLES TENOTOMY (GRADE 1.3)
knife through 90º, and cut medially.
INDICATIONS. Equinus contractures of the ankle,
CAUTION! in which there is a contracture of the posterior capsule of
(1),Use full sterile precautions, and drape with sterile the ankle joint that requires release. This is an alternative
towels. to the closed method, especially when that has not
(2),Use a gentle sawing motion, and do not break the achieved normal dorsiflexion.
blade.
(3),Do not cut the posterior tibial vessels and nerves, METHOD. Using GA, apply an exsanguinating tourniquet
which lie anteromedial to the Achilles tendon (32-18). to the thigh (3.4). Use the lateral position, with the leg to
(4),Do not try to divide the tight posterior capsule of the be operated on uppermost.
ankle joint in this method. This is not tightened in
poliomyelitis, unless there is an associated varus Make a longitudinal incision over the lower ⅓ of the leg,
deformity, which must be corrected at open operation. extending proximally from the attachment of the Achilles
To manipulate the ankle, flex it dorsally. Apply force as tendon to the calcaneus. Dissect out the Achilles tendon.
close to the joint as possible. Do not apply force to the You may see the small tendon of the plantaris (35-22I)
distal tibia; you can easily break it. In a young child with on its anteromedial side.
polio, you should be able to achieve 20º of dorsiflexion
(calcaneus); in an adult or older child you may get less. Make 2 incisions half way across the Achilles tendon: the
If necessary, manipulate it again 2wks later. lower one 1cm above its insertion, either from the medial
to the lateral side, or vice versa. If there is any varus
If the ankle does not reach the neutral position (90º), deformity of the foot leave the lateral side intact. If there is
check that the tendon has been divided properly, any valgus deformity, leave the medial side intact.
by reinserting the tenotomy knife in the same 2 tenotomy The aim of doing this is to help the distal attachment of the
sites. If the ankle is still not fully corrected to 90º, tendon to correct the deformity. At a suitable level,
wait and plan to increase correction by applying serial c. 4-10cm proximally (depending on the size and the
casts every 2-3wks. degree of plantar flexion to be corrected), make a small
N.B. If necessary, release the ankle on the same incision opposite the first one (32-18A,B). Then push up
occasion as the knee and the hip. the foot into normal dorsiflexion, without too much force:
if the fibres of the Achilles tendon pull out, stop there.
POSTOPERATIVELY, squeeze out all subcutaneous clot.
Bleeding is usually slight. Apply a small dressing. If you fail to put the foot into satisfactory dorsiflexion,
make a longitudinal incision down the middle of the
If the knee is stable, apply a well-padded below-knee tendon joining the two cuts. If this still does not correct the
walking cast, with the foot near the maximum correction, position of the foot, dissect down to the posterior aspect of
but not at the extreme limit of extension. the ankle joint, under direct vision. Divide the posterior
Elevate the leg, and encourage walking. Review a young capsule of the ankle joint transversely (32-18D),
child in 3wks, and an older child or adult in 6wks. from lateral to medial, and open up the ankle,
Remove the cast and apply a below-knee calliper with a by dorsiflexing the posterior part of the foot.
backstop (32-13B).
CAUTION! Be careful not to cut:
If the knee is unstable and has no contracture, apply an (1) the flexor hallucis longus tendon (35-22I),
above-knee cast, and later an above-knee calliper instead (2) the posterior tibial nerve and vessels, which lie on the
of a below-knee. medial side of the posterior aspect of the ankle joint.
These structures are only in danger if you divide the
posterior capsule.
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Continue plastering above the knee, using copious padding To prevent the child kicking the shoe off, make sure the
(32-21D) but avoid large amounts of plaster behind the laces are well tied. Review the child at 2wks, 12wks,
knee (32-21E). Trim the plaster dorsally up to the mtp then every 4months till age 3, every 6 months till age 4,
joints, leaving the plantar surface intact to support the toes then every year till skeletal maturity.
(32-21F).
DIFFICULTIES WITH THE PONSETI METHOD
Remove each cast just before you are ready to apply a new Avoid these errors:
one. Soak the plaster in water for 20mins before removal. (1).Do not pronate or evert the foot because this increases
Start removing it at the thigh. Do not allow a long interval the cavus and does nothing to unlock the calcaneus locked
between re-casting because you may lose considerable under the talus, and will result in a ‘bean-shaped’ foot.
correction thereby. (2).Do not abduct the foot at the mid-tarsal joints by
pressing on the cuboid with the thumb, because this will
Finally, correct equinus by dorsiflexing the foot. make correction of varus of the heel impossible.
You will usually need to do a simple percutaneous (3).Do not externally rotate the foot while the calcaneus
tenotomy of the Achilles tendon, unless the Pirani score is remains in varus, because this produces posterior
<1 for hindfoot and midfoot deformity and the talar head is displacement of the lateral malleolus.
easily palpable. (4).Do not forget to immobilize the foot after each
Do not perform a tenotomy if the heel is in varus, because manipulation, with ligaments at maximal stretch.
this means you not have achieved adequate correction. (5).Do not apply below-knee casts, because these do not
hold the forefoot abducted and tend to slip.
Infiltrate 0·5ml LA (32-21H) after cleansing the skin ((6).Do not correct equinus before correcting heel varus
(do not use too much LA as you will then find the Achilles and supination, because this results in a ‘rocker-bottom’
tendon difficult to palpate). Dorsiflex the foot to stress the deformity.
Achilles tendon. Insert the blade longitudinally medial to (7).Do not perform an incomplete tenotomy, because it will
the tendon, turn the blade transversely and cut the tendon not give enough release and the tendon anyway heals
across 1cm above the calcaneus; you will feel a sudden rapidly in infants.
‘pop’ which will allow 10-15º extra dorsiflexion. (8).Do
( not attempt to obtain a perfect anatomical
Apply a 5th cast with the forefoot abducted 60-70º with correction, because it is a functional correction that you
respect to the front of the tibia (32-21I). Never pronate the want! The radiographic appearances have no correlation
foot. Keep this cast in place for 3wks. with long-term function!
When you remove the cast, 30º of dorsiflexion should be
possible in a well-corrected foot. The tenotomy scar is If there is an adductus or varus relapse, recognized by
minute. Now apply an abduction brace for 23hrs/day at supination of the forefoot (with the child walking towards
3months (i.e. all the time except when bathing). You may you), and heel varus (with the child walking away),
have to adjust this brace as the child grows, and should go back to manipulating and casting as from infancy.
review him monthly. Make sure the brace is fitted to open- If there is an equinus relapse at 1-2yrs, apply casts
toe high-ankle straight-laced shoes, with 75º external to get the calcaneus at least into a neutral position.
rotation and 10-15º dorsiflexion for the affected foot, You may have to repeat an Achilles tenotomy and follow
and 45º for the normal foot (32-21J). this by 4wks of foot abduction in a long-leg flexed knee
cast. Then go back to using the brace at night. If there is a
The bar is slightly curved convexly forwards. The knees late relapse at 3-5yrs, check if the foot dorsiflexes to 10º
are free so that the child can stretch the gastrosoleus and perform a tenotomy as before. Otherwise more
tendon, and the bend in the brace helps to stretch the complex surgery is necessary.
gastrocnemius (35-20B) and Achilles tendon. You can get If there is persistent varus and supination during
a skilled cobbler to make the Steenbeek brace (32-21K) walking, usually because of non-compliance,
with readily obtained materials. characterized by thickened lateral plantar skin, correct any
fixed deformity with 2-3 casts and then refer for a tibialis
If the deformity recurs after bracing, you need to start anterior transfer. It is best to do this between 3-5yrs of
again with serial casting, with possibly another Achilles age, but always after ossification of the lateral cuneiform
tenotomy. Then maintain outward rotation in open shoes (usually at 2½yrs).
attached to a bar 12hrs at night and 2-4hrs in the middle of If no treatment has been started at all, you should start
the day for 3-4yrs to prevent recurrence. The results, the Ponseti method as for a newborn, but results are not as
although anatomically not always perfect, are almost good, and depend on the delay starting treatment and the
perfect functionally till late adult life. Bracing is essential: severity of the deformity.
if you don’t follow the programme diligently, you will get If other non-surgical treatment has already been
an 80% recurrence rate. Teach parents how to put on and started elsewhere before 28months, you should start the
take off the brace, and encourage the child to move both Ponseti method as for a newborn: results are just as good.
knees simultaneously. There should be no “negotiations” If treatment fails, check for a neurological cause;
about wearing the brace with the child. Compliance is as the options are further casts, lengthening the Achilles
necessary as with TB treatment. tendon (32-18) or a tibialis anterior transfer operation.
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32.11 Care of neuropathic feet The patient, or a family member, must learn to look for hot
spots, because they mean, “Stop!” He must take them
seriously, and rest the foot until all signs of inflammation
The feet are often just as important than the hands. have gone. Rest at the hot spot stage is the only way to
Someone is able to work with a paralysed hand, but if he avoid the serious damage that starts the downhill road to
cannot walk, he will probably be unable to undertake the amputation.
essential activities of daily life unaided. Many diabetics
who are being adequately treated medically, are being The risk of an anaesthetic foot developing an ulcer
allowed to walk about on ulcerated feet. The dressings that depends partly on the shoe (if there is one), and partly on
cover their ulcers do not prevent them from deepening, and how much it is injured by walking. Perhaps he can ride a
widening, and involving the bones underneath. The quiet donkey, or a bicycle? The kind of shoe he needs depends
progressive destruction of these feet is not inevitable, and on the state of the foot, as defined by the 'degree of risk'.
can be minimized. It may be a losing game, so play it as Many patients with moderate, or even high risk feet, can
cleverly as you can, and try to retain the usefulness of the remain free from ulcers without moulded shoes (32-22) if:
foot as long as possible. (1) they practise self care,
(2) they have microcellular rubber insoles in their sandals
Ulcers can be caused by: or shoes (32-22A,B,C),
(1),Constant mild pressure, which causes necrosis by (3) they limit their walking, and
impairing the blood supply to the tissues, as in neuropathic (4) they take small steps.
ulcers. In a normal person ischaemia soon causes pain, Moulded shoes are more difficult to make, and many
so that the ischaemic part is moved, and its blood supply hospitals manage without them.
restored. In an insensitive foot there is diminished pain
sensation (though some sensation to touch remains), With a little instruction a local cobbler should be able to
so that the ischaemic tissue is allowed to become necrotic make a suitable unmoulded shoe in the local style, with the
and ulcerates. Also, an unnoticed fracture will produce necessary insoles and straps, and using only the local
deformity because the bone fragments are not immobilized. materials. If you want him to make a moulded shoe,
(2),A strong force which cuts, shears or tears the tissues. he will need these special materials:
In the foot, the strength of the force is less important than
the small area over which it is applied. MICROCELLULAR RUBBER. This has a closed bubble structure, and
(3),The frequent repetition of moderate forces, is much more resilient than ordinary 'foam rubber'. Some shoe factories
can provide it. It is not the same as the foam plastic used for cheap
which cause inflammation and so weakens the tissues. sandals, which is less resilient. Car tyres make good soles, and inner
This is an important cause of ulcers, so try to minimize the tubes can make uppers.
pressure on a foot. FOAMED POLYETHYLENE, 1cm thick. This is a light thermoplastic
(4) Forces which spread infection to soft tissues and bone. which a skilful cobbler can use to make a moulded shoe, for a moderate-
or severe-risk foot. It resists wetting and is easily cleaned, but it does
An infected foot is so painful to a normal person, that there need an oven. Its main disadvantage is that it wears away in <6 months.
is to rest it: a patient with a neuropathy does not do this Heat a piece of sheet to exactly 140ºC in an oven and hold it at that
spontaneously. temperature for five minutes: place it on a 10cm polyurethane foam
(5),A previous ulcer. This is the commonest cause. pillow; and then ask the patient to stand still on it until it is cool,
or let him sit while you force the foot down on it (32-23C).
If a patient has never had an ulcer, he may escape without It will not burn him, and will set in the shape of the sole (32-23D,E).
one, if he is careful. If however he has already had many Be sure to support this moulded material with microcellular rubber, or
ulcers, he will probably not notice getting one more. cork and latex, built up to produce a flat sole; foamed polyethylene is not
resilient enough to make an insole by itself.
The key to preventing ulcers is:
(1),to teach a patient how to prevent injuries to himself in LOOK FOR SWELLING AND REDNESS
the first place, FEEL FOR 'HOT SPOTS'
(2) to teach him 'self care' for any injuries he does receive,
in their earliest stages. All primary care workers should be 'SELF CARE'. Teach a neuropathic patient to:
able to teach this. When the tissues have been damaged, (1) Recognize that his anaesthesia is abnormal.
they will usually heal, if he rests them completely. (2) Care for his anaesthetic limbs, and prevent injury.
Surgery is much less important than rest, at the right time, (3),Inspect the limbs daily, so that he can remove any
and for the right length of time. Antibiotics without rest thorns, and recognize and care for any wound, either open
will not heal ulcers. or closed, while it is still small, and before it gets worse.
Ulcers commonly start in the deeper tissues, and develop (4) Rest the limbs when they are injured.
slowly over several days, so teach him to recognize an (5),Recognize and understand the seriousness of 'hot spots'
ulcer as a 'hot spot' in its 'pre-ulcer' stage, before the skin and corn formation.
over it has been broken. A hot spot is a warm area of skin, (6) Treat the 1st ulcer as the calamity that it really is.
usually with swelling, that occurs after activity,
and persists during at least 2hrs of rest. In an anaesthetic CAUTION!
foot, a hot spot may be the only indication of some (1),Explain that it is injury to anaesthetic feet and not the
underlying pathology, such as a fracture, disintegrating disease itself which leads to ulceration and loss of tissue.
bone, a strain, or an abscess. Any of these may break (2),Walking must be limited if there is a hot spot,
through to the surface, and form an ulcer. or an area of deep tenderness.
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EXAMINING AN INSENSITIVE FOOT. FOOTPRINT MAT, also called a rubber Harris mat. This is a mat with
little rubber ridges which you ink. Place a piece of paper on the inked mat
Look for swellings, injuries and callosities. Are any of the
and ask the patient to walk on it. The greater the pressure, the blacker the
toes pushed apart (with oedema from an injury)? ink impression. If you are really interested in the care of leprosy feet,
Examine the arches of the feet on standing, and look for get a footprint mat.
flattening. Feel the whole foot. Warmth or swelling
suggest active pathology, and the need for extra care. Watch the patient walking barefoot. You can easily miss a
Press deeply over the common sites of ulceration dropped foot, if it is also short. Ask him to walk on his
(32-24A,D,G). There may still be deep pain, when all heels. He cannot do this if the anterior tibial or peroneal
ordinary sensation is lost. Assess the circulation, feel the muscles are weak. Finally, do not forget to look at his
peripheral pulses and the temperature of the skin. shoes!
Time the capillary return.
DIFFERENTIAL DIAGNOSIS OF NEUROPATHIC FOOT
(1) Diabetes mellitus,
(2) HIV disease,
(3) Peripheral vascular disease,
(4) Syphilis,
(5) Leprosy,
(6) Spinal pathology,
(7) Inherited neuropathies,
(8),Peripheral nerve damage, e.g. from badly located
IM injections.
SKIN CARE.
Denervation of the skin reduces its natural secretions and
makes it dry, so that it more easily cracks, fissures,
and becomes infected. Softening dry skin reduces these
dangers, and may allow any fissures that have formed to
heal. So ask the patient himself to get plain water, without
detergents, into the dry feet (or hands) by soaking them for
15-20mins at least twice a day. Do not use warm water in
case it is too hot! If a fungal infection is present,
add potassium permanganate to the soaks. Then ask him to
cover the skin with petroleum jelly, or any kind of grease
or oil (including car oil).
It is the water that is important, not the grease which keeps
it in. Beware cockroaches which like the oil:
advise a patient whose living conditions are poor to get a
cat, or use insect repellents.
Pare away thick corn with a surgical blade, or ask the
patient himself to rub it away with a pumice or other stone.
Remove rough corns regularly, because it may split and
crack, or cause ulcers by pressure.
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PARALYSIS OF THE FEET Simple plantar warts or corns from ill-fitting shoes can
If there is a posterior tibial nerve palsy, either: result in ulceration, especially if the patient cannot feel the
(1) Apply a firm bandage to limit friction at the back of the discomfort properly. Do not use LA to cut out plantar
ankle. Combine this with a heel retainer, to minimize the warts and shave corns; you may go too deep and the
use of the small muscles of the foot, and trauma to the injection is anyway usually unhelpful and more painful
anaesthetic sole; or, than the procedure!
(2),Apply a padded plaster boot.
Ulcers in a neuropathy patient are almost inevitable:
If there is an acute common peroneal nerve palsy, Help the patient himself to find the cause of the injury.
producing a flapping gait and foot drop, passive exercises Never let him accept that the cause was the disease.
will help to stretch the Achilles tendon and prevent a Was it caused by repeated stress, or by a blow, a puncture,
contracture: or a burn? Concentrate all your educational energies on
(1) Advise squatting with the heels flat on the ground. him. You can do much more for a patient with the 1 st ulcer,
(2) Advise standing erect about 70cm from a wall, to keep than for one whose foot is already mostly destroyed.
the feet flat on the ground, and with the palms of the hands
flat on the wall to do 'press ups' in the vertical position. If you can find some way of resting an ulcer it will usually
heal. This means that the patient must 'not take one step'
Some protective device is also necessary, with: on it, until it has finally closed over, and all the scabs have
(1),During the day, fit a toe-raising spring (32-22J). fallen off. If it is uncomplicated, this takes 4-6wks.
This will allow some work. By night, apply a posterior You can:
slab to hold the ankle in neutral position. (1),Try bed rest. Unfortunately, this is rarely successful
(2),Or, apply a complete plaster cast, including the foot because staff often do not understand fully the need for
and leg up to the middle of the thigh, with 15º of flexion of rest and neither explain or encourage this and there is no
the knee, and with the ankle in neutral position, taking care pain, and thus there is little incentive to stay in bed.
that the cast does not press on the nerve. Leave this on for (2),Allow the use of a splint and crutches continuously
6wks. until the ulcer has healed. This is unlikely to be successful
unless you educate and supervise the patient carefully.
If there is a chronic common peroneal nerve paralysis, (3),Make a special curative shoe, with a rigid rocker
he may be helped by lengthening the Achilles tendon, bottom, and a specially moulded surface for the sole of the
and transfer of the tibialis posterior tendon to the front foot. This needs much skill, and is not described here.
of the foot to make it into a dorsiflexor (32.13). (4) Put the foot in a cast.
If this is impossible, or while waiting for surgery, N.B. Antibiotics are of no use.
fit a toe-raising strap. A plaster cast is one of the most practical ways of resting
an ulcerated foot. It immobilizes the foot, it spreads the
If there is also plantar ulceration with the foot drop, strain of weight-bearing, it is quick to apply, and it is easy
be sure to use a posterior slab or a cast. If the ankle is not and effective. You can apply one in a remote clinic and
supported, the Achilles tendon is likely to contract on bed send the patient home, provided you tell him that he must
rest. Provide crutches while the ulcer heals, so that there is absolutely avoid walking on the foot. If you apply a cast
never any pressure applied on the ulcer. on the indications listed below, it will usually allow an
ulcer to heal in 6wks.
If there are clawed toes, transfer the flexor longus tendon Unfortunately, although resting a foot in a cast may heal
to the extensor expansion on each toe (32-27N,O). an ulcer, it weakens the bones and ligaments, despite
continuing walking in it. Bones only retain their normal
FIND OR TRAIN A CAPABLE SHOEMAKER strength if they are regularly used. Rest causes them to
TO HELP YOUR PATIENTS lose their minerals, and ligaments to lose their strength.
The result is that when the cast is finally removed, the
patient may be delighted to find that the ulcer is healed,
32.12 Foot ulcers but he may not realize that anaesthesia is preventing him
from experiencing the stiffness and pain that protects a
normal foot. Consequently, he may be tempted to use the
An uncomplicated ulcer is only skin deep, does not involve anaesthetic foot too vigorously, with the result that it
bone or deeper structures, and usually heals easily if the dislocates, or its tarsal bones fracture, and he ends up with
patient rests the leg. A complicated ulcer has involved the a worse neuropathic foot. So use casts cautiously and
bone underneath it. It has a deep sinus, or marked remember their risks. When you remove one:
infection, and is much more difficult to heal. (a),warn of the sad consequences of energetic early
The Wagner classification describes different stages: exercise,
(b),start a programme of 'walking training', which will in
I simple ulcer a slow return to full activity during 7-10days,
II with cellulitis (c),be sure that to teach 'self care',
III with bone involvement (d),be sure also to watch carefully for 'hot spots' (32.11),
IV with spreading infection (e),most importantly, supervise the patient for at least
V with gangrene 1wk after you remove the plaster.
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Local applications to an ulcer make little difference, Do not apply excessive padding to bony prominences.
so there is no need to change dressings at frequent
intervals. Dress the ulcer 2-3times/wk with hypochlorite
('Eusol'), hypertonic magnesium sulphate, sugar (which is
best used daily, honey, ghee or some mild antiseptic.
Or, soak it, scrape it regularly to remove excess corn, oil
it, and dress it daily. When the discharge stops, you can
apply a cast, leave the dressing unchanged for 6wks, and
send the patient home, making sure he has learnt self care.
If there is fever and other signs of generalized infection,
such as a profuse discharge, or tender groin glands,
use an appropriate antibiotic and elevate the leg.
CAUTION! Antibiotics have no place in treating
uncomplicated ulcers: what they need most is rest!
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CAUTION! CAUTION!
(1) Do not mould the cast under pressure to obtain the (1),Do not remove bone from the base of an ulcer
required position, or you may cause ulcers and gangrene. unnecessarily, especially in the heel.
(2) Ask an assistant to hold the ankle at exactly 90º or (2),Probing an ulcer will tell you if bone is exposed, but
slightly dorsiflexed (32-25E), until the plaster has set; not if it is dead. Exposed bone may be healthy, but the soft
it must not be plantar-flexed or inverted or everted. tissues will take time to grow over it.
(3) Do not press into the plaster with your fingers, (3),Never strip periosteum unnecessarily, because this may
because you may produce pressure points where more kill the bone under it.
ulcers will develop.
(4) Remember that no pain is felt. A wrongly applied cast
may cause ulcers! So do not apply excessive pressure over
a tight bandage.
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(a) a rigid sole with a central rocker, If you suspect infection under an ulcer in the middle of
(b),an insole (ideally 'plastazote') moulded exactly to the the lateral border, surgically pare down the cuboid or the
shape of the foot, base of the 5th metatarsal, and removing any infected
(c),an upper strapped round the foot and ankle, so that tissue. Make a dorsolateral incision, which leaves a
they cannot move in relation to the shoe. sufficient bridge of tissue between the incision and the
ulcer. Turn back the infected tissues by subperiosteal
If the ulcer recurs, check the way the patient cares for his dissection, trim the bone, remove necrotic tissue,
feet. Does he inspect them and soak them daily and excise the ulcer with an elliptical incision on the sole.
remove rough corn? Look at the shoes: When the wound is clean, try primary closure with
(1),Is there increased pressure in some area which has monofilament to achieve healing of the plantar wound
caused necrosis? without a large scar which might ulcerate again.
(2),Are the straps so loose that they allow movement of the You can allow the dorsolateral wound to close by
foot inside the shoe, or so tight that they cut into skin? granulation if you cannot easily close this. Do not let it
(3) Can the contour or fit of the shoes be improved? close if the depth of the cavity is not clean. A toe-raising
(4) Does the patient always wear the shoes? spring (32-22J) may help to prevent recurrence.
(5),How far does he walk without resting? Can he walk
less, or walk with less pressure on the ulcer, or more If a terminal phalanx becomes visible in an ulcer at the
slowly? tip of a toe (or finger), nibble it away with a bone nibbler.
If it is badly infected, disarticulate it. If necessary, use a
There are 2 possibilities: fish mouth incision over the top and down the sides, which
(1),You may be able to excise the ulcer, and all the scar will leave the pulp intact.
tissue under it, and then graft it with split skin.
This may provide a more suitable bed for the regrowth of If you remove part or all of the middle or proximal
subcutaneous tissue than the original scar tissue. phalanges, approach them through incisions at the sides of
(2);You may rarely be able to excise the scarred area, a toe (or finger). If the remaining toe is stiff, awkward or
and close the gap you have made with monofilament painful, amputate it (35.7).
sutures. This mean an initial relieving incision on the
dorsum or side of the foot, and packing the cavity till If bone is exposed under a heel ulcer, be very careful
healing occurs from the base of the wound. Use honey or about removing it from the calcaneus: you can easily
other suitable dressings (34.9). remove too much, and a foot without a heel can be a
If the metatarsal heads protrude, shave them off. problem. Patients can however walk on very little
calcaneus or even none, if you provide them with a rubber
If the feet are well cared for and the right shoes are worn, heel-pad. Try conservative management with special
the ulcer should not break down again. If it does, there is footwear and daily skin care. A normal calcaneus has a
some underlying abnormality, such as: spur which projects forwards along the line of the plantar
(1),Chronic osteomyelitis in of the bone under the ulcer. ligaments parallel to the ground; this is harmless.
Remove sequestra surgically (7.5).
(2) A protruding bone spur which needs excising. EXCISION OF A CALCANEAL SPUR (OR OTHER
(3) A thick scar which splits under tension with walking. BONY PROJECTION) (GRADE 2.1)
(4),Inadequate subcutaneous tissue over the metatarsal
heads. If there is an abnormal residual bony spur on the under
(5) Malignant change in the ulcer (34.5). surface of the calcaneus or elsewhere, associated with an
(6) Claw toes which repeatedly ulcerate. ulcer, projects vertically downwards, remove it.
Spurs may form under any prominent bone in a
CAUTION! When you treat ulcers avoid cutting into boat-shaped foot. Irregular bone may also develop because
living bleeding tissue unless it is to: of a fracture or an infection. Do not remove these bony
(1) Open an abscess. projections through the ulcer, because this will make the
(2) Improve drainage from a deep sinus. plantar scar bigger. Instead, paint the ulcer edge with
(3) Remove necrotic tendon, muscle, or bone. gentian violet. Then make an incision round the back or
(4) Remove a free lying sequestrum (7.5). lateral side of the heel (32-27B), so as to avoid the medial
(5) Remove bone that is so placed that healing and normal calcaneal vessels. Deepen the incision to the bone
function are mechanically impossible. (32-27C), and lift the heel pad off the bone by clean sharp
dissection. Continue the incision, so as to raise a flap of
If there is an ulcer on the lateral border of the foot heel and plantar fascia, and mobilize the ulcer. Then excise
(32-24E), it is likely to be associated with peroneal nerve and suture it as described above (32-27D).
paralysis (32.11). Treat it by bed rest and splints or casts. Trim the calcaneus with an osteotome to leave a flattened
When it has healed a toe-raising strap attached to the area surface. Do not remove bone unnecessarily, or leave new
of the 5th metatarsal head may help to prevent recurrence. sharp edges or corners to form new ulcers.
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If there is a short foot, examine the patient carefully to N.B. For seriously clawed toes, you may have to remove
see if the heel is taking its proper share of weight. at least one phalanx, or the metatarsal head, or both to
You can easily miss foot drop in a short foot. straighten them. If the remains of the toes will not bear
Ask him to walk on his heels; if he cannot do so, some of weight, because they are so badly scarred, perform a
the muscles are weak. Lengthening the Achilles tendon transmetatarsal amputation (35-23).
may help, even to the point of making the calf muscles
useless, because this will make him walk mainly on the If squamous carcinoma develops in a long-standing
heel, and less on the front of the foot. If there is definite (Marjolin’s) ulcer, the alternatives are local excision and
paralysis of the dorsiflexors, he will be better off with a amputation. You may be able to excise smaller lesions that
tendon transfer (32.13). If this is not practical, fit him with do not involve bone, and are distal to the midfoot (34.5).
a toe-raising spring (32-22J).
ANKLE DIFFICULTIES
If where there is muscle weakness, the tarsal bones
disintegrate, you may find this in any of 3 stages. If there is an irreducible dislocated ankle or a fixed
(a);1st stage: the foot is hot, it may be swollen, but its ankle deformity, a correction is necessary.
shape is unchanged. Raise the foot to allow swelling to
subside. If there is an equines or equinovarus foot, walking may
(b);2nd stage: the foot is still hot with active bone be satisfactory, but elaborate footware is necessary to
disintegration; its shape becomes abnormal, and it may be prevent ulcers recurring. If walking is difficult,
hypermobile. Raise it in a splint for 3days to reduce and particularly if there is fixed plantar flexion or
swelling. Then use the prone position (32-25E) and mould inversion, an ankle arthrodesis (32-26C,D) is necessary.
the foot into as functional a position as you can, accentuate Afterwards, an ordinary high moulded shoe, or a sandal of
its arch as much as possible, and apply a cast. Leave this microcellular rubber, may be adequate to prevent ulcers.
on for 6-12 months, and then mobilize with care.
(c);3rd stage: the foot is no longer hot, showing that the If the foot is pronated, a simple canvas tennis shoe may
bone lesions are no longer active. If there are rough bones, be enough. If not, a surgical correction is necessary.
which will be likely to cause ulcers, trim them. A high-risk Afterwards, an ordinary high moulded shoe (32-22I) or a
shoe (32-22I) may keep the foot ulcer-free. An arthrodesis sandal of microcellular rubber (32-22F) may be enough to
(32-26C,D) may then be needed, after which a walking prevent ulcers.
cast for 6-9 months is necessary. Hopefully, the foot will
revert to the 'moderate risk' class; if it does not, a special SEPTIC DIFFICULTIES
prosthetic shoe or brace will be necessary long term.
Many of these patients can manage to live well in a simple If there are signs of an acute infection with
sandal, with daily skin care. lymphadenitis, treat with rest, cloxacillin or another
suitable antibiotic, and if necessary, drainage.
If there is an old fixed deformity which cannot be There may not be a neuropathy, and the foot may merely
altered, supply a special moulded high-risk shoe till you have a soft tissue infection.
can arrange reconstructive surgery.
If heat and swelling rapidly return and persist,
If there is no practical way to establish a good arch, there is active pathology, so apply a cast for 6wks,
at least try to get its bones healed and sclerosed. If the arch repeat the radiograph and plan treatment accordingly.
of the foot becomes completely flat, it should remain After this interval stress fractures and other bony lesions
ulcer-free, but if the bottom of the foot becomes convex will have caused enough osteoporosis to be seen
and boat-shaped, it will be more likely to ulcerate. If the radiologically. If you are in doubt, or have no radiographs,
talus and calcaneus are totally destroyed, perform an suggest another trial of walking.
amputation (35.7).
If in a case of leprosy, heat and swelling return a
If clawed toes develop, stage them, as ulcers are often 2nd time, bone disintegration is highly likely; so reapply a
associated, and treat as follows: well fitting walking cast for 6-12 months, depending on its
GRADE 1 GRADE 2 GRADE 3 site and severity.
Weak Limited Fixed toes
intrinsic movements ± dislocation of mtp joints If there is septic arthritis in a toe ip joint,
muscles, of toes excise it through a dorsal incision, remove the remains of
mobile toes its ligaments and cartilage, pack the cavity, and keep the
No Moderate Severe toe straight at its ip and mtp joints: this will produce a
contractures contractures contractures fixed toe.
Flexor + Excision + ≥1phalanx amputation, or
tendon metatarsal transmetatarsal amputation
transfer heads
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If septic tenosynovitis complicates an ulcer, If there is a deep ulcer with a sinus track, outline this
draining the tendon sheath may assist healing. with gentian violet. Cut away all the violet-stained tissue,
Drain it through an incision along the arch of the foot. so that you remove all the infected areas.
Clean out all the infection, as far back as is necessary
to find and remove the infected tendon stump. If there is osteitis, excise or curette the sinus tracks and
Close the skin with monofilament, so as to leave the insert a pack.
smallest possible scar on the weight-bearing area.
Leave both ends open, so that you can irrigate the lesion EXCISING AN ULCER ON THE HEEL
until it is clean. Allow it to heal by secondary intention.
If osteitis is already draining through the centre of the
If a septic toe requires amputation, use a racquet heel, curette and pack the lesion, without trying to excise
incision on the dorsum (35-24), leave the metatarsal head, the ulcer. Stop all weight-bearing until the ulcer is healed.
and only resect the surface cartilage if there is septic provide a splint. When the infection is controlled, trim any
arthritis of the mtp joint. Drain or pack the wound dorsally. rough bone. As soon as the osteitis is controlled, excise the
ulcer scar and pack the lesion laterally till it is clean.
If plantar ulceration results in osteitis of a metatarsal Do not allow walking on trimmed bone for 6wks, or until
head, you may need to excise it (32-27I). This will move the wound is fully healed, and the scabs have fallen off.
the weight-bearing area proximally, so that more Heel skin is specialized, so try to obtain primary closure.
ulceration is likely. If you can save a toe in good position, Make a 'fish mouth' relieving incision around the back or
it will help to protect the area of the new 'metatarsal head'. lateral margin of the heel (32-27B), then dissect to lift the
If you can save the distal part of the first toe, it will help to heel pad off the calcaneus (32-27C), in order to be able to
protect the second metatarsal head, which may otherwise close the plantar defect.
soon ulcerate. Sometimes, you may have to remove several
metatarsal heads. Do this through dorsal longitudinal
incisions between them. If there are plantar ulcers over the
metatarsal heads, excise them, and close the incisions in
the sole with monofilament. Leave drains or packs in
dorsally.
OPERATIONS ON THE FEET IN LEPROSY
Most leprosy ulcers do not need an operation, but there are
some simple operations which you should be able to do.
Try to correct clawed toes, because they predispose to
ulcers at the tip of a toe, on the knuckle, and under the
metatarsal head. Apart from the correction of clawed toes,
most other tendon transfers are work for an expert.
The only other possible exception is a posterior tibialis
transfer for foot drop (32.13).
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TENDON TRANSFERS FOR CLAW TOES (GRADE 2.4) Do not leave one metatarsal obviously longer than the
This operation allows the toes to take more part in others. Excise any ulcers on the sole, as above, and close
weight-bearing, and so protects the metatarsal heads. them when they are clean.
It is not applicable where toe joints are fixed. Avoid damaging the proximal phalanges.
INDICATIONS. If the foot has become shortened, the toes may remain
(1) Stiff, clawed toes (especially >1) projecting, and make it difficult to fit a shoe, or they may
(2) Ulcers under the metatarsal heads. be subject to excessive pressure. If so, amputate them
(35-24).
Aim to reduce the scarred area, by shortening the
metatarsals of one or all of the toes, so bringing the toes If the dip joints of the toes only are fixed, or they have
down to take some weight. Keep all incisions dorsal, repeated ulceration, amputate them (35-24).
and aim for a mobile pseudarthrosis, not an ankylosis.
Sepsis is not a contraindication, if you leave the dorsal If the foot is chronically scarred and ulcerated,
wound open and pack it, but try to get the operation sit as and part of all the toes are lost, but there is good sole
clean as you can. tissue proximally, perform a transmetatarsal amputation
(35-23).
METHOD. CAUTION! Foot operations leaving shorter stumps are
Over every stiff toe make a dorsal incision which is long prone to develop complications.
enough for you to see the mtp joint, and 2cm of the
metatarsal. Elevate the periosteum, and remove the If the heel pad has some sensation and a good
metatarsal head with bone nibblers or cutters. Take care to prosthetist is available, consider a Syme’s amputation
preserve all the viable plantar skin. Smooth the remaining (35-22): this is, however, too short and too small to be
shaft with a small bone file or nibbler. You should now be used for weight-bearing unless you can provide a good
able to straighten the toe; if it is still dorsiflexed, remove a elephant boot.
little more metatarsal.
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32.13 Tibialis Posterior transfer for foot drop (4) Straighten the knee. If you can passively dorsiflex the
ankle to 15º (unusual), a tendon transfer alone is enough.
(5),If you cannot do this, perform an Achilles tendon
A dropped foot, which a patient is constantly tripping over, lengthening at the same time.
is a great disability, but it is also a treatable one, whatever
its cause: If the ankle is too stiff to dorsiflex without inverting,
(1) If there is a strong tibialis posterior and gastrocnemius, you will not achieve a good gait. Try to refer for a wedge
and a mobile ankle, you may be able to transfer the tibialis osteotomy, perhaps with a tendon transfer later.
posterior tendon.
(2);If surgery is impractical, you can fit a toe-raising TENDON TRANSFERS FOR THE TOES.
spring (32-22J), if necessary made with canvas or plastic If a foot is not being dorsiflexed normally, its toe flexors
straps, and using the rubber from an inner tube as the shorten. If you correct the foot drop, the toes will remain
'spring' or callipers (32-13), which will need careful fitting abnormally flexed, unless they are corrected.
on an anaesthetic limb, if they are not to cause friction So the clawed toes also need tendon transfers (32.12F,G),
burns. either at the same time as the tibialis posterior transfer, or
When the lateral popliteal nerve is paralysed, dorsiflexion later. If you fail to do this, walking may continue with the
of the ankle is impossible, so that walking is liable to toe-nails turned under the toes, which will cause them to
injure the lateral side of the foot, the toes, and the ball of ulcerate.
the foot. Severe ulcers and marked deformity may follow.
Transferring the tibialis posterior tendon to the dorsum of RECORD THE PROGRESS OF THE FOOT
the foot will restore dorsiflexion of the ankle, and reduce preoperatively and again after removing the plaster cast,
the risk of ulcers. Remember that reconstructive surgery and at regular intervals afterwards. Record the angles of
without physiotherapy is useless; train a physiotherapist rest, active dorsiflexion, and active plantar flexion with the
yourself before embarking on this procedure. knee straight, and passive dorsiflexion with the knee at
Tibialis posterior and gastrocnemius are normally used 90º.
together in walking. An important part of physiotherapy is
education to separate these actions.
EXAMINATION.
Check the power of:
(1) The tibialis posterior. Test inversion of the foot against
resistance (move it medially). The only other inverter is
tibialis anterior, which is usually powerless or very weak
in patients needing this transfer.
(2),The peroneal muscles. Test eversion of the foot,
and feel the peroneal tendons contracting behind the lateral
malleolus (if they are strong, you should not sacrifice
them).
INDICATIONS.
(1),Foot drop from any cause, provided there is a strong
tibialis posterior and gastrocnemius, and a mobile ankle.
(2) If there is leprosy all these conditions must apply:
(a) the leprosy must have been controlled, and there must
have been no reaction for at least 6 months,
(b) the lateral popliteal nerve should have shown no sign Fig. 32-28 SOME CRITICAL DETAILS.
of improving after 6months of treatment and the use of a A, measure the movement of the ankle like this. B, locally made
toe-raising spring, goniometer. Hinge 2 boards together and nail a protractor to one
edge. Mark the angles of dorsi- and plantar-flexion on it. C, exercises
(c) the power of the tibialis posterior must be 4 at least for tibialis posterior. D, locally made foot-drop-positioning frame
and preferably 4+ or 5 (32.1), made in three parts, hinged together, and adjusted by chains.
(d) the patient must have no ulcers or infections, E, frame for a leg rest (24x24x36cm). F, how the leg rests on webbing,
(e) preferably, he should be skin-smear -ve, cloth, or bandage stretched across the frame.
Kindly contributed by Grace Warren.
(f) you must be able passively to dorsiflex the ankle to
15º (with the knee flexed at 90º),
PREOPERATIVE PHYSIOTHERAPY is necessary to
(g) the ankle must be suitably mobile, so test it like this:
strengthen the tibialis posterior. Get the patient to sit with
(3) Flex the knee to 90º. If you cannot passively dorsiflex the affected foot resting on the other knee and to invert it
the ankle beyond 0º, tendon transfer alone is
without using the Achilles tendon (32-28C).
contraindicated.
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Hang a weight (starting with ½kg and increasing to 4kg, 1ST INCISION. Make a gently curved incision on the
as the muscle strengthens) on the front of the foot, and ask medial aspect of the leg, starting 2cm above the calcaneus
him to lift this by inverting it. This exercise will help him and 1cm in front of the Achilles tendon, running parallel to
to localize the action of the muscle that is to be transferred, the tendon for 5cm, and then curving up to reach the tibia
so that it is easier for him to use afterwards. about 14cm above the medial malleolus (32-29A).
Cut the fat and deep fascia, and find the Achilles tendon.
PERIOPERATIVE ANTIBIOTICS. Open its sheath, and lengthen it (32-18). Suture it so that
An infected tendon transfer is a real disaster, the ankle will dorsiflex to 15º-25º with the knee straight.
so make absolutely sure the leg is thoroughly clean; Lift the tissues proximal to the medial malleolus, until you
use chloramphenicol and metronidazole (2.8) see the tendons, under the deep fascia. Slit this to find the
prophylactically. tibialis posterior tendon which lies deeper than the flexor
digitorum longus, (32-18D, 32-27A,F). Make sure you
EQUIPMENT AND TECHNIQUE. have got the right tendon by pulling on it and seeing what
Make a foot-drop-positioning frame (32-28D), from it does: tibialis posterior inverts the foot, and does not flex
hardwood, hooks, hinges, screws, and two short chains. the toes.
Ideally, you should use a 22 or 30cm curved Anderssen CAUTION! Keep the exposed tendons moist by
tunneler, but you can also use long Kocher's forceps. covering them with saline-soaked gauze.
You will also need a leg rest, or cradle, to hold the
leg about 20cm above the bed after surgery. 2ND INCISION. Pull the tibialis posterior above the medial
Ask your carpenter to make a tubular metal or wooden malleolus to find where it is inserted into the navicular.
frame with webbing across it (32-28E). Make a 2-3cm incision along the plantar side of the
For a tendon use several small sutures rather than one large tendon, from the navicular proximally (32-27C).
one, and make sure that no single suture bites >½ its Incise into the tendon sheath and raise the tendon with a
thickness (which makes it liable to break later). blunt hook or curved forceps.
CAUTION! Make sure you have got the right tendon.
Rough tendon ends are harmless on the dorsum of the foot, It is the only one which is inserted into the navicular, and
but if a tendon needs to glide, as when you weave is usually thick and strong and the size of your little finger.
peroneus brevis to tibialis posterior above the ankle, Clamp the tibialis posterior tendon with Kocher's forceps,
use fine (6/0) nylon monofilament to close over and as far distally as you can easily reach it, on the medial
bury the ends of both tendon and the larger sutures, aspect of the foot, and cut it at this point. (Do not follow it
so as to prevent them sticking to surrounding structures. and try to cut it where it inserts distally, among the arches
CAUTION! of the foot). Pull it up with its sheath into the 2nd incision,
(1) Clamp a tendon as close to its cut end as you can, and and free it from any adhesions, which would make it
excise the crushed area, which should be as short as difficult to pull out of its sheath later. If there is a large
possible. sesamoid bone in it, remove this and reattach the Kocher's.
(2) Watch for and avoid the main vessels. There is no need Don’t pull it out of its sheath yet!
to tie off all the small ones.
3RD INCISION. Find the tibialis anterior on the
PREPARATION. dorsomedial aspect of the navicular (32-27A).
Use the supine position, apply a tourniquet to the thigh It is the most medial of the tendons on the front of the
(3.9), and sterilize the whole leg and foot below the knee. ankle. Twist the foot into dorsiflexion and abduction to see
Clip a sterile towel round the thigh, so that you can lift the it more clearly.
sterile leg without breaking sterility. A sandbag under the Make a J-shaped incision, with its long arm along the
drapes will steady the leg, until you place it on the medial side of the tibialis anterior tendon, from the lower
footboard. end of the tibia to the naviculo-cuneiform joint, and its
In this operation, you detach the tibialis posterior from its short arm crossing the tendon laterally for 1cm.
insertion into the navicular, and divide its distal end into Reflect the flap at the level of the deep fascia, and try not
2 slips. Thread these under the skin of the front of the leg to cut the dorsalis pedis artery. Find the tibialis anterior
and foot. Weave the medial slip into the distal end of the tendon (check that you are not pulling on the extensor
tibialis anterior tendon. Then weave the lateral slip into hallucis longus), and open its sheath.
one of the following:
(1) the distal end of the peroneus tertius tendon (only 75% 4TH INCISION. Make a ¼-circle curved incision, with its
of people have one; it is really the 5 th tendon of extensor convexity towards the toes, extending from 2·5cm lateral
digitorum longus, and inserts into the medial part of the to the distal end of the 3rd incision, and passing across the
dorsal surface of the 5th metatarsal). dorsum of the foot, to reach the base of the 5th metatarsal,
(2);the distal end of the peroneus brevis tendon, but not extending over the bone itself (32-29B).
if the peroneus tertius is absent, and the peroneal muscles Use big scissors and the 'push and spread technique' (4-9)
are weak enough to be sacrificed. to raise all the superficial tissues off the deep fascia over
(3);a piece of tendon and use this as a free graft, if the the dorsum of the foot, so that you can see the toe
peroneal muscles are not weak enough to sacrifice, extensors, the peroneus brevis, and the peroneus tertius
or if the lateral slip of the tibialis posterior is too short to (if there is one) inserting into the shaft of the 5 th
reach the lateral side of the foot. metatarsal.
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Define and dissect out the peroneus tertius as far from its Pass your finger along the tibialis posterior tendon to
insertion as you can, above the extensor retinaculum. make sure it lies easily in its new bed, that it runs smoothly
Cut its tendon free proximally, separate it from its muscle round the tibia, and that no fascia obstructs its direct pull.
fibres, and leave it free, attached distally to its insertion. Use everting monofilament sutures (4-8) to close the
CAUTION! The superficial fascia is thin here. 1st & 2nd incisions, without closing the deep fascia.
Be careful not to cut the extensor retinaculum, which is the Put the foot on the positioning splint, to hold the knee at
deep fascia at this point. 80º-90º of flexion, and the ankle at 20º-25º of dorsiflexion,
Use finger dissection, and blunt Kocher's, to tunnel up with the foot everted. While you adjust the tension in the
under the skin above the extensor retinaculum, raise the tendons, ask an assistant to hold the foot in this position,
skin and superficial fascia to join the 3rd & 4th incisions, or tie it to the foot splint with sterile bandages.
leaving a skin bridge. Keep in the midline initially,
and then turn medially towards the proximal end of the CAUTION!
1st incision. (1) Do not let the foot invert.
Starting about 7cm above the ankle, raise the skin from the (2) Get the heel into the angle of the board.
deep structures. Complete a tunnel joining the 1st, 3rd & 4th
incisions. Tunnel under the skin and preserve the long Through the 3rd incision, place a Kocher's across c.¼ of the
saphenous vein (32-27C). Make a pocket into which the tibialis anterior tendon 2cm from its insertion. While your
muscle belly of the tibialis posterior will fit. If necessary, assistant holds the distal part of this tendon tense,
cut the deep fascia over the crest of the tibia, but avoid use a #15 blade to make a small longitudinal incision in it
cutting the tibial periosteum (if you do it will promote (stab I), just distal to the Kocher's. Push a haemostat into
adhesions later). stab I, enlarge it a little and pull the slip of tibialis
Above the medial malleolus put a finger under the tibialis posterior tendon through it. Make stab II at 90º to stab I
posterior tendon, remove the Kocher's forceps from its ½cm distal to it, and then pull the tendon slip through that.
distal end in the 2nd incision, and pull the tendon up into Make stab III ½cm further distally again, and pass the
the 1st incision (32-29C). tendon through that (32-29H) (if the tendon is not long
Reclamp its distal end, and use the clamp to give you a enough, two stabs will do). Do not suture this 'weave' yet.
good grip for traction, while your finger frees its muscle
belly from the surrounding tissue at the back of the tibia. Turn to the 4th incision.
CAUTION! Take care:
(1);Be careful to retract flexor digitorum longus (1) Be sure to join the various tendons at just the correct
posteriorly, so that tibialis posterior comes to lie anteriorly length and tension, to get the right degree of dorsiflexion
(32-29F), between the flexor digitorum longus and the and eversion of the foot (this is the position in which the
tibia. lateral side of the foot is higher than the medial side).
Avoid tibialis posterior twisting round digitorum longus. The foot must be tightly dorsiflexed when you put it into
(2);Be careful not to damage the main vessels, the muscle plaster. A special foot-drop-positioning splint is critical at
fibres of the tibialis posterior, or the periosteum. this stage.
(2) If the transferred tendon weave gives way, your work
Using finger dissection, a Langenbeck retractor and, is wasted, so be sure to keep the foot dorsiflexed until it
if necessary, scissors, free the tibialis posterior, until it has united firmly.
will lift up and roll easily round the edge of the tibia in an (3) Avoid subsequent toe drop by suturing the transferred
oblique direction towards the base of the 5 th metatarsal tibialis posterior to the extensor tendons of the toes.
(which it will usually reach), crossing the centre of the leg (4) Do not anchor the tibialis posterior to a hole drilled in
about 4cm above the ankle joint. Enlarge the tunnel if the foot in a case of leprosy. This may work with other
necessary. diseases, but in leprosy it will promote the disintegration
When you have freed the tendon sufficiently to reach the of the tarsal bones.
dorsum of the foot, clamp its distal end with 2 Kocher’s,
and divide it between them. Pull the two slips apart into a THE 1ST METHOD is indicated if there is a peroneus
'Y' with 6cm arms. To prevent the slips separating any tertius of suitable size. Holding the distal end of the
further, place a suture where they meet, and bury its knot tibialis posterior tight in Kocher's, weave the distal end of
inside the tendons when they lie together (32-29G). the peroneus tertius through it, in the same way that you
wove the tibialis posterior through the tibialis anterior.
If the tibialis posterior will not reach the dorsum of the
foot, check that you have freed its belly sufficiently. Make stab I in the tibialis posterior about level with the
If so, pass long Kocher's proximally, in the midline of the proximal end of the 5th metatarsal, just distal to the
leg, from the 4th incision for about 10cm, and then deviate extensor retinaculum; make stabs II and III more
towards the proximal end of the 1st incision. Pick up both proximally. When you have woven the 2 tendons, work
slips of the tibialis posterior, and pull them through onto them along one another, until there is no slack tendon.
the dorsum of the foot. Then, holding both firm so that they are just in tension,
Pass the Kocher's from the 3rd to the 4th incisions. with the foot on the positioning board and the ankle
Pull one slip of tendon into the 3rd incision and leave the everted, join them with 6 small sutures, passing through a
other one in the 4th incision. Keep a Kocher's on each slip. little of each tendon (32-29D).
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THE CAST must keep the foot dorsiflexed and everted, Apply another 10cm bandage at the upper end of the
and leave the dorsum of the ankle free. For this it needs a backslab. Only now should your assistant remove his hand.
backslab and two side struts or braces. Strengthen the side struts and the foot, but leave the front
Ask your assistant to stand beside the patient, facing the of the ankle and the toes open.
foot of the table, to flex the patient’s knee, and to flex and CAUTION!
externally rotate the hip. The knee should rest on your (1) Make sure the toes are not dorsiflexed.
assistant's abdomen. Your assistant’s hand which is (2) Do not leave finger depressions in the cast.
furthest from the patient should be flat on the sole of the (3) Do not pull the bandages tight.
foot (to avoid pressure areas), with its little finger over the
head of the 5th metatarsal, its fingers straight, and with the POSTOPERATIVELY, raise the foot preferably in a
ankle 20º-25º dorsiflexed and everted. The hand must stay special prepared frame (32-28D), so that the foot is parallel
in this position until the cast has set. Ask him to support to the femur, and the knee is bent. If necessary (unusual in
the calf with the flat of the other hand, moving it as the leprosy), use morphine. Check the colour of the toes and
cast is applied. the pulse hourly for 24hrs.
CAUTION! The patient cannot complain of pain On Day 4 provide crutches, without weight-bearing.
because the foot is anaesthetic, so pad the heel well, or else
pressure ulcers may ensue. In the 4th wk. (5th wk if physiotherapy supervision is
limited), bivalve the cast down both sides, so that the struts
are left attached to the posterior half of the cast (reinforced
if necessary), which can be used as a protective resting
splint during rehabilitation.
CAUTION!
Keep the foot dorsiflexed when you remove the sutures.
If you do not, the flexors, aided by gravity, may pull away
the healing tendons. Start exercises the day you remove the
cast.
5th wk. (1st wk after removing the cast) Instruct the use of
the transferred tendon in its new position. In supine
position, with the hips flexed and externally rotated, and
the knees flexed, with both feet in the frog position, so that
the soles of the feet are almost touching each other, ask the
patient to practice the inverting movements he did before
surgery, the unoperated foot first.
When he does that satisfactorily, ask him to do it with both
feet together, and with the eyes closed: the movement
produced by the transfer is not what he is used to seeing.
Hold the operated foot with your palm flat on the sole,
so that it cannot plantarflex. When he can do this without
looking, let him look; the first movement may be very
slight. Then let him graduate to doing it with only one leg.
Fig. 32-30 A VERY SPECIAL CAST for a patient who has had a Concentrate on getting him to dorsiflex the foot without
tibialis posterior transfer. A, backslab applied with the foot
dorsiflexed and everted. B, lateral strut of plaster. C, medial strut
using the gastrocnemius muscle, while trying to get a long,
applied and the plaster being passed round the toes. slow pull on the foot. Slowly increase the range and
Kindly contributed by Grace Warren. strength of the exercises with the leg horizontal in bed.
Once he can do them, let him sit and watch them.
With the foot in this position, firmly bandage on cotton After about 5days, when he can move the transferred
wool, but not too tightly, with extra layers over the heel. muscle easily and on command, sit him on the edge of the
Apply an 8-layer backslab from the tips of the toes to the bed, and let him dangle his legs over it. Once he sits, he is
mid upper calf (your assistant’s hand will be between the lifting the foot against gravity, so he must not start doing
backslab and the sole). Secure the slab with a 10cm this until he can isolate the transferred muscle and use it
bandage. Start at the big toe (32-30A), go across the sole without gastrocnemius.
medial to lateral, and pass 3 turns round the forefoot, just
proximal to the toes. Then pass 2 turns round the lower leg CAUTION!
(this will leave a strut of bandage at the lateral side of the (1),These exercises are tiring. During the 1st wk, encourage
ankle, and enable you to give the foot a good everting tilt him to do them many times a day for 5mins only, with
as you do so: 32-30B). Then bring the bandage down the 10mins rest periods with the foot back in its cast.
medial side of the ankle (to provide a medial strut) and run (2),Do not allow plantarflexion of the foot: the strong
a turn or two round the forefoot. Continue until the gastrocnemius can easily pull the sutures out of the tendon
bandage is finished. transfer.
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6th wk. If he can isolate the transfer, and has good Cut down until you see the deep fascia, cut this in the line
movement, let him stand with crutches or in parallel bars. of the tendon, and find peroneus brevis (usually deep to
Instruct him like this: 'Put your operated foot on the peroneus longus). Cut it out of the muscle (which will not
ground behind your other foot. Lift up your toes be used), pull it back into the foot at the 4 th incision, weave
(by contracting your transferred muscle), lift up your foot it into the lateral slip of the tibialis posterior, and repair
as if you are walking, and put it down heel first in front of the 6th incision.
your other foot. Lift it up and put it back again behind the CAUTION! Check the peroneal tendons behind the
other one'. Progress to walking carefully with crutches. lateral malleolus, because peroneus longus and brevis are
Make sure that every step uses the transferred tendon, often attached together there. If necessary, cut the peroneal
and that contraction is held until the foot reaches the retinaculum behind, but not below, the lateral malleolus,
ground again. Let him walk for periods of 10mins and rest so that you can pull the peroneus brevis down and out at
for 10mins. the base of the 5th metatarsal without harming the tendon.
Weave, adjust, and suture the peroneus brevis to the
7th wk. While he walks with crutches, check that he uses tibialis posterior as in the 2nd method.
the transferred tendon with each step. Practise on steps,
slopes and stairs. When he is confident, graduate to Then tunnel its free end back under the skin and, through a
walking without crutches. small J-shaped 7th incision, suture it to the periosteum on
When he is not doing physiotherapy, keep a bandage on the neck of the 5th metatarsal (32-29E). This will provide a
the posterior half of the cast, until he learns to control the better anterior lift if there is a very mobile foot.
foot without trying to plantarflex it. He should be walking
reasonably well at the end of the 7th wk, and be able to If pressure of the dressing causes sloughing and
discard the cast by day. Continue the protective splint at infection, dress and graft the bare area.
night until the end of the 3rd month.
If the wound becomes infected, the tibialis posterior
8th wk. When he is off crutches, he can start rising on tendon may adhere to other structures, or break. Splint the
tiptoe while supporting himself with his hands on a table. leg and apply a honey dressing (34.9). Rest it until you
The tendon join will gradually stretch, and the muscles have controlled the infection, then slowly resume
will adapt to the range of movement required of them: exercises.
provided you did not damage the periosteum, and so
promote the formation of adhesions above the ankle. If the patient does not use the transferred tendon,
exclude infection and persist with physiotherapy.
CAUTION!
(1),Do not try to force the foot into plantar flexion: If the toes curl under the foot, ulcers may form and the
it will gradually come down as he walks. toes and even the foot may be lost. Keep exercising them
(2),He must not start plantar flexion too early, or he will to prevent stiffness, and correct them surgically (32.12).
lose the power of dorsiflexion.
(3),Unless he learns to walk using the transfer with each If the foot is slack on the lateral side, and tends to
step, he will not get a good gait; but even if he doesn't use invert, consider doing another operation to tighten the
it properly he should be much improved. tendon, and perhaps bring peroneus brevis into the graft.
If the tibialis posterior tendon is short or is badly A. CONGENITAL HIP DISLOCATION (CDH)
scarred, so that its whole length cannot be used, transfer Congenital dislocation of the hip causes no symptoms at
what tendon is available, and insert it into the tibialis birth, so it has to be diagnosed by screening all newborn
anterior tendon more proximally. Then attach the babies. The danger is that it may cause premature
peroneus brevis as in the 2nd method, taking it long so that osteoarthritis in later life. If however you can recognize a
it bypasses the scarred region. baby's dislocated hip at birth, reduce it, and hold it in place
with a simple splint, you can usually prevent later
If the lateral slip of the tibialis posterior will not reach complications. If it is not diagnosed at birth, the child may
the lateral side of the foot without causing excessive present with a limp (often very mild) when he starts to
eversion, and the peroneal muscles are not functioning, walk. The leg may then be shortened and the hip unstable.
use a longer piece of peroneus brevis than that described in If however the dislocation is bilateral, you will not be able
the 2nd method. If necessary, there is 25cm of free tendon. to diagnose shortening, and he may appear to walk
Do not make the 5th incision but instead make a 6th incision normally, although careful observation should show a
10cm long, starting 1cm behind the lateral malleolus and slight waddle. Baby girls are more likely to dislocate their
running up the leg in line with the fibula (32-29B). hips than baby boys.
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Perthes disease is an avascular necrosis of all or part of the CLASSIFICATION AFTER CATTERALL:
epiphysis of the head of the femur. Essentially, the disease GROUP I GROUP II GROUP III GROUP IV
passes through five stages over a period of 2-4yrs: Height of No loss Mild loss Obvious loss No height
head
(1) To begin with the radiographs are normal. Sequestration None ½ to ⅔ <¼ normal Total
(2),All or part of the head of the femur looks abnormally of head bone only
dense, which indicates reduced vascularity. The cartilage Epiphysis Some lytic Significant Marked Collapsed
surrounding it does not die; instead, it continues to enlarge, areas increased increased with
radiodensity density mushroom-
and makes the joint space appear larger. like
(3) The epiphysis may fragment. protrusion
(4) New blood vessels gradually grow in, and the epiphysis Metaphysis Normal Some radio- Generalized Destruction
looks less dense. lucency changes
The epiphysis and metaphysis may soften,
so that the metaphysis bends and causes a mild coxa vara Risk factors:
(the head and the neck of the femur are angled more (1),Lateral subluxation of the head leaving it partly
medially from the shaft). uncovered.
(5) Eventually, the head returns to its normal density, (2) A translucent area in the lateral third of the epiphysis.
but it remains flatter, and the neck remains wider than (3) Specks of calcium lateral to the epiphysis.
normal. (4),Severe radiolucency of the metaphysis. A fragmented
Avascular necrosis of the femoral head also occurs in later upper femoral epiphysis which appears to be extruding
life because of steroid therapy, alcohol abuse and HIV from the acetabulum is a poor prognostic sign.
disease.
TREATMENT
A child is more likely to get osteoarthritis later in life, Do not intervene for Group I, or Group II & III if the child
if the head of the femur flattens. The older he is, and the is <7yrs, unless risk factors are present when a femoral or
more misshapen the head, the worse the prognosis. pelvic osteotomy is needed to contain the femoral head in
But, even if it is seriously flattened, he will probably not the acetabulum. Partial weight-bearing with elbow
get symptoms until he is middle aged. Unlike in slipped crutches and analgesics for 1yr is useful in the
femoral epiphyses, the involvement of both hips is unusual co-operative child: add active hip exercises, folic acid and
in Perthes disease (15% of cases, mostly in younger aggressive antibiotic treatment for staphylococcus or
children). salmonella infection.
The hope of treatment is to prevent deformity, as long as The prognosis in Group IV is bad and forcing the femoral
the epiphysis and underlying metaphysis are soft, which is head into the acetabulum makes things worse.
during the avascular phase and during revascularization. C..OTHER CAUSES
There are various possibilities, either alone or combined,
Hip disease in a child can present as: this may be so
none particularly satisfactory:
serious, that you should be on the look out for these 4
(1) Prolonged traction (1-2yrs) produces little benefit,
signs, which may be due to several diseases:
and is quite impractical.
(1) A painful hip.
(2),Attempting to avoid weight-bearing by restricting a
(2),A painful hip and a painful, but otherwise normal,
child's activity is difficult.
knee, due to referred pain along the obturator nerve.
(3),Weight-bearing callipers probably do not work and
(3) A painful knee with no pain in the hip.
should be avoided.
(4) A painless limp.
(4) Salter's Toronto splint is expensive and impractical.
Do not miss tuberculosis (32.3) and septic arthritis (7.16),
(5),Surgery has never been proved to be better than
because they need early treatment: septic arthritis urgently!
non-operative management.
N.B. Do not forget that abdominal and spinal conditions
TESTING FOR SPASM
can also cause pain in the hip.
IN EXTENSION. Lay the child supine, place your hands
Remember also the possibility of disease near the hip
on the affected thigh, and roll it backwards and forwards
e.g. iliac adenitis, pyomyositis (7.1), appendix abscess
(7-17). Compare both sides. If there is no spasm in
(6.16).
extension, test it in flexion.
IN FLEXION. Flex the hip and knee to 90º. Rotate the leg
Suggesting transient synovitis: no radiographic changes,
inwards and outwards. Rotation is usually more limited
spontaneous resolution in a few weeks without further
than abduction or adduction.
episodes. Some cases are viral, notably those due to the
ABDUCTION IN FLEXION is usually limited (32-34A).
parvovirus, and several joints may be involved. There may
be a history of mild trauma.
RADIOGRAPHS. Take an AP and a lateral view.
Abduct the hips, rotate the femurs inwards, and take an AP
view to include both hips, so that you can compare them.
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Suggesting septic arthritis/osteomyelitis (7.9,18): Flexion and adduction of the thumb causes pain over the
an acute onset, often a few hours. The hip is acutely radial styloid.
painful, and is immobile in any direction, with general
symptoms of acute infection. There are no bony changes If he complains of a ‘trigger finger or thumb’ so that,
for about 2wks. If a radiograph is good, you may see when he flexes one of the digits it locks, and he cannot
displacement of the fat shadow, or a widened joint space, extend it again, until he does so passively and forcefully,
indicating fluid in the hip joint. Partially treated cases are the flexor tendons are involved. The powerful flexors are
more difficult to distinguish clinically and by radiography. able to pull the swollen part of the tendon proximal to the
constriction, but the weaker extensors are unable to extend
Suggesting sickle-cell disease: onset 14-15yrs, especially the finger again unaided.
in a boy, with crises of pain, especially on internal rotation
and in the other hip (50% are bilateral) and other parts of TREATMENT
the body also, due to infarction, with a +ve sickle-cell test. If you see the disease early, inject the thickened tendon
sheath with 0·5ml lidocaine/hydrocortisone mixture using
Suggesting rheumatic fever: age 5-20yrs. Transient strict antiseptic precautions. Place the point of a very fine
symptoms and the involvement of other joints. needle into the palpable swelling and inject between the
tendon sheath, and the bone. You will see a wheal
Suggesting tuberculosis (32.3): any age, but common in appearing on the proximal side of the tendon sheath.
childhood and adolescence. Bone erosion around the If injection is not successful (50% of cases), apply a
acetabulum (appearing to enlarge upwards), often with tourniquet and get fine instruments. Make a small
damage of the femoral head. transverse skin incision. Use a fine tenotomy knife to make
a longitudinal incision in the sheath to release the tendon.
Suggesting rheumatoid arthritis: from childhood to Leave the sheath open, suture the skin only, and start
40yrs (at the onset). The involvement of several joints is active movements immediately. The result will be good.
usual, although mono-articular disease does occur. CAUTION!
(1);Avoid the cutaneous branch of the radial nerve near
Suggesting reactive arthritis (e.g. gonococcal or Reiter's the radial styloid and the digital nerves, so look for them
syndrome): urethral discharge, conjunctivitis and/or immediately you incise the skin.
anterior uveitis. A gonococcal arthritis is usually acute. (2) Do not try to make the tendon narrower or thinner.
Reiter's syndrome often follows a chlamydial infection, or (3);There may be several slips to the tendon, and thus
shigella, salmonella, campylobacter or yersinia diarrhoea. several compartments in the sheath; make sure each is free.
Review the anatomy before you operate.
Suggesting a slipped upper femoral epiphysis: 12-18yrs.
Usually a history of an acute onset, sometimes with a fall.
Occurs typically in tall obese sexually immature children. 32.16 Ganglions
Radiographs show a wide ‘woolly’ upper femoral growth
plate and extrusion of the femoral head from the
acetabulum on a lateral view. A ganglion is a round cystic swelling that develops on the
back of the wrist, or less commonly on the dorsum of the
CAUTION! foot, usually in connection with a tendon sheath, or a joint
(1) If you diagnose transient synovitis, follow up the child capsule. Flex the wrist over the edge of a table; this will
carefully: some children develop Perthes disease later. usually make the fluid in the cyst tense. You may be able
(2) Pain in the knee is often due to hip disease. to rupture the ganglion by pressing firmly with your
thumb; the fluid is then absorbed.
A PAINFUL HIP IN A YOUNG CHILD IS
INFLAMMATORY, UNTIL PROVED OTHERWISE If this fails, repeat it under general anaesthesia.
You may need to use a rubber mallet, or a similar object.
The chances of recurrence are no greater than following
surgery. Avoid operating because scar tissue will make it
32.15 Stenosing tenosynovitis
virtually impossible to rupture a ganglion easily.
Moreover, if you fail surgically to remove a ganglion
This is a chronic benign condition, in which the tendons no
completely, it is more likely to recur, and if you dissect too
longer run smoothly in their sheaths. The symptoms
energetically, you may damage a tendon.
depend upon which tendon is involved.
Never try to aspirate a ganglion!
If the patient complains of pain (and sometimes an
If you have to explore for a ganglion, because you cannot
abnormal prominence) over the radial styloid, which may
rupture it, use a tourniquet, and remove some tendon
be worse on extending and/or abducting the thumb,
sheath with the ganglion, trying if possible to keep the cyst
its abductor and short extensor tendons are constricted in
of sticky synovial fluid inside the ganglion intact.
their sheaths, as they pass over the groove in the end of the
Sometimes, a ‘ganglion’ is actually a synovioma (34.15D),
radius (this is de Quervain's disease). They are tender and
or even a tuberculous nodule! A synovioma gives a
you can usually feel a thickening in the tendon sheath.
characteristic ‘snowstorm’ appearance on a radiograph.
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If there is one or more severely deformed fingers, If you feel rough bone at the base of an ulcer or sinus in
such as a terminal phalanx bent to 90º, the hand and pus oozes from a joint, this is osteomyelitis
consider amputation or, better, an arthrodesis with or septic arthritis.
shortening of the bones to allow for the contracted tissue
on the front of the joint. If you feel rough bone at the bottom of a sinus over the
tip of the finger, this is osteomyelitis of the terminal
If the little finger is badly deformed, remove it with half phalanx. If only part of a phalanx is dead, allow dead bone
its metacarpal. Its absence will hardly be noticed. to separate spontaneously. Otherwise, you are likely to
open the joint, causing loss of more finger length.
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If most of a phalanx is dead, disarticulate the joint and If there is a grossly swollen hand, with pitting oedema of
remove the base. the dorsum, and obliteration of the concavity of the palm,
there is probably a midpalmar space infection (8.9)
If there is septic arthritis, aim stiffness in a useful
position. Splint the hand and fingers as nearly as possible If the septic arthritis does not heal, excise the joint.
in the position of function (7.17), and use cloxacillin or Make a dorsal incision, remove the joint surfaces,
chloramphenicol. Immobilize the infected joint for at least and any dead tissues, and splint the joint in a position of
4-6wks after the infection is controlled, and the ulcer function (7.17). Pack the cavity that remains, and allow it
healed, while putting all the other joints through their full to heal by granulation. Keep the joint splinted in the
range of movement daily. If splinting one finger is position of function, and wait 12wks till the joints are no
difficult, you may be justified in splinting it with one of its longer painful.
neighbours, depending on their condition. Curette dead
bone and granulations, and pack the cavity with
hypochlorite (‘Eusol’), honey, ghee or sugar to encourage
sequestra to discharge and granulations to fill the cavity. 32.19 Ingrowing toe-nail
An ankylosis usually takes 12wks and a fibrous arthrodesis
6-8wks. Ingrowing toe-nails are unusual in barefooted people.
One of the hazards of a shoe is that it may press on the
sides of the big toe over a long period, and make the side
of the nail grow into the soft tissues and cause pain,
inflammation, and the discharge of pus from the nail fold.
Carefully cutting away the nail may relieve the symptoms,
but if this fails, more radical surgery is indicated. If the
toe-nail is not deformed, you can excise a wedge of soft
tissue; but if it is deformed, a more comfortable toe will
result if you remove the whole toe-nail, including its bed.
If the nail grows back in the same way, you can again
remove a wedge, including a wedge of the nail bed.
A tourniquet gives a bloodless field: you can achieve this
with a rubber twisted around the base of the toe.
Use a ring block with lidocaine. Do not do this operation
if there is peripheral vascular disease; use prophylactic
antibiotics with diabetics and advise elevation for 24hrs.
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If a bone cyst develops, usually in a child in the shaft of EPICONDYLITIS (TENNIS ELBOW)
the humerus or femur, the possibilities include a benign This is a common condition in people who use the
bone cyst, fibrous dysplasia, benign osteoblastoma,
extensor muscles of their forearms vigorously, and not
non-osteogenic fibroma, enchondroma, Brodie's abscess
only in tennis players. It is caused by minute tears in the
(7-2A), and tuberculosis. If it is benign, it is probably a
origin of the forearm extensor muscles. The patient
BENIGN BONE CYST, or an area of fibrous dysplasia.
complains of pain just distal to the lateral epicondyle of the
Aim to avoid a pathological fracture. The cyst may need to humerus, without any history of trauma. The pain is worse
be opened, scraped out, and filled with a cancellous bone when you press over the radio-humeral joint during
graft, if it does not resorb spontaneously.
pronation and supination. It lasts for months, or years, and
may eventually disappear spontaneously. If it is
If the bone fractures across a small cyst, it will probably
debilitating, treat by injection of hydrocortisone
heal spontaneously.
suspension 2·5ml with an equal volume of 2% lidocaine
into the tender area. One injection has an 80% chance of
success, and a second one 2-3wks later another 10%.
Take very careful aseptic precautions, and do not use
>3 injections. If the disability is severe, a muscle slide on
the extensor origin is necessary.
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PERIOPERATIVE MANAGEMENT
33 Paediatric surgery POSITIONING & WARMING
Whenever possible keep the child next to his mother or
nearest relative. If he is old enough, try to explain what is
33.1 Surgery in children, infants & neonates happening and do not lie by saying things won’t hurt when
they will! Wherever possible, let a neonate breastfeed,
otherwise use glucose on a stick, finger or dummy to
There is an increasing proportion of children in LMICs.
pacify him.
The number of specialized paediatric surgeons available in
If you need to perform an invasive procedure, wrap the
Europe is c.1:50,000 population; in South Africa
child in a warm blanket to immobilize him safely
1:2,669,000, and elsewhere in Africa much less.
and to prevent him from fighting and kicking you!
These figures reflect the fact that in Africa well over 50%
Prepare what you need beforehand, and get the mother and
of the population are children.
a nurse to assist you.
More relevantly, there are c.500 live births per year per
Make sure the theatre is warm. Place a child on a
European paediatric surgeon; in South Africa over 35,000.
well-padded cross made of two splints, and bandage the
So the specialist in Europe will wait 6yrs to see a case of
arms and legs to it. Cover the rest of the body except for
oesophageal atresia (c.1:3,000 live births), whereas the
the part to be operated with cotton wool or commercially-
specialist in South Africa sees one about every month!
produced silver foil. Use warmed solutions for preparation,
Taking this argument further, it is obvious that every child
infusion and washouts.
needing surgery cannot hope, in the poorer parts of the
world, to be treated by a specialist. This is why we
INTRAVENOUS LINES. An infant requiring GA should
describe the simpler procedures here for the non-specialist.
have a good IV access, namely, in the antecubital fossa,
scalp, or neck. Avoid using a tourniquet to bring up a vein:
CHILDREN ARE NOT SMALL ADULTS
the pressure of a finger in a small child suffices.
You rarely need to make a cut-down, but may need a
You may be accustomed to operating on adults but find the
central venous line preferably using the subclavian route.
child patient, especially the neonate, an unfamiliar and
Never attempt this twice on the same side without checking
intimidating prospect. You may find also you have to pay
that no iatrogenic pneumothorax has developed.
special attention to the concerns of the parents and family.
If you are unable to find a suitable vein to cannulate,
try in the OT under good light and with the child sedated.
“TO TREAT AN ADULT AS A CHILD
Use ultrasound to help you, if possible.
IS NO MISDEMEANOUR;
BUT TO TREAT A CHILD AS AN ADULT
UMBILICAL VEIN CANNULATION is a good and
MOST OFTEN ENDS IN DISASTER”
reliable option; avoid cannulating the femoral vein in
children wearing nappies because of the high risk of
Children differ from adults in every anatomical,
infection. If available, use ultrasound to detect veins
physiological, pathological or psychological sense.
suitable for cannulation and to facilitate insertion.
They cannot handle fluids, blood sugar, electrolyte
changes and heat like adults. Their fluid requirements are
Alternatively, introduce an INTRA-OSSEOUS NEEDLE
different and their anaesthetic requirements likewise.
into the tibia. This is fast and reliable in children of all
Neonates tolerate fluid and electrolyte loss particularly
ages. Take care to avoid the epiphyseal plate.
badly: they do not have the ability to retain sodium and
Remember many substances are toxic to bone marrow as
water postoperatively or concentrate urine like adults,
well as venous endothelium and can easily cause
and they also easily become cold, dehydrated and
thrombosis or even extravasation in neonates.
hypoglycaemic. They bleed easily and have little
Therefore fix the cannulae properly and re-check its
physiological reserve, so they can deteriorate quickly,
position and functioning repeatedly.
and do not tolerate delays in treatment (e.g. referral to a
distant hospital).
FLUIDS. Replace all the initial fluid deficit with Ringer’s
lactate or 0·9% saline during the 3-6hrs of preoperative
Specific paediatric surgical problems are described in this
chapter; other important aspects of paediatric surgery are preparation time. Prescribe the postoperative fluids
described elsewhere (consult the list at the end of this chapter). yourself. Do not leave this to the nurses, and do not exceed
5ml/kg/hr unless the fluid deficit is uncorrected.
Trauma which covers fractures, burns, snake bites, and other Where possible, provide the fluid needed as half-strength
violence including sexual abuse, is covered in Volume 2. Darrow's solution with 5% dextrose, or Ringer’s lactate
with 5% dextrose, or half-strength (0·45%) saline with 5%
dextrose.
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Fluid balance in a neonate is even more critical: take great CALCIUM. Normal maintenance in the neonate is
care he gets enough but not too much. A term baby 2∙25-4∙5mmol/kg/day, which means 10-20ml/kg of 10%
usually needs c. 100ml/kg/day (less in the first 48-72hrs), calcium gluconate per day.
and a premature baby 120-150ml/kg/day. For a child
between 10-20kg, use 80ml/kg; and >20kg, 60ml/kg. NASOGASTRIC TUBE (4.9).
It is best to administer IV fluids as boluses rather than Insert a well-lubricated tube of appropriate size,
relying on an unreliable or unmonitored infusion. which has been stiffened by placing it for a short time in
the freezer, through the nose with the neck fully flexed.
For major surgery, make sure you monitor postoperative In neonates, you can pass the tube through the mouth.
urine output. A child should pass 1-2ml/kg/hr,
and a neonate 2-4ml/kg/hr. You do not need an indwelling NUTRITION.
catheter unless you are absolutely sure the urine output Interrupt feeding as little as you can. Do not starve a child
will be observed and measured. A urethral catheter is often for >4hrs before an operation, and restart feeding as soon
not appropriate; so, for a boy, use a condom catheter afterwards as you can. Ask whether he has passed flatus.
(Paul's tubing: 27-3) of suitable size; alternatively, use a Listen every 4hrs for the return of bowel sounds, and note
fine feeding tube. If you do need a urethral catheter, pass it whether he has passed faeces or flatus; these signs show
yourself and take the precautions described (27.2), making that feeding can start. Bowel sounds alone are not so
sure a girl’s hips are fully flexed and externally rotated for reliable in children, so you can assess gastric emptying
a good view. Make sure you have a good light, and can see more accurately by aspirating the stomach hourly,
the urethral orifice. In a boy, you might find the foreskin before each intake of feed. Adjust the amount of feed
quite sticky with smegma: carefully clean it with sterile tolerated according to the amount aspirated. Proceed with
water while pulling back the foreskin gently. In girls, a staged feeding regime: start with ¼ of a normal
spread the labia to expose the vulva: the urethral orifice (pre-operative) feed portion, diluted 1:2 with water;
may be very difficult to see. It might help to push gently in double this volume after 2hrs and then again after a further
the suprapubic area to cause some urine to come out: 2hrs, and then give the full undiluted feed after a further
watch carefully from where it emerges! If you have 2hrs. If the child brings up the feed, go back one stage, and
accidentally put a catheter in the vagina, leave it there try again. Most children are back on feeds 48hrs post
temporarily before trying again with a new catheter (to surgery. If a child was starved <4hrs, and feeds are
show you which is the wrong passage). Always be very restarted soon, he is unlikely to be short of energy.
careful, because you can tear the urethra if you use force!
Where nutrition is going to be delayed for some time,
Replace blood with blood ml for ml if you lose >10ml (or you can provide 50% glucose through a central venous
less in premature neonates); a child has a blood volume of line, using it to replace the energy deficit resulting from
approximately 75ml/kg, a neonate 85ml/kg and a starvation. Reckon that, if he cannot feed orally for more
premature baby up to 100ml/kg. Monitor and replace than 3 days, he needs 1-2g/kg/day. Test the urine and
blood loss with the greatest care (3-1). Weigh all watch for glycosuria and an osmotic diuresis.
blood-soaked swabs accurately, on a scale borrowed from Alternatively, dilute 25ml of 50% dextrose in 500ml of
the pharmacy, if necessary. Try to avoid blood loss by all half-strength Darrow's solution and increase the
means! Make sure all neonates get 1mg Vitamin K IM or concentration gradually.
IV pre-operatively.
In working out the energy content of various fluids,
POTASSIUM. Normal maintenance is 1-3mmol/kg/day. remember that 1l 10% dextrose contains 1700kJ
No extra potassium is needed in the 1st 24hrs of life. (=400kcal). A child's daily postoperative energy needs are:
If a child is not taking oral fluids by 24hrs, he needs a
potassium supplement. Add 10mmol to 500ml of IV fluid Neonate 3-10kg 10-25kg 25-35kg 35-60kg
(=20mM K+). Do not infuse >10mmol/hr or 420- 250- 190- 145- 125-
840kJ/kg 330kJ/kg 270kJ/kg 190kJ/kg 145kJ/kg
3mmol/kg/day. Or, use 5% dextrose in half-strength saline, (100- (60- (45- (35- (30-
which contains 18mM K+. Potassium replacement can be 200kcal/kg) 80kcal/kg) 65kcal/kg) 45kca/kg) 35kcal/kg)
very dangerous in children, if it is handled incorrectly.
Avoid adding potassium if renal function is disturbed. Note that stress, cold, infection, trauma and surgery
If a child becomes drowsy postoperatively (and the increase ordinary nutrition requirements; these should be
glucose is correct), and the bowel becomes silent, suspect 2-3g/kg protein and 10-15g/kg carbohydrate per day for
ileus, and add more potassium. the neonate.
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If the obstruction is proximal to the middle of the small Suggesting subarachnoid haemorrhage: impaired
bowel, the abdomen does not distend significantly, conscious level; also look for signs of hydrocephalus.
but if the obstruction is below this point, it does.
The distension may be localized or generalized. The child Suggesting some other cause of abdominal distension:
often presents only after 3-5days, with severe dehydration. a part of the abdomen which is dull to percussion.
Causes include distension of the bladder in urethral
An obstructed bowel is an emergency. Electrolyte and obstruction, tumours, ascites, congenital cystic kidneys,
calorie loss affect a baby more dramatically than an adult, and hydronephrosis.
so he needs urgent treatment, within a few hours.
Suggesting necrotizing enterocolitis (see below): a toxic
If you are a careful, dextrous operator, you may be able to lethargic preterm (<2kg) or HIV+ve baby, refusing feeds,
save a few of these children despite not having with abdominal distension, vomiting and rectal bleeding
sophisticated back-up: you will not have time to transfer (>25%), with radiological signs of intramural intestinal gas
these patients elsewhere. and air bubbles in the portal vein.
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JEJUNO-ILEAL ATRESIA OR STENOSIS may occur at At laparotomy, you need to resect the affected bowel and
any point in the small bowel. Typically, it presents as fashion one or even multiple enterostomies (11.5).
bilious vomiting within 24hrs of birth, slightly later than The mortality is high (up to 50%), and in severe cases,
with duodenal atresia, perhaps 1hr after the first you might get better results by simple lavage and drainage
breast-feed; but it may be delayed for 2-3days. of the abdomen. Unless you can manage mechanical
ventilation and careful intensive care of these babies, their
If there is jejunal stenosis (narrowing) rather than prognosis is very poor.
atresia (blockage), vomiting may be delayed for as long
as 2wks. Obstruction in the upper jejunum is more MECONIUM ILEUS is rare: it occurs in babies with
common. If the obstruction is low, it presents more slowly, cystic fibrosis (mucoviscidosis) because absence of
with distension more evident than vomiting. About 50% of proteolytic enzymes from the pancreas make the intestinal
these children pass some meconium! Hydramnios is content putty-like, and failure of mucus production
common in the mother prenatally. Erect AP radiographs from the intestinal mucosa leaves it unlubricated.
show considerable gaseous distension, ending at the site of The baby’s sweat has high levels of sodium (>80mM).
obstruction, with several fluid levels. Unfortunately, There is bile-stained vomiting and gross abdominal
by the time that several fluid levels are present obstruction distension, with visible peristalsis and often
is advanced. A bowel resection (33.3) is necessary. palpable compressible bead-like stool in the intestines.
Erect AP radiographs rarely show fluid levels,
VOLVULUS OF THE SMALL BOWEL may present in and distended loops of bowel may vary greatly from one
older children (12.8), with sudden abdominal pain, part of the abdomen to another. You may be able to detect
distension and shock, or it may present in the 1 st week of the hyperechoic intraluminal bowel content on ultrasound.
life, as an acute abdomen with bile-stained vomiting and Occasionally there is a single impacted lump (plug) of
abdominal distension. Volvulus usually involves the distal meconium blocking the bowel.
small bowel and proximal colon, and is due to a congenital
malrotation of the intestine. If Ladd's bands (see below) You can often break up the thickened meconium with a
are responsible, surgery is usually simple, because there is warmed gastrografin enema, but you need an IV infusion
no need to resect bowel, if you managed to detect the running to correct fluid shifts, and must beware of bowel
obstruction early. However, strangulation in volvulus perforation. Never use barium because this can block the
develops rapidly, and then resection is mandatory. bowel solid! Continue with repeated rectal washouts with
This often means an extensive bowel removal, leading to warm water. Rarely you might need to perform a washout
short bowel syndrome. via an ileostomy (11-12G).
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LAPAROTOMY FOR NEONATAL BOWEL OBSTRUCTION Pass a thin soft long nasojejunal tube through the
(GRADE 3.5) anastomosis for feeding post-operatively. Stiff plastic
tubes cause problems, so use a soft silicone tube
Make a transverse muscle-cutting incision (11-1), (VP shunt tubes work well). You will also need a
as this breaks down less often than a midline opening. nasogastric tube for suction.
Use the finest haemostats, and handle the bowel with the
greatest care (11.3). Hold it with stay sutures, and do not Occasionally, you will not be able to perform a
use bowel clamps unless you have vascular ‘bulldog or duodeno-duodenostomy if the atresia is too distal;
Blalock’ clamps (3-2). Cover exposed bowel with moist then an end-to-side retrocolic duodeno-jejunostomy is the
warm swabs. Examine the whole bowel, because there alternative. Do not fashion a gastrojejunostomy as this will
may be more than one area of obstruction. Inject air into result in anastomotic peptic ulceration later.
the distal bowel through the wall with a very fine needle If you cannot do either, fashion a feeding jejunostomy
and milk it along to see if there are any further sites of (11.7) to bide time till you can arrange the definitive
stenosis. Once you have opened both limbs of the bowel surgery.
between stay sutures, insert a small tube and flush both
clear of inspissated meconium completely and repeatedly, For JEJUNAL ATRESIA, you will have to anastomose the
taking care not to spill the contents. By doing this you will dilated jejunum above the stenosed segment to the
be able to check for any further areas of stenosis or atresia. collapsed jejunum below it. The blood supply of both ends
Furthermore, in the dilated proximal segment you will note of the affected bowel is often deficient, so resect it
where bowel movement is present and where you can proximally at a point where it is about 1-1·5cm in
expect recovery. In the distal unused part, irrigation will diameter, i.e. normal. Fashion a ‘fish-mouth’ opening so as
provide some dilatation and lubrication for subsequent to make an ‘end-to-back’ anastomosis as described above
passage of stools. (33-1D,E). Do not make an end-to-side anastomosis
because this results in the blind-loop syndrome (bacterial
The proximal bowel is hugely distended and the distal overgrowth leading to malabsorption).
bowel collapsed, so a straightforward anastomosis is
difficult. Tailor the ends so that their sizes are a little more Make quite sure there are no further stenotic segments by
equal by dividing the distal part at 45˚ (33-1D) and make a injecting saline into the distal bowel lumen and massaging
cut on the anti-mesenteric border to give it a V-shape it into the caecum. If there are (in 20%), try to include
(33-1D). Make a single layer of instrument-tied 4/0 or 5/0 them all by doing one resection, if this does not remove
long-acting absorbable sutures (33-1E). Gently invert the excessive bowel. Otherwise make multiple resections or
posterior wall of the bowel, as you insert the first sutures. multiple stomas. Decompress the proximal intestine with
If you can do this satisfactorily, inverting the anterior wall suction through a Ch12 Foley catheter. Do not try to milk
should not be difficult. As you go round the corner from intestinal contents into the stomach, as they may spill out
the posterior wall of the anastomosis to the anterior, through the oesophagus into the trachea.
continue to invert the bowel wall. Suture the serosa if
appropriate. Always check that the anastomosis is free of For VOLVULUS OF THE MIDGUT, when you open the
tension, watertight and well vascularized. abdomen, you will see distended coils of small bowel,
A child grows, so suture the bowel and the wound with which may be cyanotic and congested, and obscure the
absorbable sutures. Suture everything meticulously. right colon. Deliver the small bowel to the surface,
and protect it with warm moist packs. Examine the base
For DUODENAL ATRESIA, the best operation is a of the mesentery to see which way it has twisted
duodeno-duodenostomy. Bring the proximal (dilated) and (usually clockwise). Untwist it (there may be 2 twists),
distal (collapsed) duodenal loops next to each other by and check that its normal colour returns.
carefully separating adhesions to the liver, gallbladder,
bile duct and pancreas. Where there is a significant gap There may be an incomplete malrotation where the
between the atretic segments, you can usually mobilize the caecum is found in the right hypochondrium fixed by
distal part, together with the duodeno-jejunal junction to Ladd’s bands passing across the 2nd & 3rd parts of the
the right behind the superior mesenteric vessels. If there is duodenum to the lateral abdominal wall. This means the
an annular pancreas (very rare), do not divide it: mobilize caecum is very close to the duodeno-jejunal flexure,
the duodenum enough to make an anastomosis in front of and the base of the mesentery is narrow and
the pancreatic ring. so prone to twist. Divide the constricting bands (33-2):
there are frequently more than one. Free up the ligament of
Aim to make a large (2-3 cm) diamond-shaped side-to-side Treitz, and so straighten the duodenal loop.
anastomosis between them (33-1B), by making a Then carefully separate all adhesions between loops of
transverse incision in the dilated and a longitudinal bowel, and make sure the duodenum is not kinked,
incision in the collapsed segment. If you encounter an and is patent. Do this by manipulating the stomach
intraluminal web, cut this out carefully leaving a thin rim contents through into the small bowel. Make sure that the
circumferentially. caecum is now resting in the left iliac fossa.
Remove the appendix attached, because of its subsequent
abnormal position.
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Occasionally, bowel twists around a remnant of the If the membrane is intact and the viscera are covered,
omphalomesenteric (vitelline) duct; divide this and assess delay surgical intervention. Non-operative treatment is
the bowel viability as before. simple but needs particularly good nursing care, and has
the disadvantage of not being able to inspect the internal
DIFFICULTIES WITH NEONATAL BOWEL OBSTRUCTION organs.
If you find a tube (often solid) of duplicated small Clean the sac with an antiseptic, and apply 70% alcohol or
bowel, resect both the ‘normal’ and duplicated segments 1% gentian violet hourly for the 1st 48hrs, and then less
do not try to separate them as the blood supply of the often as a crust forms which takes about 3wks. The crust
normal part will be compromised. will separate from the periphery, as epithelialisation takes
Do not drain the duplication into the normal bowel as place. This will then result in a large skin-covered ventral
malignant change may result later on. If the duplication is hernia (33-3H) which will need repair later (18.10).
one large cyst, open it and try to strip its mucosa.
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Place these within the silo gently, taking time for oedema
to reduce, making sure that you aspirate the stomach at
the same time. Tuck the open end of the silo with its ring
into the peritoneal cavity under the abdominal wall skin,
and try to fix it under the abdominal wall. Extend the
defect by incisions superiorly and inferiorly. Retract the
abdominal wall edges and suspend the silo gently from
above the bed and wait for the bowel to reduce
spontaneously (usually 5days), and then wait 24hrs
before removing the silo. The defect will close
spontaneously if you pull the umbilical cord to the right
over it. Monitor the neonate for respiratory problems
from pulling up the diaphragm or increased intra-
abdominal pressure, and start feeding as soon as the
reduction is complete.
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SURGICAL REPAIR OF OMPHALOCOELES (GRADE 3.3) Reduce the hernia, and close the defect in three layers.
If necessary, hold up the edges of the defect with
Prepare the skin, including the omphalocoele sac. haemostats. Close the abdomen with long-lasting
Tie and divide the cord, as it emerges from the sac, with '0' absorbable sutures and the skin with simple sutures of 4/0
absorbable suture (monofilament cuts through too easily). monofilament. Postoperatively, feed with expressed breast
Incise the skin ½cm, or less, from the edge of the defect. milk by nasogastric tube, until the baby is sucking well,
At the edge of the sac, find and tie the umbilical usually in 2-3days.
arteries infero-laterally in the 5&7 o'clock) positions;
tie the umbilical vein superiorly (in the 12 o'clock If you fail to reduce the contents of the sac, or if the sac
position). Expose the edge of the fascia and peritoneum, is ruptured, leave as much of it intact as possible.
and remove a ring of tissue. Excise any tissue of doubtful Find and tie the vessels as above. Excise any tissue of
viability from the sac wall. doubtful viability from the wall of the sac, including the
stumps of the vessels.
GASTROSCHISIS TREATMENT USING A STERILE SILO Stretch the abdominal wall with your fingers to allow as
much of the viscera to reduce as possible; free any
adhesions of the sac from the liver.
As for gastroschisis above, fix up a silo; gently
twist this to reduce the visceral content after 5days,
every 2-3days. When you can reduce the
omphalocoele easily, you can remove the bag and
close the defect as above.
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There are many kinds of lesions, but what matters most is EXAMINATION. Ask your midwives to examine the anus
whether a child's rectum ends close or far from the skin. in all children. Ask them to refer:
If the rectum extends close (<1cm) to the skin (1) any child with an abnormal anus,
(infra-levator lesions), you can create an anus, or dilate a (2);any child who passes no faeces for 12hrs, and whose
stenosed anus relatively easily. But if the rectum ends abdomen distends. Examine him, and if necessary,
further from the skin (intra- and supra-levator lesions), pass a rectal thermometer or a stiff catheter.
make a temporary colostomy, and arrange later for the
sigmoid colon to be pulled through to the perineum, or an If there is no anus, make an opening before the bowel
anorectoplasty to be performed. This is difficult surgery, distends. Look for other congenital abnormalities.
and continence is often not perfect.
The anus or rectum may fail to develop entirely (agenesis), If there is a mass of irregular epithelium where the
it may partly fail to develop (atresia), or the rectum or anus anus should be, the diagnosis is almost certainly anal
may be narrowed (stenosis). Agenesis (but not the other stenosis. Probe it and look for even a trace of meconium to
lesions) may be combined with fistulae between the confirm the presence of an opening, however tiny.
rectum, and the urinary, or genital tracts, of either sex.
These variables combine to produce a complex series of If there is a thin veil of epithelium overlying the anal
lesions. Some fistulae are useful, because you may be able orifice, surrounded by normal skin folds and rugae,
to dilate them to make an anus. About 75% of cases are there is an imperforate anal membrane.
low lesions with fistulae.
If the anus looks normal, until you put a probe into it,
LOW ANORECTAL LESIONS: when you find that the rectum is almost or completely
(1) Anal stenosis or imperforate anal membrane in boys or blocked, the diagnosis is rectal atresia. You may find a
girls (33-5B,C). very small hole which you can dilate.
(2) Anocutaneous fistula in boys and girls.
(3) Anovestibular fistula in girls (33-8). If the anal skin is smooth, there must be some other kind
of lesion, other than stenosis.
INTERMEDIATE LESIONS:
(1) Rectobulbar urethral fistula in boys; rectovestibular & LOOK FOR FISTULAE:
rectovaginal fistula in girls. Check for meconium in the urine, or in the vagina or
(2) Anal agenesis without fistula in boys and girls (33-6D). vulvar vestibule. Look for a dark blob of meconium under
the skin, especially in the midline raphe. A perineal
HIGH ANORECTAL LESIONS: ultrasound scan, demonstrating a fluid-filled track, may
(1),Anorectal agenesis with rectoprostatic, urethral or well help you diagnosing a fistula.
rectovesical fistula in boys; or rectovaginal fistula in girls.
(2),Anorectal agenesis without fistula in boys and girls
(33-6E).
(3),Rectal atresia in boys and girls (33-6F). There is a
normal looking anus in the normal place, with low bowel
obstruction (no meconium, abdominal distension and only
vomiting late in the presentation).
N.B. A contrast enema is safer than probing in this
situation.
(4),Cloaca (a combined opening of urethra, vagina and
rectum) in girls. This looks like a ‘one-hole’ perineum.
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RADIOGRAPHS (INVERTOGRAM, 33-7) Suture the anal mucosa to the skin, using interrupted long-
Wait until 12-16hrs after birth, when the gas the child has lasting absorbable sutures. Dilate the anus as in (1) after
swallowed has reached the blind lower end of the bowel. 5days. You can deal with the ‘anterior ectopic anus’
Place the baby prone on a pillow so that the anus is (really a type of anocutaneous fistula) in the same way
uppermost. Flex the knees. Strap a small piece of metal with a cutback operation.
such as a paper clip flat on the skin where the anus should
be.
Take a lateral film. The bubble of gas in the bowel will be
uppermost. The distance between it and the metal will
show you how much tissue there is between the bottom of
the bowel and the skin.
Interpret the films as follows: if the gas bubble is < 1cm
from the anus, this is a low lesion; if it is >1cm from the
skin, it probably is a high lesion. More accurately, draw a
line between the posterior part of the pubis, and the
coccyx. If you see any blind dilated bowel distal to this
line, this is a low lesion. If it remains proximal to this line,
the lesion is high. Anything in between is intermediate.
CAUTION!
(1),Radiographs are useful but not completely reliable.
There may not have been enough gas in the bowel, or there
may be a fistula higher up.
MANAGEMENT
If a child has a low lesion, operate early. The obstructed
bowel is going to distend, so, as soon as he has swallowed
enough air to help make the radiographic diagnosis,
pass a nasogastric tube. Maintain hydration and add 1mg
IM vitamin K1.
CAUTION! If you are in doubt, fashion a colostomy.
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This is much less of a disability than it might seem; The child becomes constipated, and the abdomen distends;
it is, for example, compatible with a normal sex life, and in acute cases the bowel may obstruct.
and the husband may be quite unaware of it! However,
some faecal incontinence may always be a problem. SUBACUTE PRESENTATION: a child presents soon
after birth with subacute intestinal obstruction; its onset is
ALL OTHER ANORECTAL LESIONS: more gradual than with complete mechanical obstruction,
but may still be fairly acute. There is usually a history of
Create a SIGMOID COLOSTOMY (11.6). Make a small delayed passage of meconium >24hrs after birth.
Lanz-type transverse incision (11-1) in the left lower
abdomen and carefully retract the muscle layers until you Rectal examination often results in explosive projectile
reach the peritoneum. Open this very carefully; underneath passage of meconium or faeces, which may result in
you should find colon: gently pull some out, perforate it visible deflation of the abdomen. Abdominal distension is
and aspirate its contents. This will reduce abdominal always present, and may be quite alarming if there is
distension and hopefully allow you to extract enough enterocolitis or bowel perforation (20%), resulting in a
bowel to make a skin bridge to let you really divide the TOXIC MEGACOLON. There are then signs of peritoneal
colon. If you cannot do this, fashion a loop colostomy. inflammation. In this situation, repeated washouts will
make the situation worse!
Wash the distal colon free of meconium with warm saline:
if you do not do this early the meconium will solidify like LATE PRESENTATION: an older child has a chronic
concrete! Make sure you do frequent washouts if there is history of constipation without laxative abuse or
a recto-urinary fistula in order to minimize urinary tract psychosocial problems. The abdominal distension may be
infection. gross and affect breathing. Intermittent bowel actions tend
to be explosively incontinent and infrequent.
Do not perform a formal laparotomy: it is difficult and
unnecessary and the baby may well not survive it. INVESTIGATIONS
You do not need stoma bags for a neonate! Abdominal radiographs show multiple loops of distended
Wrap the nappy over the stoma, and advise mother to bowel occupying the whole abdomen, with only
clean gently around the stoma as she would for the anus. occasional air-fluid levels and minimal or no air in the
rectum; if there are gas bubbles in the bowel wall, this is a
Do not be tempted to operate on the anus of any sign of enterocolitis. If there is a pneumoperitoneum
intermediate or high anorectal agenesis; leave fashioning (which may be huge), this is a sign of bowel perforation.
a neat anoplasty to an expert. This will not be possible if A barium (or safer, gastrografin, which does not become
you have damaged the sphincter musculature. solid) enema may conclusively make the diagnosis:
look for a dilated proximal segment of colon and narrow
DIFFICULTIES WITH ANORECTAL MALFORMATIONS distal rectum. This delineates the ‘transition zone’.
If the anus becomes stenosed, it has become fibrosed. Repeat the film after 24hrs to see if there is retained
Unfortunately, regular dilatation perpetuates the cause of barium proximally. A post-evacuation film can be
the fibrosis. A formal anoplasty will eventually be needed. particularly helpful.
If there is a mucosal prolapse or skin excoriation after Check the thyroid function: hypothyroidism may totally
an anal operation, apply talc powder and carefully mimic Hirschsprung’s disease.
prevent soiling of the perineum. The prolapsed will reduce
spontaneously. FULL THICKNESS RECTAL BIOPSY (GRADE 1.4)
If excess fluid is lost from a colostomy, wait for 14days, You need this investigation to make a definitive diagnosis.
while adding extra fluid to maintain a satisfactory fluid If the presentation is acute, do it at the same time as a
balance. The stools will usually become formed. sigmoid colostomy (11.6).
OTHER COLOSTOMY COMPLICATIONS: (11.6) Put the child in lithotomy position under anaesthesia
(e.g. ketamine), and dilate the anus with Hegar’s dilators.
Clean the anorectum with non-alcoholic antiseptic
solution, and leave a swab soaked with this inside the
33.7 Hirschsprung's disease rectum, proximal to the operation site. Remember to
record this swab inside! It is best if you tie a suture to it to
In this not uncommon disease, the neuroganglion cells in hang outside the anus on a mosquito forceps.
the wall of the rectum are absent, so that faeces are not
propelled onwards as they should be. The length of the Evert the posterior wall of the anus on both sides with
aganglionic segment varies although it is usually confined Allis forceps and place all-layer stay sutures postero-
to the rectosigmoid in 75%, but may be tiny (ultra-short laterally on both sides at the level of the internal sphincter
segment) or extend to the caecum or beyond (c.5%). (33-9A). Retract the anterior wall of the anus upwards,
This results in dilation and hypertrophy of the proximal exposing the rectal wall.
(neurologically intact) segment with transition to a
normal-sized or narrowed distal (aganglionic) segment.
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If there is an extra-hepatic
stump, this too can be
anastomosed. Without surgery,
death is inevitable. Even in
experienced hands the outlook
is poor, and 30% of children
develop liver failure.
NEONATAL JAUNDICE
The time of onset is of great
diagnostic value.
If a child starts to become
jaundiced in the first 6-24hrs,
jaundice is likely to be
haemolytic from:
(1),Septicaemia from an
umbilical infection. Look for
signs of infection of the cord
and the surrounding tissues
(septicaemia from cord infection
can also occur later).
(2),Haemolytic disease of the Fig. 33-11 HYPOSPADIAS CORRECTION: 1ST STAGE
newborn. Usually, the baby is Rh D+ve, the mother is Chordee correction. A, apply a tourniquet. B, correct the chordee:
D-ve and has anti-D antibodies as the result of having had circumferential incision. C, excise the fibrous band. D, slit the glans
a previous D+ve child or abortion, or of having been given penis. E,F, divide the dorsal foreskin into 2 long flaps. G, bring flaps
round to cover raw ventral penile surface. After Blandy J. Operative
D+ve blood. Other blood group incompatibilities may Urology, Blackwell 2nd ed 1986 p.206 Figs 14.2-6
have the same effect (e.g. ABO).
(3) Congenital syphilis (severe infection).
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PREPARATION. Take the strictest aseptic precautions SUSPENDING A BABY AFTER MENINGOMYELOCOELE REPAIR
and be careful not to damage the cord.
Lay the child prone with the head of the table depressed
at least 30º, to minimize the loss of CSF when you incise
the sac. Prepare and drape a wide operative field.
Clean the sac meticulously with aqueous disinfectant.
OPERATION
If the swelling is covered by skin, make a longitudinal
elliptical incision, through normal skin at the base of the
swelling (33-15A,B). Cut through the subcutaneous
tissue to the deep fascia, and define the neck of the sac by
blunt dissection. The defect in the fascia will usually be
quite small, and easy to expose. Free all surfaces of the
sac, and open it over its dome. Send the CSF for culture
if possible.
If there are no nerve filaments, amputate the sac at its
base, and close it with continuous 4/0 or 5/0
non-absorbable suture.
Fig. 33-16 POST-OP SUSPENSION OF A BABY AFTER
MENINGOMYELOCOELE REPAIR. A, orthopaedic strapping.
If you find nerve filaments or the meningocoele is open, B, special supporting frame. This keeps tension off the suture line;
preserve the nerve filaments with the greatest care, and try do not dress the wound but make sure faeces and urine drain away
to free them from the sac (33-15C). Do not excise more from it.
healthy skin than you need, but be sure to remove all the
skin covering the placode in order to prevent the If the child also has hydrocephalus, a shunt (33.12) or
development of an epithelial remnant cyst later. ventriculostomy will be necessary, but wait at least 1wk
If possible, after you have freed the neural plaque after the back closure, till the risk of infection is
(placode), fold it over and close it along its axis (33-15D). diminished. Proceed when the back is healed, the
Then close the dura over it with 4/0 or 5/0 prolene after ultrasound (38.2L) shows enlarging hydrocephalus, the
freeing it on both sides of the plaque (33-15E). child is well, and the CSF (from a ventricular tap) is clear.
Now free up the thick fibrous layer overlying the The long-term management of neurologically impaired
deformed spinal laminae on each side of the defect, children with spina bifida is extensive, requiring bladder
and approximate these with the musculofascial layer evaluation with possible clean intermittent catheterization,
(33-15F) so that you can obtain tension-free and solid skin renal follow-up with ultrasound, bowel management, and
cover. occupational therapy. Find a centre where such care exists:
(the International Federation for Spina Bifida and
Seal the wound meticulously, and nurse in the prone Hydrocephalus can assist in the process.)
position. Apply a corset of orthopaedic strapping so that
the abdomen is pulled upwards (33-16). This keeps tension
off the suture line and allows faeces and urine to drain
away from the wound. Leave a nasogastric tube in situ for
24hrs, and then start feeding. Keep the prone position for
10-14 days till you remove sutures. If there is a neurogenic
bladder, make sure you train the mother to empty the
bladder regularly by suprapubic pressure. You will then
later have to teach her intermittent catheterization.
Keep faeces away from the wound!
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33.12 Hydrocephalus
Congenital hydrocephalus
usually arises from obstruction of the aqueduct of Sylvius, Fig. 33-17 ANATOMY OF THE VENTRICULAR SYSTEM.
and in children with spina bifida from cerebellar About 20ml/hr of CSF is actively secreted in the choroid plexuses in
the lateral ventricle (A), the 3rd ventricle in the diencephalon between
and medullar herniation through the foramen magnum the 2 thalami (C). It leaves these by the aqueduct of Sylvius (D) to the
(the Chiari II malformation). 4th ventricle in the hindbrain (E), where more CSF is secreted.
Acquired hydrocephalus commonly arises from From here it passes through the 2 lateral foramina of Luschka (F)
meningitis, but may result from intraventricular and the midline foramen of Magendie (G) to bathe the brain and
spinal cord in the subarachnoid space. The total volume of CSF in an
haemorrhage of prematurity, posterior fossa tumours or adult is c.130ml.
ventricular cysts. After Rosenfeld JV, Watters DAK Neurosurgery in the Tropics,
Macmillan 2000 p.90 Fig 4.1 with kind permission.
SYMPTOMS IN TODDLERS & CHILDREN.
Vomiting, drowsiness, irritability, fever, headache and loss You should measure the head against a standard head
of cognitive function or coordination are the commonest circumference chart:
symptoms.
OCCIPITAL CIRCUMFERENCE
SIGNS.
The anterior fontanelle is bulging and tense, and scalp
veins may be prominent; skull sutures separate and may
become palpable, and the head may give a ‘cracked pot’
sound on percussion. In advanced cases, the child becomes
lethargic and anorexic. When the 3rd ventricle expands,
pressure on the oculomotor nerves causes down-turned
(‘setting sun’) eyes. Cranial nerve palsies (especially VIth
causing a squint, or Xth causing stridor) are not
uncommon.
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MANAGEMENT
The commonest treatment for hydrocephalus is to insert a
shunt to drain the CSF either into the peritoneal cavity or
rarely into the atrium. The ventriculo-peritoneal (VP)
shunt is simpler to insert, but will probably not be effective
if there has been peritonitis previously, because of
adhesions.
Various types of shunt exist, with different valve
mechanisms, but it is not necessary to use expensive
commercially-produced shunts. An affordable shunt is the
Chhabra shunt from India (provided free to qualified
centres by the International Federation for Spina Bifida
and Hydrocephalus).
VENTRICULO-PERITONEAL SHUNT
FOR HYDROCEPHALUS (GRADE 3.4)
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As soon as the shunt has entered the ventricle, you will see If the skin over the shunt necroses, it has probably been
CSF emerge; remove the stilette: you should see a closed under tension. The skin needs debridement, and
substantial flow of clear CSF. Send this for culture, usually you will have to re-position the shunt on the
if possible. Then, check with ultrasound, if you can, opposite side of the head.
that the shunt is well placed in the anterior horn of the
lateral ventricle, withdraw it 2cm and attach it to the valve, If the child develops peritonitis, the distal peritoneal end
or a connecting L-piece, trying not to handle the shunt of the shunt needs to be removed from the abdomen,
except with instruments. and allowed to drain into an external closed drainage
Fix the valve, or L-piece, with non-absorbable sutures to system till the inflammation has settled down.
the skull periosteum. Make sure that CSF is dripping
regularly from the distal end of the shunt, and then pass If there was only localized peritonitis (e.g. from
this into the peritoneal cavity either over the liver or deep appendicitis) the abdomen can probably still be used for
into the pelvis. drainage, but if the peritoneal inflammation was
Fix it to the peritoneum with an absorbable suture and generalized, it may no longer absorb properly.
close the abdomen taking care not to include the shunt In this case, a ventriculo-atrial shunt may be necessary.
tubing in your stitch or kinking its position.
Close the scalp flap over the tubing so that sutures lie well If the abdomen distends with fluid, the CSF may not be
away from it. absorbed properly as above. Alternatively the fluid may
collect into a loculated ‘pseudocyst’ which is visible on
DIFFICULTIES WITH VENTRICULO-PERITONEAL SHUNT ultrasound (38.2K). In this case perform a laparotomy to
Advise the parents to return the child in case of any serious break down the cyst walls and reposition the shunt if it
symptoms: late presentation of complications is the remains patent.
commonest cause of death and long-term disability in
these children! Complications are common, and usually N.B. More sophisticated surgery for hydrocephalus
occur in >30% of cases! You must warn parents that you consists of endoscopic 3rd ventriculostomy which has much
may have to replace the shunt several times, fewer complications and is effective in the majority of
and particularly as he grows. cases. This procedure is not that difficult to grasp and has
been effectively performed up-country in Mbale, Uganda.
If the shunt blocks, it may do so at the ventricular end You need a flexible paediatric endoscope like a
(where the choroid plexus adheres to the tubing) or the cystoscope, and to be shown how to do the procedure by
peritoneal end (where the omentum or adhesions may an expert.
occlude its end). Symptoms and signs depend on the rate
and degree of the blockage, but essentially are worsening
of the original hydrocephalus problems, especially 33.13 Congenital vascular lesions
vomiting, headache and loss of neurological function.
To treat the blockage, you need to explore the shunt,
disconnect it and test the flow through it at the peritoneal Congenital vascular lesions are not uncommon, and may
and ventricular ends. You may be able to unblock the worry a parent, so you should know how to advise.
ventricular catheter by introducing a stilette down it, Some will regress, some will grow as the child grows,
and passing a diathermy current along it. If it remains and some increase in size alarmingly.
blocked, and remains stuck, it is best to place another Try to identify them correctly to advise the right treatment.
shunt next to it rather than forcibly removing it. Differentiate between angiomas (which are tumours) and
vascular malformations (which are not). You may be able
If the shunt disconnects or migrates, (which may be to diagnose cystic lesions prenatally with ultrasound.
visible on simple radiographs), especially during a growth
spurt, the peritoneal end may end up disconnected inside A capillary haemangioma is, characteristically, a bright
the abdomen, or under the skin. Reconnection with new red, raised lesion varying from mms to cms in diameter.
tubing will solve the problem. It is well circumscribed and only partially compressible.
If the shunt becomes infected, either de novo or more A cavernous haemangioma is nodular and may be very
commonly within a few months as a result of sepsis large in diameter and depth. It is often bluish or purple and
spreading from elsewhere (e.g. teeth, throat etc.), easily compressible.
the child deteriorates with headache, fever, vomiting and Mixed variants exist; they are histologically benign
maybe fits. Try antibiotics alone, but if this fails, neoplasms of proliferative endothelium.
disconnect the shunt tubing and drain the CSF externally
into a closed drainage system (an external shunt). A capillary cavernous haemangioma consists of
When the CSF is clear and no longer infected, re-insert the abnormal capillaries, arteries, and veins, and is partly
distal end of the shunt. However, it is frequently necessary compressible. It is usually present at birth, and commonly
to remove the shunt entirely and replace it with a new one. occurs on a child's face, axillae, or neck, where it may
extend into the mediastinum.
It may occasionally resolve spontaneously over several
years (unusual), or it may enlarge rapidly.
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Occasionally it connects with arteries and pulsates, Resolution may be precipitated by trauma, but this usually
expanding progressively: the feeding vessels then need causes only minor scarring. Advise the mother that the
ligation. Excision is indicated if there is functional lesion will probably disappear slowly. Warn her not to
disability (e.g. amblyopia from an eyelid haemangioma, allow traditional healers to scarify the lesion, which may
28.9), gross disfigurement or significant haemorrhage, cause bleeding, infection, and worse scarring. If resolution
or skin necrosis overlying the lesion. is slow, and parents pressurize you, refer the child to a
plastic surgeon specialist because the final results of
excision may otherwise be very disfiguring.
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EXCISION OF SACROCOCCYGEAL TERATOMA Nurse the baby prone post-operatively (as for
(GRADE 3.5) meningomyelocoele, 33-16) till you remove sutures after
Place the baby prone with legs abducted and the lower 10-14 days. Do 6monthly follow-up rectal examinations to
abdomen raised on a small sandbag (33-21). detect presacral recurrences, as well as serial α-fetoprotein
Pack the rectum with vaseline gauze to ease its levels, if possible.
identification in the operation. Make sure you cross-match
blood. If a neonate (or older child) has respiratory difficulties
and a radiograph shows bowel or stomach in the chest,
this is due to a DIAPHRAGMATIC HERNIA.
This may be congenital or, rarely, traumatic.
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pyomyositis (7.1),
osteomyelitis (7.3),
ascaris infestation (12.5),
intussusception (12.7),
hypertrophic pyloric stenosis (13.6),
Burkitt’s lymphoma (17.6),
inguinal hernia & hydrocoele (18.5),
umbilical hernia (18.10),
haematocolpos (23.17),
rectovaginal fistula (23.17),
physiological goitre (25.4),
rectal prolapse (26.8),
pelvi-ureteric junction obstruction (27.14)
bladder stones (27.17),
urethral stones (27.18),
circumcision (27.29),
phimosis & paraphimosis (27.30),
testicular torsion (27.25),
maldescended testis (27.27),
nephroblastoma (27.35),
eye tests (28.1),
corneal scarring (28.4),
congenital glaucoma (28.6),
myopia (28.8),
amblyopia & squint (28.9),
proptosis (28.11),
trachoma (28.13),
retinoblastoma (28.16),
hearing tests (29.2),
otitis media (29.4),
foreign bodies in the ear (29.6),
foreign bodies in the nose (29.11),
tracheostomy (29.15),
foreign bodies in the throat (30.1),
corrosive oesophagitis (30.3),
deciduous teeth (31.1)
cancrum oris (31.5),
cleft lip (31.7),
tongue tie (31.9),
contractures (32.1),
spinal TB (32.4),
poliomyelitis (32.7),
club foot (32.10),
painful hip & limp (32.14),
extra digits (32.21),
cancer pain control (37.2).
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POSTOPERATIVELY.
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TREATMENT: CAUTION!
(1) Use a sharp knife.
A. HYPERTROPHIC SCAR. (2) Do not pull on the keloid as you excise it, or you may
Give reassurance that it will eventually regress naturally. enter the subcutaneous tissue. Instead, if necessary,
Never operate during the active phase. If you decide to depress the surrounding tissues.
operate, do so during the mature phase, ≥3yrs after the (3) Do not use diathermy.
original wound. Then, excise the scar, and apply the (4) Do not place sutures.
preventive measures above. Considerable improvement is
possible.
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Fortunately, a child's joints do not become stiff nearly so Cut perpendicularly through the scar down to the
easily as those of an adult. After you have grafted the subcutaneous tissue, in the middle of the contracture.
flexor surfaces of a child's fingers, you can safely Keep it under tension as you do so. If necessary, cut right
immobilize them in extension. Contractures may be linear down to the tendons. Try to separate the scar from the
or, more commonly, broad. deeper tissues by blunt dissection. Push your scissors into
the tissues, then open them (4-9B). This will help you to
Excise linear contractures with a Z-plasty. Release broad avoid any superficial veins. It is wise not to try to excise
contractures widely without excising them, then graft the the scar initially, either in the main part of the contracture,
bare area with a medium or thick split skin graft. or at its upper or lower ends.
Splint the limb in a position opposite from the contracture,
and start exercises as soon as the graft has taken CAUTION!
(c. 10-14days). (1),Release the contracture first, and then decide if you
Use sheets of thick split skin as your graft, meshed if the need to excise any scar tissue.
graft is large. The result is less good, though, than if you (2),Do not cut the deep fascia, unless the scar tissue
use unmeshed full-thickness graft. extends right through it.
Make children your first priority: you will be much less (3),Contractures will take more extensive incisions to
successful with adults. release than you expect.
Do not try to relieve burns contractures by using serial (4) Beware of congested veins, especially in the axilla and
casts (32.1). neck.
Start taking skin from the donor site. When the contracture
is straightened out, you will need more skin than you
expect. Cover the bare area with a sheet split skin graft,
and suture it in place preferably with a tie-over dressing.
Immobilize the area carefully, with splints or plaster of
Paris in the position of full release of the contracture.
CAUTION!
Graft the exposed raw areas immediately, especially over
joints. This will reduce the risk of the contracture
recurring, and the risk of infection reaching the joint.
Remove the dressing yourself after 5days. Keep the area in
a night splint for 3months. Maintain a regular review;
you may need to make serial releases with several
operations.
Fig. 34-3 CONTRACTURE OF THE NECK AND AXILLA.
A, contractures of the axilla, elbow and wrist. If the joints had been
splinted in the positions of function, their contractures would have
RELEASE OF NECK CONTRACTURES
been prevented. B, contractures of the neck and axilla. C, a narrow
contracture which is suitable for simple Z-plasty. D, a broad If the chin is contracted down on the sternum (34-3),
contracture which needs excision and skin grafting. the anaesthetic problems are considerable: you cannot
Kindly contributed by Jack Cason, Ian MacGregor & Peter Bewes.
extend the neck to see the vocal cords, unless you have a
flexible bronchoscope over which you can thread an
MANAGEMENT OF A BROAD CONTRACTURE
endotracheal tube. You may be able to use a laryngeal
(GRADE 2.3)
mask, but it is probably safer to infiltrate the scar with LA,
administer ketamine, cut through the scar quickly,
Wait until a burn has healed completely. Operation is not
and then perform the intubation.
a task for the minor theatre. Administer iron & folate so
that the Hb is >10g/dl. Have blood cross-matched if you
METHOD. Incise the scar transversely, if necessary
cannot use a tourniquet (3.4).
almost from ear to ear. Carefully release the scar tissue by
Infiltrate into and under the contracture a mixture of saline
blunt dissection to reveal a huge gap in the front and sides
80ml, 2% lignocaine 20ml, 1:1,000 adrenaline 0·5ml, and
of the neck. Try to apply a single sheet of split-skin graft
preferably hyaluronidase 1500 U.
secured with a tie-over dressing. Immobilize the neck with
This solution will:
the head well extended. To prevent recurrence, keep the
(1) demonstrate the tissue planes more clearly,
neck in extension. Apply a soft collar as soon as the skin is
(2) allow you to separate the scar more easily,
soundly healed, and leave it there for at least 6months.
(3) control bleeding,
(4) reduce the amount of GA needed.
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A night splint is mandatory for several more months. If the mcp joints are hyperextended as part of a claw
If necessary, repeat the procedure, several times if hand, this is a particularly difficult contracture, because
required, to obtain a little more movement each time, the capsules of the joints may need opening up and
particularly if the lips are involved. freeing. Make transverse incisions over their dorsal
surfaces, flex them, graft the gap, and splint the hand in
RELEASE OF AXILLARY CONTRACTURES the position of function.
Try to restore full abduction and elevation in a single If there are flexion contractures of the fingers, incise
operation. If there is a broad contracture, incise the scar as them transversely maximally taking care not to damage
above, and abduct the arm. Apply a large medium the digital nerves & arteries, and fill the gap with a full
thickness split-skin graft to the bare areas, and secure it thickness, or a thick split-skin graft sutured into place.
with a tie-over dressing. Cover this with plenty of dry For a child, splint the fingers in extension for 3months,
wool, and bandage this (preferably with crepe bandages) or the contracture will recur. To help the cast stay in place,
to include the whole arm as well as the axilla and chest. apply it with the wrist extended. Examine the cast daily at
first, and later weekly, to make sure it has not slipped.
In a small child, a large ball of cotton wool bandaged into For an adult, do not immobilize the extended fingers for
the axilla may hold the arm in the right position. >10days. Use dynamic splints, and night splints.
In an older child or an adult, raise the head and back on If there is a very severe finger deformity, you may need
a suitable support as for a hip spica, and apply a plaster to amputate the finger, or arthrodese it in the position of
shoulder spica to include the arm and hand, with the arm at function.
90° from the chest, the elbow flexed, and the wrist
dorsiflexed. This is the most comfortable position. RELEASE OF GROIN, KNEE, ANKLE, AND FOOT
CONTRACTURES
CAUTION ! Follow the general method, as described above, taking
(1) Do not injure the axillary vessels or nerves. care to extend the incision well beyond the axis of the
(2) Do not hyper-abduct the shoulder, as you may injure joint. Tendons may bow-string across the knee and prevent
the brachial plexus. full extension: in this case you will need to make a
tenotomy and tendon lengthening (32.8, 10).
RELEASE OF ELBOW CONTRACTURES
DIFFICULTIES WITH BURNS CONTRACTURES
A large scar may involve the whole flexor surface of the If you cannot get sufficient release of a contracture in a
elbow. Make a cautious transverse incision across the fold single stage, release it as much as you can; splint it,
of the elbow, starting laterally, and avoiding any congested leaving it open, and release it further after a few days, then
veins. If the whole width of the elbow is involved, graft it.
extend the incision into healthy tissue on each side.
Find a fatty layer and then work gently medially. If there is an ulcer within a scar, think of squamous
If you have found the right fatty plane, this should free up carcinoma: excise it with adequate margins and send it for
the scar tissue. When the incision is complete, divide any histology (34.5).
deeper strands of fibrous tissue. Fill the large diamond
shaped gap with a medium thickness split-skin graft. MOST SEVERE CONTRACTURES ARE
Secure it with a tie-over dressing. Immobilize the extended THE RESULT OF POOR CARE
and supinated elbow in a cast which should also
immobilize the wrist. NARROW BURNS CONTRACTURES
When the wound has healed, apply a cast of the elbow
alone in extension for at least 6-12wks. You are operating A Z-plasty is a useful way of releasing a contracture,
for a flexion contracture so lack of flexion will not be a if it is narrow enough. It is not an easy method, but if your
problem. result is not perfect, you can always graft any bare areas
that remain. Good results are easier to achieve than with
RELEASE OF HAND CONTRACTURES wide contractures which need grafting.
If the contracture is mild, a dynamic splint may cure it, Make a Z-plasty by excising the scar and then cutting
or at least partially correct the deformity, so that operation 2 flaps in the form of isosceles triangles which share one
will be easier. common limb, and so form a Z. When you extend the
limb, the triangular flaps will change their positions
If the wrist is hyperextended, divide the scar spontaneously. Initially, the 2 triangles together form a
transversely, and apply a medium thickness split skin parallelogram, with its shorter diagonal in the line of the
graft: beware of the median nerve and ulnar nerve & contracture, and its longer diagonal transversely across it
artery! (34-4C).
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INDICATIONS
A narrow contracture of the axilla, elbows, fingers, knee or
neck, especially one of the bowstring type, provided the
surrounding tissues are reasonably lax and undamaged.
If there is no transverse slack tissue to start with,
a Z-plasty will not work on its own, but it still may be
helpful combined with excision of scar and skin-grafting.
SINGLE 'Z'
Use a pen to draw your proposed Z-plasty on the skin;
the longer the transverse diagonal, the more length you Fig. 34-4 Z-PLASTIES.
will gain. Its length will however be limited by the amount A, how flaps are usually cut. B, how to cut them if you are doubtful
of loose tissue available at the sides. about their blood supply. C, initial layout of incisions, and how the
flaps will transpose. D, final result: the contracture diagonal has
You have 2 ways of choosing the direction of the Z’s. lengthened and the transverse diagonal has shortened in equal
Select the best one by drawing equilateral triangles on measure. E,F, single ‘Z’ showing how the lateral tension is
either side of the central limb, in both of the possible ways. concentrated in a single line. G, H, multiple `Zs' distributing the
Choose the flaps which: lateral tension. I,J, same but with fewer larger 'Zs'. K,L, 'Zs' joined
up. M, scar. N, excise the scar. O, plan the flaps. P, raise the flaps.
(1) have the better blood supply, Q, transpose the flaps. R, the flaps in place: note the special suture
(2) avoid scarring across the base, at the apices.
(3) will give the best cosmetic result, and After MacGregor IA. Fundamental Techniques of Plastic Surgery,
(4) are likely to rotate most easily. Churchill Livingstone 1980 with kind permission.
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A..: PYOGENIC GRANULOMA Most of these may ulcerate, and have many causes, some
(Lobular Capillary Haemangioma) of which are specific to certain areas or people.
Pyogenic granuloma is a misnomer; it can occur anywhere, Remember many small ulcers are caused by insect or tick
but is commonest on the face, fingers, or toes, as a soft or bites; these may result in various types of fever,
moderately firm, dull red, 1cm lump, covered with e.g. rickettsial typhus or trypanosomiasis.
atrophic epidermis or crusts, and which bleeds easily.
This trivial lesion can be misdiagnosed and thought to be a Some ulcers, e.g. gouty tophi on elbows, are metabolic in
sarcoma (34.15), when all that is needed is simple excision origin, and need medical treatment as well as excision for
and curettage. Its cause is unknown but may be related to diagnositic or cosmetic purposes. Many are inflammatory
antiretroviral treatment. An antibiotic is only needed rarely or infective, however, and may have different treatments:
if there are signs of spreading infection.
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B. BASAL CARCINOMA
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If there is a large defect but a satisfactory base, Lotions with high protective factor (50+), e.g. Uvastat,
for example muscle, excise any deep fascia and apply a are very expensive; you can use zinc oxide on the lips as
split skin graft. Tie-over sutures are useful to keep the this blocks the sunlight. You may be able to abort
dressing in place. pre-cancerous lesions with topical 5% 5FU. Otherwise,
treat squamous carcinoma in the same way as above.
If the base is not suitable for grafting, (if it is connective
tissue, fat, tendon, or infected), wait 5-7days till If the lesion is bleeding profusely, apply hydrogen
granulations are satisfactory, and then apply a split skin peroxide or 10% formalin soaked onto gauze,
graft. (You can store graft wrapped in paraffin gauze in a avoiding contact with normal skin.
refrigerator for c. 10days).
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Suspect that a white patient has a melanoma if: EXCISION OF MALIGNANT MELANOMA (GRADE 1.3)
(1),any previously existing pigmented mole enlarges,
weeps, scabs, bleeds, itches, ulcerates, becomes darker, If you suspect that a lesion is a melanoma, but have not
or produces a dark surrounding halo. previously biopsied it, excise it with a margin of at least
(2),any pigmented lesion keeps growing progressively. 1cm of normal tissue all round for each mm of tumour
Be especially suspicious if it is >1cm, with an irregular thickness, with preferably more on the proximal end.
border, surface, or pigmentation. Remove all the underlying subcutaneous tissue and deep
(3),a rapidly growing brownish fleshy ulcerated skin fascia. If the bed that remains is suitable, graft it
tumour, even if it is pale (it may be amelanotic). immediately. Take a split skin graft from the opposite
limb, not the limb bearing the melanoma.
Prophylactic block dissection of the regional nodes
probably does not help. However, you can inject 5ml of
blue dye around the primary lesion, and then explore the
groin 20mins later, and remove a blue-tinted sentinel node.
If this is visibly black on section or contains melanoma on
histology, a block dissection is indicated. Otherwise follow
up regularly, so that if the regional nodes enlarge,
you can perform a block dissection.
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TESTS. Fix a smear or aspirate from a nodule or ulcer, If a large rubbery cystic mass develops, usually on the
from a lymph node, or from the spleen (after checking the trunk, and typically on the back near the angle of the
clotting & bleeding times) in methanol, and stain it with scapula, distinguish a guinea worm cyst (a low-grade
Giemsa. You should see many amastigotes (Leishman- encapsulated abscess) from a lipoma.
Donovan bodies) which are rounded 2-3μm bodies inside
macrophages. (1),A guinea worm cyst often has a small scar on its
surface.
TREATMENT. (2),On contraction of the muscles, you can see that a
Although nodules heal, they take long and do so with lipoma is usually superficial, and a guinea worm deep.
scarring; if they are many, the disfigurement is significant. (3),Aspirate the mass with a wide needle. A guinea worm
Single dose IV liposomal amphoteric in B 3mg/kg cyst usually contains sterile pus. If necessary dissect out
followed by oral miltefosine 2·5mg/kg for 7days gives the mass, taking care not to injure surrounding structures.
>95% cure rates. Antimonials were standard treatment but There is no easy plane of cleavage.
may cause pancreatitis or cardiac angina. Drug resistance
and toxicity are very common with HIV+ve patients; If the cyst becomes infected, it may be impossible to
relapse is frequent after 1month to 3yrs. Repeated relapses distinguish it from pyomyositis (7.1), or septic arthritis
may occur. Ketoconazole and the application of honey are (7.17), especially of the knee: you will have to drain these
useful for early cutaneous lesions. in the usual way.
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If possible, apply the graft as a single sheet, which has IPSILATERAL THIGH-TO-LEG TENSOR FASCIA LATAE FLAP
been meshed to allow the escape
of exudate and blood, or, less
satisfactorily, apply it as patches
or pinch grafts. Immobilize the
affected part, and expose the
graft on the 5th day, or earlier if
it is smelly.
Then soak off the dressing
slowly to avoid removing the
graft at the same time. It may
need covering for another week.
The donor site should have
healed in 10days.
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Commonly a child under 15yrs presents with a painless, Hidradenitis suppurativa (Verneuil’s disease) or
small, well demarcated, indurated swelling, attached to the pyoderma fistulans sinifica (fox-den disease) may have a
skin, but not to deeper tissues. It is almost always single genetic pre-disposition. These result in localized skin
and on the limbs, and is often near a joint, although the site sepsis arising from apocrine glands (so do not develop in
is variable. There is little pain or tenderness, little or no children), especially in the axillae, groins, perineum,
fever, and the regional lymph nodes are not enlarged. back of the neck and under the breasts. The result is quite
The lesion grows, the skin over it desquamates creating a marked skin thickening, fistulae and multiple skin bridges,
plaque, becomes pigmented, and then breaks down to form but the disease does not extend below the fascia.
a chronic expanding ulcer with a necrotic base and edges Be careful to distinguish this from necrotizing fasciitis
which may be undermined 5-15cm. Secondary infection (6.23). You will only achieve a lasting cure by excising the
occurs, and a foul slough forms. Satellite ulcers may whole affected area and leaving the wound to granulate.
appear, but metastatic spread is rare. Some ulcers remain
unchanged for weeks; others cover much of a limb, or the
trunk, in a few weeks. Untreated they result in scarring and 34.10 Kaposi sarcoma
severe contractures.
Kaposi sarcoma (KS) starts as a proliferation of lymphatic
DIAGNOSIS is suggested by the appearance of the endothelial cells which transform into a sarcoma;
swelling and the ulcer, the absence of lymph node the stimulus is infection with the herpes virus type 8,
enlargement, and the failure to respond to tropical ulcer transmitted by saliva, promoted by co-factors such as
therapy. immunosuppression, caused deliberately by drugs or by
HIV disease. The HIV tat protein also promotes KS.
SPECIAL TESTS. Look for AAFB in the ulcer base;
send material for culture. M. ulcerans grows on media There are 4 main types of presentation (in decreasing order
used for M. tuberculosis, but only at 33ºC. Mycolactone of frequency):
produced can be detected by PCR. (1),By far most commonly, HIV-related KS in men &
women, with symmetric lymphadenopathy, oral purplish
TREATMENT. Early on, use streptomycin and rifampicin patches or plaques, pulmonary infiltration and skin
for 8wks; healing continues after completing the course of nodules (though these are often absent).
treatrment. If the lesion is ulcerated, control secondary The nodules do not occur in areas subject to sustained
pyogenic infection with antibiotics, and irrigate with warm pressure (e.g. the soles of the feet or under dental
water. Excise all diseased tissue, and when granulations prostheses). Ultimately lesions lead to woody hard oedema
are healthy (c. 3wks) cover the wound with a skin graft. and ulceration.
(2),Endemic (HIV-ve) African KS usually of younger
Desert sore (Diphtheritic ulcer) occurs in dry desert men, with indolent nodules on the limbs preceded by hot
climates, starting as a painful vesicle leaving a raw and oedema, ultimately resulting in widespread infiltrating and
tender ulcer with a grey-brown base. Later this becomes visceral involvement.
punched out with an undermined edge. The organism, (3),Iatrogenic KS as a result of immunosuppressive drugs
corynebacterium diphtheriae, produces an exotoxin which for cancer or connective tissue disease, where if the drugs
can give rise to myocarditis and peripheral neuropathy. are withdrawn, KS regresses, often completely.
Use benzylpenicillin and immunize contacts with (4),Classical KS of elderly men usually of Arabic, Jewish
diphtheria toxoid. or Southern European descent, with indolent nodules on
the limbs that may regress spontaneously.
Yaws (Framboesia) occurs amongst poor children living in
unsanitary and overcrowded conditions in warm humid DIAGNOSIS
tropical climates. It is caused by treponema pertinue which Plaques and nodules are so typical that skin biopsy is
is transmitted by direct contact through clothing and rarely necessary in the presence of HIV disease;
insects. A painless swelling which occasionally ulcerates, N.B. biopsy of oedematous skin may produce a non-
the ‘mother yaw’, starts at the site of the contact with healing wound.
concurrent regional lymphadenopathy. This heals Lymph node excision biopsy may be useful (17.1).
spontaneously after 3-6 months when the infection spreads All patients suspected of KS must have an HIV test.
to moist areas of the skin, e.g. soles, palms and the back of
the knees. These usually ulcerate, become infected, TREATMENT
and may destroy joints and bone. Use a single oral dose of Chemotherapy (doxorubicin, vincristine, or bleomycin)
azithromycin 30mg/kg. gives a dramatic response, but there is early relapse in
HIV+ve patients unless they also have ARV therapy (5.8).
Herpetic ulcers occur characteristically in HIV+ve Radiotherapy is useful for isolated limb lesions,
patients following the acute episode of the herpes zoster but supplement it by chemotherapy. Early KS may not
reaction. One or more dermatomes may be involved. warrant treatment, which may cause serious side-effects:
Acyclovir 800mg x5 od for 1wk is useful early in the in HIV+ve patients, co-existent pulmonary disease is
eruption. Post-herpetic neuralgia may be severe. common: you usually have to treat this first.
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The primary site of infection is usually in the subcutaneous Excise a margin of healthy tissue with actinomyces as its
fat; it may spread beyond the plantar or palmar fascia, border is ill-defined. Always use a tourniquet.to produce a
which form a natural barrier. It may then spread in the bloodless field. Flood the operative field at the end of the
deep fat between the tendons, along the lumbrical canals, operation with iodine to minimize risks of contamination.
and even through the carpal tunnel, up into the forearm.
The bone may be invaded relatively early, still without If bone is involved, or will be, Syme's amputation (35.7)
causing pain, and is rapidly destroyed. Mycetomas never is appropriate provided you can clear the disease
regress spontaneously. adequately.
Regional lymph nodes are usually not enlarged, but may
be affected by secondary sepsis and occasionally by If there is a lesion of the hind foot with severe bone and
lymphatic spread of mycetoma. joint destruction, perform a below-knee amputation
(35.6).
DIAGNOSIS. Try to find the granules, because without
them all a pathologist can say is that there is a If there is a lesion of the hindfoot with minor bone
granulomatous infection with multiple micro-abscesses. involvement, and without severe destruction of its
The colour and size of the grains can give a clue to the joints, you will probably have to amputate, but wait until
cause: actinomyces pelletieri are small red, streptomyces the foot becomes a real nuisance. Make sure there is no
somaliensis medium-sized yellow, actinomyces madurae response to medical treatment.
large white, nocardia brasiliensis small yellow, Always combine surgery with long-term medical treatment
madurella mycetomi and other eumyces large for at least 6months.
brown-black. If you cannot see the grains with the
naked eye, get an aspiration specimen for cytology. CAUTION!
You should see filaments with x40 magnification. (1),Mycetoma is painless, so do not amputate a limb until
the patient is quite convinced that the limb is of no use.
RADIOGRAPHS. Once the periosteum is breached, the (2),Follow the patient up carefully, and make sure he
tarsal and metatarsal bones are rapidly destroyed. reports any involvement of the inguinal nodes.
New bone in the walls of abscesses forms buttresses When he does, this is an indication for urgent amputation
projecting outwards at angles to the shaft of a long bone. and block dissection of the nodes (17.8).
The centre of an infected bone has a honeycomb
appearance, and a good film shows tiny cystic areas of
bone destruction, each the site of a micro-abscess.
Differentiate this from an osteosarcoma or tuberculosis. 34.12 Elephantiasis
ULTRASOUND. This shows typical thick-walled cavities If there is gross generalized swelling of the leg, arm, or
with no acoustic enhancement, with the grains giving scrotum, or if a woman has a similar swelling of her breast
numerous bright hyperreflective echoes, especially with or vulva, the condition is known colloquially as
eumyces. These are less distinct with actinomyces. elephantiasis. Usually, this is due to long-standing
lymphatic obstruction. Occasionally, it is due to venous
DIFFERENTIAL DIAGNOSIS. obstruction, but this is seldom gross enough to need
Actinomycosis produces yellow granules but occurs very surgery. Distinguishing between lymphatic and venous
rarely on the foot. obstruction can be difficult. Oedema due to lymphatic
obstruction becomes firm quite rapidly, but early cases
TREATMENT may show pitting. Oedema due to venous obstruction
For actinomyces, use streptomycin 14mg/kg od with becomes solid late, and eventually reaches a stage where it
dapsone 1·5mg/kg bd for 1yr at least; you can replace fails to pit.
dapsone with cotrimoxazole if there are side-effects.
Rifampicin can replace streptomycin and sulfadoxine- In most areas, the causes of lymphatic obstruction
pyrimethamine (Fansidar), and ciprofloxacin can replace (lymphoedema), in decreasing order of frequency are:
cotrimoxazole in resistant cases. (1) Tuberculosis.
For eumyces, try ketoconazole 400mg od, also for 1yr, (2),Repeated lymphangitis due to lymphatic obstruction,
but the chance of cure is much lower. usually from streptococci, filariasis or podoconiosis
Otherwise, try griseofulvin 500mg od. (34.13).
Curette and drain any low-grade abscesses that form. (3) Malignant glands in the groin, or less often the axilla.
(4) Kaposi's sarcoma.
If a lesion is localized, and is confined to the soft (5) Block dissection of the glands, usually for carcinoma.
tissues, excise it and repair the defect with a split skin (6) Congenital lymphatic hypoplasia (Milroy's disease).
graft. Take great care not to rupture the capsule of
eumyces as you will otherwise transfer the fungus to Other causes include:
adjacent areas, and recurrence will be inevitable. (7) Chronic fungal infections,
(8) Onchocerciasis (34.8),
(9) Lymphogranuloma venereum.
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Filariasis due to infection in tropical and subtropical N.B. The site involved indicates the probable cause:
regions with Wuchereria bancrofti and less often to Brugia Breast and arm, or vulva tuberculosis, filariasis
malayi, or B. timori is restricted by the prevalence of the Scrotum or vulva filariasis.
insect vectors but affects c.1billion people in 80 countries, Lower leg filariasis, podoconiosis
mainly in remote rural or poor peri-urban areas. B. malayi
and B. timori give rise to lymphoedema below the knees; TREATMENT
W. bancrofti to the whole leg, arm, breast, scrotum, If you are in doubt, try the appropriate specific treatment
or vulva. for tuberculosis or filariasis. Lymphoedema due to
Elephantiasis due to advanced podoconiosis (whether it tuberculosis nearly always settles with anti-TB therapy,
has reached the 'mossy foot' stage or not) responds fairly unless it is diagnosed very late. Antibiotics are unlikely to
well to surgery. Elephantiasis due to filariasis is difficult to influence chronic non-specific inflammation.
treat surgically (34.14).
DIFFERENTIAL DIAGNOSIS
Suggesting venous oedema: rapid onset, pitting of the 34.13 Podoconiosis
skin with ulceration, varicose veins, medical causes
(e.g. heart failure, hypoproteinaemia, nephritis, cirrhosis) Podoconiosis ('dust in the feet': non-filarial endemic
elephantiasis) is found in fertile highland volcanic regions
Suggesting filariasis (34.14): scrotal involvement, in Uganda, Tanzania, Cameroun & Sao Tome, and Central
oedema which starts at the most dependent part for each & Southern America and Indonesia due to alkaline red
site and moves upwards; below the malleoli for the leg, clay soils whose silicates penetrate the skin and are taken
the fundus for the scrotum, the foreskin for the penis, and into the lymphatics. It only involves the legs, presenting as
the dorsum of the hand for the arm. Microfilariae found in bilateral asymmetrical swelling of the feet and lower legs.
blood films. This causes the lymphatics to fibrose, and obstruct, and the
femoral nodes to enlarge.
Suggesting podoconiosis (34.13): a bare-footed patient
from a podoconiosis area; worse on one leg than the other; This in turn makes the legs and feet swell, and progress
below-knee swellings most marked distally. Symptoms are through stages which are described as 'water bag',
the first evidence of disease (in filariasis they are the last), 'rubbery', and 'wooden' (34-15). Finally, the leg becomes
and include burning of the lower legs at night, hyperkeratotic, 'mossy', and nodular. Lymph may ooze
with persistent itching of the 1st and 2nd toe clefts, through the skin, which may be secondarily infected by
and plantar oedema of the forefoot. No microfilariae in the fungi or bacteria. The disease may progress steadily,
blood, and a chronic warty thickening of the lower legs or there may be a succession of acute episodes which
('mossy foot'). resolve incompletely. Villagers in endemic areas are often
able to recognize the early stages.
Suggesting chronic non-specific lymphangitis:
some source for it, such as a tropical ulcer (if the swelling 'Mossy foot’ can also describe other disease
is in the lower leg). Acute recurrent attacks of causing multiple excrescences on the feet, notably
lymphangitis. Enlargement of the nodes draining the chromoblastomycosis (34.5).
swollen area only: these may be large and firm, or small
and fibrotic. Lines of hyperpigmentation on the skin Elevation, elastic stockings, and long leather boots help in
indicating previous lymphangitis. A lymph node biopsy the earlier stages, but once the 'wooden' stage has
showing fibrosis and non-specific inflammatory changes. developed, the only treatment is surgical. If you see a
patient early, persuade him to wear boots or shoes which
Suggesting tuberculosis (17.4): chronic enlargement of will minimize further progression. The main preventive
many superficial nodes (inguinal, axillary, and cervical); measure is wearing fully protective shoes rather than
a history of prolonged illness in the past, with fever and sandals or open shoes from childhood.
enlarged nodes, some of which discharged for long
periods; multiple sinuses, or the scars that follow their Podoconiosis is disfiguring, and may result in chronic
healing, especially over the lower end of the vertical chain. disability, so treatment is important. Unfortunately,
Involvement of an entire leg from toes to groin, or an on presentation, the lymphatics are often incurably
entire arm or a woman's breast. A +ve lymph node biopsy blocked, so that medical treatment is ineffective.
confirms the diagnosis; if tuberculosis is no longer active
only non-specific fibrosis may be seen. Surgically, you can:
(1),Compress the leg of a 'soft' case by intermittent
Suggesting lymphogranuloma: also produces sinuses, compression.
but these are usually confined to the superior group of (2) Excise individual nodules over the toes.
nodes, over the medial part of the inguinal ligament.
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Plantar oedema is asymmetrical (unlike cardiac or renal Symptoms start within a few wks to months of infection,
oedema). Press with your thumb on the sole over the head as fever, lymphangitis, tender lymphadenopathy,
of the first metatarsal. You may see mild lymphatic erythema, and oedema. The inguinal, epitrochlear,
oozing, tiny blebs of lymph, or an unusual number of flies and axillary nodes are commonly involved.
attracted to it. Attacks may be repeated every few months.
There may also be secondary bacterial infection.
The forefoot shows an excessive deposit of keratin on the In males, the spermatic cord, epididymis and testes are
dorsum at the base of the first or second toe cleft. often involved, resulting in painful recurrent attacks of
The clefts themselves usually remain normal, even in epididymo-orchitis (27.3), which may be followed by
advanced disease with increased skin markings at the base suppuration in the scrotum.
of the first toe cleft and running longitudinally rather than Synovitis, arthritis and asthmatic-type attacks also occur.
laterally (as is normal). Compressing the toe (34-15D)
shows the marks more clearly. The chronic effects are the result of lymphatic obstruction,
commonly in the retroperitoneum. This can produce:
EARLY TREATMENT. (1),Lymphoedema, which may progress to gross
(1),Raise the foot of the bed to the height which relieves hypertrophy of the subcutaneous tissues (elephantiasis:
the discomfort; a hammock is suitable. 27.37) affecting the whole leg and scrotum (W. bancrofti)
(2),Apply ankle-length elastic socks before rising in the or below the knee (B. malayi or timori), or the arm, breast,
morning; or apply wide (10cm) one-way stretch elastic or abdominal wall (less common). No known treatment
bandages; crepe bandages are inadequate. will reverse these changes.
(3),Protect the skin of the feet from the soil, preferably in (2),Hydrocoele (27.24) which is very common in areas of
shoes. Treat any other conditions present. filariasis, usually with chronic epidydimo-orchitis.
(4) Use pH-neutral soap. (3),Vulval lymphoedema, which is very uncomfortable
(5),Start to reduce the size of the swellings with and embarrassing, may become enormous. This causes
intermittent compression (34-16A-C). obvious sexual dysfunction, extreme mental anguish, and
(6) Advise the wearing of stockings and boots (34-16E). may result in urinary retention, and severe difficulty in
walking. Surgery is complicated and needs an expert.
EXCISION OF FOOT NODULES. Excise these for (4) Varicocoele (27.37).
aesthetic reasons, or to make wearing shoes easier (5),Lymphocoele of the spermatic cord, which may be
(34-16D). They have no sensory nerves, so you can diffuse, resembling a varicocoele (34-12E), or encysted
remove them without anaesthesia. (34-12F). Beware: it may exist with an irreducible inguinal
CAUTION! Do not try to remove the femoral nodes. hernia (32-14G)!
Do not try to remove redundant tissue unless rigorous (6),Lymphatic varix (hygroma). This is a soft cystic
barriers are in place to prevent contact with the soil. lymph-filled swelling in the axilla, neck, or groin.
Recurrent swelling is more painful and debilitating than (7),Chyluria (27.37), due to rupture of dilated lymphatics
the original disease. into the urinary tract.
(8),Chylous ascites, due to rupture of dilated lymphatics
N.B. The difference in treatment between podoconiosis into the peritoneal cavity.
and filariasis is that the first is caused by contents of the
soil, which are hard to avoid without moving home and SPECIAL TESTS.
work. The second is caused by a vector, mosquitoes, (1),The microfilariae of W. bancrofti and B. malayi are
which can, at least in theory, be avoided. usually present in Giemsa-stained thick blood films taken
between 10pm and 2am.
Although the long-term consequence is blockage of the (2),Puncture an enlarged node, or lymphatic varix, with a
lymphatics, surgery has therefore more to offer in filariasis needle, and look for microfilariae in the small volume of
than in podoconiosis. fluid you aspirate.
(3),Fluid aspirated from an infested hydrocoele is amber-
coloured and has vacuolated mesothelial cells, fibrin,
old blood clots, cholesterol crystals and ‘calcium dust’:
34.14 Filariasis these findings associated with epididymitis are highly
suggestive of filariasis in an endemic area. You can test
Filariasis is a parasitic infection which causes considerable this fluid for filarial by ELISA or PCR tests, if they are
morbidity to c.120 million people in 80 countries of the available. Microscopic examination of the fluid rarely
tropics and subtropics Wuchereria bancrofti is the cause in reveals the filaria.
>90% of cases, but Brugia malayi, or B. timori occur in
Asia. Larvae ingested by Culex Anopheles, Aedes or ULTRASOUND of dilated lymphatics can show viable
Mansonia mosquitoes are deposited on the skin of humans, adult worms ‘dancing’. The hydrocele fluid shows a
and microfilariae then migrate to the lymphatics via the mottled echogenicity.
insect bite.
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TREATMENT
Use doxycycline 100mg bd for 6wks, which also treats
symbiotic Wolbachia. Add a single dose albendazole
400mg, and then a single dose of ivermectin (at dose
according to weight, 34.8) after 4wks.
(Although both albendazole and ivermectin have limited
effects on adult worms, doxycycline, by eliminating
Wolbachia will remove the microfilariae.)
N.B. Diethylcarbamazine is no longer recommended
especially in areas endemic for onchocerciasis of loaiasis.
because of the potentially fatal reactions. Likewise the
provocation test (for sampling blood) is not advised.
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34.15 Sarcomas
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When you make a rotation flap, the bigger the flap size, You can make the blood supply of the flap more reliable if
the less tension there will be; make a ‘back-cut’ (34-21) you incorporate the ilio-tibial tract (the tensor fasciae latae
along the diameter of its circle as this will allow some muscle) into the flap, thus making it a myocutaneous flap.
lateral movement as well. Close the defects created (Its length can then be up to 3x its base). Remember to cut
primarily, or secondarily with a skin graft if there is not off a wedge of protruding femoral trochanter (34-23C).
enough laxity to close without tension.
For both types of flap, use subcutaneous suction drains
post-operatively.
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Flex the hip when you plan the flap: ensure suture lines do
TROCHANTERIC PRESSURE SORE REPAIR not rest on pressure points. Make a very broad based flap,
and excise the ischial tuberosity; this leaves a dead space
which, in a paraplegic, you can fill by dividing the lower
end of the hamstring muscle, dividing the lower half of its
perforating vasculature, and rolling it upwards into the
defect (34-24C). Then transpose the flap superiorly to
cover the defect.
N.B. If you use a tensor fascia latae flap, the blood
supply is more assured, but make the flap longer.
Fig. 34-24 ISCHIAL PRESSURE SORE REPAIR. If the foot is hopelessly infected,
A, mark the transposition flap. B, expose the hamstring muscle with perform an amputation (35.3).
the flap prepared. C, divide the hamstring muscle and roll its distal
end into the cavity left by excising the ischial tuberosity. D, close the
wound, and graft the small defect inferiorly.
After MacGregor, IA. Fundamental Techniques of Plastic Surgery,
Churchill Livingstone, Edinburgh 1980. p.233 (Fig7.5)
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CAUTION! Make sure that the stockings are not too EQUIPMENT. 5 small syringes fitted with fine needles and filled with
0·5ml of 3% sodium tetradecyl sulphate, or 5% ethanolamine oleate.
tight to give a tourniquet effect: however, they are no use
2 different colour marking pens, strapping, gauze, crepe bandages and
if too loose! Ordinary elastic bandaging is not as good but graduated compression stockings.
better than nothing.
N.B. They are uncomfortable in hot climates though! CAUTION! Anaphylaxis is rare but may occur,
so have hydrocortisone & adrenaline to hand.
SCLEROTHERAPY OF VARICOSE VEINS The veins must be almost empty when you inject, and be
kept empty so that their walls adhere, so careful bandaging
is critical. If you inject sclerosant into an artery, you may
cause extensive gangrene, so do not inject around the
ankle.
METHOD.
You need an assistant. Ask the patient to stand up,
observe, palpate, and percuss the veins; mark them with a
permanent marking pen. Then ask him to lie down, elevate
the foot, and feel the course of the veins for gaps in the
fascia (sites of incompetent communicating veins).
Mark these with a pen of a different colour. Press with the
tips of your fingers on as many of these gaps as you can,
and, still pressing, ask him to stand. Remove your
lowermost fingers first. If removing your finger from a gap
in the fascia immediately causes the vein to fill, that gap is
the site of an incompetent perforating vein. If it does not
fill, there was no perforator in it. The sites where pressure
controls the filling are the best sites for injection. Inject the
lowest sites first.
Ask him to sit on a couch with the affected leg over the
edge of the bed so that the vein fills, insert the mounted
needle at the marked sites c. 5cm apart, and aspirate only
as far as the transparent hub to be sure you are in the vein,
and strap the syringes securely to the skin; then empty the
vein by raising the leg above the horizontal.
Isolate the segment to be injected by pressing with your
fingers above and below it, and inject 0·5ml of sclerosant.
Apply a pressure pad over the injection site to keep the
vein empty, and apply a crepe bandage up to that site.
Then move up to the next site, and repeat the process until
Fig. 35-3 SCLEROTHERAPY. all your chosen sites have been injected. Do not inject
Method. A, mark the visible varicose veins. B, choose maximum >5 sites. Leave a gap in the bandaging for knee flexion.
5 injection sites c. 5cm apart: mark these in a different colour ink.
C, insert a needle and syringe and check that the needle is correctly N.B. You might find butterfly needles easier.
in the vein by withdrawing a spot of blood, then tape needle and
syringe to the skin. D, tape further needles and syringes to the skin. Apply a graduated compression stocking over the bandage
E, elevate the leg and inject the sclerosant, starting from the site and immediately encourage walking for 1hr, and thereafter
nearest the foot and apply pressure. F, apply crepe bandage up to
last injection site, and continue the injections. for 5km daily. Advise elevation of the legs as much as
Kindly contributed by George Poulton possible. Remove the bandages for a wash after 1wk.
Then re-apply the bandages od, with the leg raised,
SCLEROTHERAPY (GRADE 1.2) for at least 3wks in order to maintain pressure without
INDICATIONS. interruption. If the bandages become loose, reapply them.
(1),The cosmetic treatment of small primary varicose Further injections for missed or recurrent veins may be
veins. necessary: wait 3months before doing this.
(2);Incompetent perforating veins without an obvious
incompetent major valve. If there is severe pain after the injections, take off the
(3) Varicose veins which persist or recur after stripping. bandages with the leg elevated and look for skin necrosis
or gangrene. Use analgesics and encourage walking if
CONTRAINDICATIONS. there are no untoward effects.
(1) An incompetent major valve.
(2) Large varicosities.
(3) Gross obesity (it is difficult to maintain compression).
(4) Deep venous thrombosis.
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LONG SAPHENOUS VEIN LIGATION, STRIPPING & You may find the superficial external pudendal artery in
AVULSIONS FOR VARICOSITIES (GRADE 2.5) the way, running over or under the long saphenous vein;
make no hesitation in ligating and dividing it if it is in the
Determine whether there is long sapheno-femoral or short way. You often come to tributary veins of the saphenous
sapheno-popliteal incompetence. Make sure the deep first before the vein itself. Tie and divide all these
venous system is patent. Wait till after delivery if the tributaries (35-4C). Then dissect out the groin end of the
patient is pregnant. If a patient is on oral contraceptives, saphenous vein and demonstrate the sapheno-femoral
she should stop them one month before operation. junction as the vein dips down through the cribriform
fascia (35-1F).
EQUIPMENT. STRIPPER, for varicose veins, Nabatoff, in sterilizer case,
complete with 3 metal olives, cable and handle. (Some strippers have
olives that can be attached at either end) Tie the saphenous vein securely with two ligatures as close
to its entry to the femoral vein as you can, making sure
no further tributaries enter above your ligature.
Clamp the saphenous vein a suitable distance from the
femoral vein with haemostats and divide it.
N.B. There may be a saphena varix, a dilated saccule
below the incompetent valve; you will need carefully to
get above this to ligate the vein satisfactorily.
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Now make 0·5cm long incisions through the skin FOR THE SHORT SAPHENOUS VEIN, you need either
over the various tributaries marked in indelible ink. spinal anaesthesia or GA and intubation. Use at least
Select prominent remaining varicosities, and by spreading 2 assistants to turn the patient by a log roll and lay him
forceps raise a loop of varicose vein by gentle blunt prone with the feet apart, and the knees slightly flexed.
dissection. Follow it as carefully as you can in each Put pillows under the chest and pelvis, and make sure the
direction and when you have exposed as much length of neck is supported, and the abdomen can move freely.
vein as you can, pull it out. Get your assistant to press on It is best to put the arms flexed above the head.
the site to stop the bleeding. There is usually no need to tie
the vein unless it is large or perforates the deep fascia. CAUTION! If your team is not familiar with GA in the
Close the smallb skin incisions with one suture. prone position, do not attempt it!
N.B. Do not go as far as the ankle with avulsions.
Make a transverse incision across the middle of the
Now raise the leg high and slowly pull out the stripper popliteal fossa and deepen it through the deep fascia to
attached to the vein out from the groin. Keep the leg high expose the short saphenous vein (which lies deep to it).
for a few minutes afterwards to reduce bleeding. Examine Dissect it out, ligating its tributaries, and trace the knee
the groin wound for bleeding. Examine the avulsed vein end down into the popliteal fossa, and doubly ligate it
for its length to make sure you have extracted it in toto; close to its communication with the popliteal vein.
make sure the olive is still attached to the stripper.
Close the remaining wounds, and bandage the leg firmly. CAUTION! The anatomy of the short sapheno-popliteal
junction is notoriously variable (35-5). Do not attempt to
DIFFICULTIES WITH STRIPPING VARICOSE VEINS strip the short saphenous vein as it is closely accompanied
by the sural nerve, and avulsion may well result in
If the varicosities do not bulge with the syringe test, anaesthesia of the lateral foot and calf. Also, there may be
incompetence may be in the anterolateral tributary short and long saphenous incompetence! However, select
(35-2D): dissect this out, and do the test again. Pass the prominent remaining superficial varicosities outside the
stripper down this vein. deep fascia, dissect these out through 0·5cm incisions,
and avulse them.
If the stripper does not pass below the knee,
make an incision over the marked route of the varicosed POSTOPERATIVELY, keep the legs elevated at 30º for
saphenous vein at a suitable point, and introduce another 24hrs. Encourage walking as soon as possible for 1hr
stripper in the same way from below, so that the daily. Leave the pressure bandage applied at operation for
2 strippers meet. You can then try to manipulate the 1wk, then remove the sutures. Advise wearing bandages
proximal stripper upwards, following withdrawal of the for a further 2wks.
first one, or simply pull out each stripper in turn.
If varicose veins recur, try sclerotherapy if the
If the olive becomes detached, palpate where it has varicosities are limited. Recurrence may occur when some
dislodged, and make a 3cm incision over it. tributaries of the saphenous vein or a double vein are not
Dissect down and remove it; bleeding may be ligated; to re-explore the sapheno-femoral junction is quite
troublesome, so have suction ready. hazardous because of scarring, though, and mapping of the
veins by Doppler is usually necessary.
ANATOMICAL VARIATIONS OF THE SHORT SAPHENOUS
COMPLICATIONS OF VARICOSE VEINS
VARICOSE ULCERATION.
N.B. Most lower leg ulcers in the tropics are chronic
tropical ulcers (34.9) and varicose ulcers due to
incompetent perforators are less common. If the ulcer is
not typically the result of varicose veins, consider
alternative causes.
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35.2;Peripheral gangrene Measure the ratio of the ankle to the brachial systolic
pressure (significant occlusion exists if it is <0·85)
Inadequate blood supply leads to gangrene of the but this may be unreliable if arteries are calcified as in
peripheries; strictly speaking, gangrene implies digestion diabetes or renal failure. If you have a Doppler ultrasound
of dead tissue by anaerobic bacteria. This may occur as a probe, this gives greater sensitivity than the finger and can
primary process in gas gangrene due to clostridia (6.24), give very useful objective information about flow rates.
or more usually secondarily to ischaemia. If there is little However, you may not be able to tell where the occlusion
subcutaneous fat, and no oedema, the skin becomes cold lies, and if there is a stenosis whether there is a more
and waxy, haemoglobin diffuses out of the veins, significant stenosis more proximally placed.
discolouring the skin purple, and then black and ischaemia Similarly if you compare the paO2 taken with a pulse
results in shrinking of the tissues (mummification or dry oximeter at the big toe and the thumb, you can get an idea
gangrene). There results a clear line of demarcation of the degree of relative hypoxia: this is significant if the
between viable and dead tissue, and the dead part ratio is <0·6; a reading of <20mm Hg in the lower leg
sometimes simply falls off, leaving the stump to heal. demonstrates significant ischaemia.
At the junction between live and dead tissues, however,
organisms do survive, as is the case with the more VASCULAR RECONSTRUCTION
common scenario of fatty oedematous tissues, particularly It is, sadly, often too late with many patients to consider
found with diabetes mellitus. The result is a mass of this. However, with minor areas of gangrene or ischaemia,
infected, necrotic, smelly, partially destroyed tissue, a patient will do better if you can arrange a successful
known loosely as wet (or moist) gangrene. revascularization of the limb and perform a minor
amputation, rather than a major amputation without any
improvement in vascular supply.
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If you see a patient with claudication at <200m, or rest CONSERVE EVERY CENTIMETRE IN THE ARM;
pain, try to refer him before gangrene sets in. DO A STANDARD AMPUTATION IN THE LEG
You can relieve much pain (and peripheral inflow) with
epidural analgesia. In a perfect stump:
(1) The scar is not exposed to pressure.
(2) The skin slides easily over the bone.
35.3 Amputations in general (3) The skin is not infolded.
(4) There is no redundant soft tissue.
INTRODUCTION (5) There is no protruding spur of bone.
Once you have cut off a limb there is no going back, (6) The stump is painless.
so try to retain as much function as you can. The patient is (7) The wound has healed by first intention.
unlikely to get an arm prosthesis, and it may be of little use (8) The skin has good sensation.
even if he does get one. So aim instead for the longest (9) The shape of most should be conical.
possible stump of an arm. Every centimetre is useful;
so is an elbow which he can use as a hook, and so is any Deciding where to amputate can be difficult. The lower in
kind of a wrist. the leg you amputate, the greater the chance that the
patient will walk again afterwards. But there is also more
Bailey & Love’s famous aphorism, on the indications for chance that the tissue through which you cut will not be
amputation, that if a limb or part of a limb is “dead, deadly viable. So, feel the pulses carefully and take measurements
or a dead loss”, is as true as ever. to assess the degree of ischaemia (35.2): do not perform a
below-knee amputation if you cannot feel a popliteal pulse.
The leg must have a prosthesis which will bear his weight. If the tissues have poor bleeding and the muscle is purple,
There are a limited number of these, and the stumps for abandon this amputation level and go higher up.
them are standardized. So always do one of the standard
leg amputations. There are three technological grades of Consider a through-knee amputation in any frail and
prosthesis; of these the third is not necessarily the worst. elderly patient unsuitable for a below-knee amputation.
A patient might have: Do not delay doing a below knee amputation for severe
(1),A sophisticated modern prosthesis costing US$300 or injuries; otherwise you may well need to do an amputation
more. higher up!
(2),A simpler modern prosthesis costing US$30, such as
one of those developed by BMVSS Jaipur foot (35-21A), Make sure you have properly counselled the patient and
which a mechanic can mend (www.jaipurfoot.org). obtained consent for amputation; do not force him into this
(3),A traditional prosthesis, such as a pylon, a peg leg, against his own judgement, otherwise he will not
(35-21B) or elephant boot. co-operate and mobilize well post-operatively.
An emergency amputation for sepsis or crushed limb may,
Do not despise these; when well made they last longer however, save someone from the jaws of death!
than any of the others, and are better than a modern
prosthesis for working in the fields. Remember that the Many patients (particularly labourers and even some
patient may be used to sitting on the floor rather than on a surgeons) hardly miss an amputated finger, for example.
chair, and so his prosthesis must take this into account. If you decide to amputate, discuss the decision carefully
To this end, the Jaipur prosthesis is most suitable. with the patient. If he is going to take a long time to
It does not require any shoe: amputees can walk barefoot, recover, tell him so. Discuss any alternatives, and if a
or use a shoe. It is made of waterproof material, difficult decision has to be made, let him share it.
so that amputees can walk in wet and muddy fields. If he is involved in the decision, he is much more likely to
It permits enough foot dorsiflexion and other movements be enthusiastic about subsequent rehabilitation.
necessary to walk on uneven surfaces.
A leg prosthesis can: Fish mouth flaps must be long enough to cover the soft
(1), have a cup to bear weight on the sides of the stump, tissues of the stump, but not be so long that their blood
in which case the scar should be at the end. supply is inadequate and they necrose. If the flaps are
(2),bear weight on the end of the stump, in which case the equal, the scar will sit at the end of a stump. If they are
scar should be posterior.