Dr. Saleh Surgery Discussion

29/11/2023

Standard strategy of safe Cholecystectomy.

03/10/2023

𝗦𝗵𝗶𝗲𝗹𝗱 𝗼𝗳 𝗠𝗰𝗘𝗹𝗺𝗼𝘆𝗹𝗲 & 𝗧𝗼𝗽-𝗮𝗿𝗼𝘂𝗻𝗱 𝗮𝗽𝗽𝗿𝗼𝗮𝗰𝗵 𝗱𝘂𝗿𝗶𝗻𝗴 𝗹𝗮𝗽 𝗰𝗵𝗼𝗹𝗲𝗰𝘆𝘀𝘁𝗲𝗰𝘁𝗼𝗺𝘆:

•Once adequate retraction is achieved during lap cholecystectomy, the cystohepatic triangle is evaluated for overlying inflammation & fibrosis. 👉𝗧𝗵𝗲 𝗽𝗲𝗿𝗶𝘁𝗼𝗻𝗲𝘂𝗺 𝗼𝘃𝗲𝗿𝗹𝘆𝗶𝗻𝗴 𝘁𝗵𝗲 𝗰𝘆𝘀𝘁𝗼𝗵𝗲𝗽𝗮𝘁𝗶𝗰 𝘁𝗿𝗶𝗮𝗻𝗴𝗹𝗲 𝗵𝗮𝗱 𝗯𝗲𝗲𝗻 𝘁𝗲𝗿𝗺𝗲𝗱 𝗮𝘀 “Shield of McElmoyle”. Hostile, stiff, & inflamed tissue in this region should alert the surgeon to the 𝗽𝗼𝘁𝗲𝗻𝘁𝗶𝗮𝗹 𝗳𝗼𝗿 𝗯𝗶𝗹𝗶𝗮𝗿𝘆 𝗶𝗻𝗷𝘂𝗿𝘆.

•If it is 𝘂𝗻𝘀𝗮𝗳𝗲 to 𝗱𝗶𝘀𝘀𝗲𝗰𝘁 through the Shield of McElmoyle, we recommend “𝘁𝗼𝗽-𝗮𝗿𝗼𝘂𝗻𝗱” mobilization of the gallbladder (G.B) or opening the G.B for controlled removal of stones. The top-around approach begins with dissection above the Line of Safety, along the medial border of the G.B. The plan is developed in a counter-clockwise fashion between the G.B fundus & cystic plate. This approach, by definition, begins above the biliary pedicles & dissects away from them before stopping the dissection above the Line of Safety on the lateral side of the G.B. From the fundus, the plane is extended towards Hartmann’s pouch until the G.B is separated from the G.B.

•An alternative approach (bail-out) is to open the gallbladder & extract stones in a controlled manner. The Line of Safety may be used as a landmark above which it is safe to open the gallbladder to remove stones & visualize the cystic duct or***ce from inside the gallbladder

𝗥𝗲𝗳: https://aos.amegroups.com/article/view/6810/html

https://www.sciencedirect.com/science/article/abs/pii/S1072751521003744

30/09/2023

https://www.facebook.com/100008346547760/posts/3590801077874742/?mibextid=NOb6eG

27/09/2023

Importance of R4U line in Laparoscopic cholecystectomy.

Rouviers sulcus-segment4-Umbilical fissure.

Dissection must be carried above it.

27/09/2023

The superior mesenteric artery (SMA) can result in 2 compression syndromes:

1) SMA syndrome: Duodenal (D3) compression
2) Nutcracker syndrome: Renal vein compression

20/09/2023

20/09/2023

Importance of Retraction in Laparoscopic Cholecystectomy:

•Once the fundus of the gallbladder is retracted & the liver is moved up, some adhesions on the inferior surface of the liver will occasionally prevent adequate liver retraction. Such adhesions should be removed first before even attempting dissection of the triangle of Calot, as at this point of the procedure, maximal superior retraction of the gallbladder is needed.

•Lateral retraction is the key to safe dissection of the triangle of Calot (Fig. 2.3a). This is performed with the left hand of the surgeon pulling laterally and inferiorly (towards the right Anterior Superior Iliac Spine) on Hartmann’s pouch while the first assistant retracts the fundus of the gallbladder towards the lateral right hemidiaphragm. This will open up the triangle of Calot and the risk of a common bile duct (CBD) injury will be minimized. Wrong retraction closing the angle between the cystic duct and the CBD is depicted in Fig. 2.3b. If the anterior peritoneum overlying the cystic duct and artery is scarred, it is very important to retract the cystic duct in a cephalad direction and incise the posterior peritoneum as closely as possible to the neck of the gallbladder. That will allow safe dissection of the cystic duct next to the neck of the gallbladder, & will create a window around the cystic duct.

𝗥𝗲𝗳:Advanced Laparoscopic Surgery, Techniques & Tips, 2nd ed.

05/09/2023

by desarda method.

Better results then Lichtenstein mesh repair.

Recent study told the same , same recurrence rate with less post operative pain.

Picture shows desarda method herniorrhaphy
Arrow mark shows posterior wall of inguinal canal.
Done by me .
😷

22/08/2023

Patient disease process hampering daily life assessment.
ECOG Scoring
European cooperative oncological group

16/08/2023

CT Pancreatic Protocol

09/08/2023

অ্যাপেন্ডিসাইটিস রোগ নির্ণয়ে রিপাসা (RIPASA) স্কোরিং এর গবেষণাপত্র।


# Ripasa_Score