This one is a real interesting case I have in my ward. She is a 35 year old lady with history of upper abdominal distension after meals.2 years ago she had features of gastric outlet obstruction and was operated in a govt hospital outside. No records of the previous surgery are available.
Now she has a small upper midline scar and scars of 4 laparoscopic ports. ( We are assuming lap assisted gastrojejunostomy was done). She has distension abdomen with bloating and a pelvic mass with ascites.
CT abdomen shows thickening of the pylorus and is suggestive of bilateral ovarian mass (Krukenberg’s tumor). Barium meal is suggestive of dilated stomach with an irregular ulcerative growth in the antrum.
Endoscopy was done which showed normal mucosa and two normal openiings.Palliative Surgery is being planned to relieve the upper abdomainal symptoms followed by B/L salpingoophrectomy and hysterectomy.
Surgery was done today, there was a growth in the antrum with malignancy spreading to the GE junction. Previous surgery was just gastrojejunostomy which was infiltrated by tumor.
We did a palliative partial gastrectomy with roux en y gastrojejunostomy.It was followed by Bilateral salpingo oophrectomy and hysterectomy.
The past week was not very productive for me from surgical point of view. I assisted in a few laparoscopic inguinal hernia and epigastric hernia surgeries. Sometimes I wonder if laparoscopic hernia repair truly has an advantage over open hernia meshplasty. I guess you should learn both and then make your choices.
The coming week i think is going to be more interesting, a couple of hemicolectomies and gastrstomies are lined up. I also have some good radiograph of a malignant gastric ulcer which ill try to post next time.
Medical college and hostel life was fun, I dont remember when i attended the 9 am class i n final year, (Maybe thats why I have to be early in the hospital now;; Life evens out things)
I got hold of an old college magazine in which there was an article of HIlarious case presentations and history taking by 3rd year students
…Student asking from a grandson– Did your grand father get any head injury when he was a kid.
…. In Paedetrics ward case presentation - 11 mth old male blah blah … No history of alcohol intake in the past.
…student to a family member (In Village posting) What do you think about T.B.(Tuberculosis).?
Member; Sir we watch TB (TV) at night only .
… In a door to door survey
Student– from a father- Do u have any children below 5 years of age
Father– Not any more
Student — Sorry! What happened to them
Father –They grew up
India Counts
Delhi was ruled by members of the Maurya dynasty in around 300 BC and covered most of Northern India ;the main capital though was in Patliputra.(present day Bihar)
Under Chandra Gupta Maurya and later Ashoka many battles were won and the city experienced prolonged periods of peace and Harmony.Arthashastra written by Chanakya and the Edicts of Ashoka are primary sources of written records of the Mauryan times.
The Empire was founded in 322 BCE by Chandragupta Maurya with the help of his Prime Minister Chanakya also known as kautilya. They overthrew the Nanda Dynasty and rapidly began to expand their power westwards across central and western India
At its greatest extent, the Empire stretched to the north along the natural boundaries of the Himalayas, and to the east stretching into what is now Assam. To the west, it reached beyond modern Pakistan and significant portions of what is now Afghanistan, including the modern Herat and Kandahar provinces and Sistan and Baluchestan Province in Iran.
The rise of Chanakya and stories associated with him are legendary. He wanted to work with the Nanda king and offered him his services, but the rude king was not amused and Chanakya was thrown out of his court. A fuming Chanakya swore revenge and found Chandragupta, whom he recognised as a born leader. Ch?nakya’s initial attempt to overthrow Nanda failed, whereupon he came across a mother scolding her child for burning himself by eating from the middle of a bun or bowl of porridge rather than the cooler edge. Ch??akya realized his initial strategic error and, instead of attacking the heart of Nanda territory, slowly chiped away at its edges.
Under Chandragupta, the Mauryan Empire conquered the trans-Indus region, which was under Macedonian rule. Chandragupta then defeated the invasion led by Seleucus I, a Greek general from Alexander’s army.
I know its not important but still Id like to describe my preparation for on OR day… I usually refresh my memory a bit if the surgery hasnt been done for a while, the book i most frequently read is Farquharsons (mainly because it is concise and ive read it many times) but if i have time id prefer to go througha major book like Mastery of surgery or Rob & smith.
For laparoscopic videos i prefer websurg.com although youtube has some very good videos.
I reach the hospital at about 8.20 do the ward rounds and try to reach the theatre by 9.00 AM
Usually we are there before the anesthesia consultants and have to wait for them to shift the patients on the OT table. After that everything is smooth,after surgery patient is shifted out and the next patient brought in. This goes on 3-4 times. We usually have two consultants,one of them shouts a lot and makes everyone tense, the other one is cool and calculating but he does a limited no. of surgeries only. So if want to learn new things u have to accept the shouting surgeon and bear with him…
What kind of OT days do u have..Is it more fun than mine.
Some say Delhi got its name from King Dhilu in 800 BC, After that period there are many conflicting theories about rulers of Delhi, there was no significant achievments or wars and Delhi was ruled by hindu rulers for a long time.(817 BC - 372 BC)
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Its 2008 and tuberculosis (which is unheard of in the western world) is still the disease i fear most. Most of the mortality and morbidity i have seen in my ward is due to tuberculosis. It hurts more because it is a preventable and treatable condition. So why is it such a troublesome disease. We had two cases in the past four months, young females patients who had pulmonary tuberculosis and peritonitis. On exploration the whole of jejunum and ileum was friable, unhealthy and there were multiple perforations through out the jejunum and ileum. Normally a tubercular perforation occurs in the distal ileum and in such cases the least you can do is make an ileostomy.
But the cases we did had proximal perforations is in the jejunum (about 1 foot from the duodenojejunal junction) with multiple perfoarations through out. Resection and Anastomosis was out of question, diverting proximal jejunostomy would require long term parenteral nutrition.
Tuberculosis peritonitis of the Abdomen is not like a regular peritonitis, it doesnt have the classical guarding and rigidity features early on and patient does not have much pain, it is like peritonitis in an elderly or child and high index of suspicion is needed to diagnose it.
We also see a lot of cases in the early period of abdominal tuberculosis in which there is a strong suspicicon but often there is no evidence of TB in the radiological and biochemistry work up. May be there is a strong case of doing diagnostic laparoscopies more liberally.
History of delhi is as old as the civilisation itself. The city has seen many ups and downs,It has been built and destroyed over and over again; the invaders wiping out the entire population. the city and the spirit of the people have withstood the onslaughts time and again.
In the time of Mahabharta (2500 BC), the clan of Kaurvas ruled the city of Hastinapur (elephant city) which includes what now is the modern Delhi.
Pandavas their cousins ruled the city of Indraprastha, which was developed by them from a scratch, Indraprastha was later won by Kaurvas on the gambling table. Pandavas lost their kingdom and had to live in the jungles for 13 years, They came back and fought the Great Battle of Mahabharta in Kurukshetra which is now about 180 km from delhi. Pandavs defeated the Kaurvas and ruled both Indraprastha and hastinapur.
Indraprastha was where the modern Pragti Maidan and old fort is.
Asia Cup is over and the Indian team is now going to sri Lanka. The unimitable star of the Asia Cup was Ajanta Mendis.This was the 1st time I saw him bowl and that was some phenomenal stuff
Indians tried to dominate him from the start and lost virender Sehwag on the 2nd bowl of his first over when indians were going at 8 uns/over. That was the sign of things to come and five more indin wickets perished scoring only 9 more runs.
In view of this bowler, the srilankan series assumes greater proportions for me. The past sri lankan series have all been boring draws or wins by large margin.
Indians come here after relative success in the test matches in Australia but playing Muralidharan and Mendis will not be easy on any turf.
Dhoni has decided to opt out of the series, That’s fair enough and it gives Prthiv patel one more chance at the international level.
Tendulkar, Laxman, Dravid and Ganguly are back for the tests after the IPL stint and we’ll have to wait and watch how they handle the Sri lankan bowling attack
Carcinoma Gall Bladder is on table tomorrow, she has ascites on CT abdomen which we are suspecting to be malignant but the patient is pretty well preserved (50 year old female).
If thats the case it would strongly affect the prognosis. she is not jaundiced and all the systems are pretty well preserved.
We hope to do a cholecystectomy with liver bed resection at least.
9.7.08
The surgery was started as planned but there was gross ascites with multiple nodules in the peritoneum, mesocolon and mesentary.
Omentun was thick fibrosed and adherent, Gall bladder was replaced by a mass adherent to the calot’s triangle
Cholecystectomy with omental biopsy was done, the only hope for the patient is if it turns out to be tubercular
If this is malignant, Thats pretty much it
