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By I. Thorus. East Stroudsburg State University.

This may be especially noticeable when be avoided in patients treated with botulinum toxin order zenegra online pills. This is thought aminoglycosides zenegra 100 mg for sale, penicillamine discount zenegra 100 mg on line, quinine, and calcium channel to occur from a weakening of the sternocleidomastoid muscles, blockers. This rare complication, Te most common reactions to botulinum toxin injections are anecdotally, appears to be more common in women with long, thin generally mild and transient and they are discussed in detail in their necks. Generally, in the United States reasonable risks must be detailed Untoward sequelae commonly caused by a percutaneous injection to the prospective patient. More than one-third were mon meaningful adverse efect is unwanted weakness in nontargeted related to the legal of-label use of the drug. Fortunately, unwanted weakness caused by the action of included injection site reactions, lack of intended efect, ptosis, muscle the toxin usually resolves in several months and in some patients in weakness, and headache. Te standard of care is somewhat simplistically Muscle weakness is the result of the desired toxin efect on injected defned as “what would a reasonable physician do if in an identical musculature. This can be a desired goal in most and a problem with situation with an identical patient. For of action in negligence are derived from formal legal textbooks, the example, patients who depend on emotive expression, such as actors standard of care is not necessarily derived from some well-known and politicians, can be signifcantly negatively impacted by a poten- textbook. Excess weakness following frontalis is defned by some, as whatever an expert witness says it is in the con- injection may cause paralysis rather than weakening of the muscle. In a case against any Patients may report that they appear mask-like and further, that cosmetic physician, the specialist must have the knowledge and skill their brow feels heavy. If brow ptosis occurs, a hooded appearance ordinarily possessed by a specialist in that feld, and has used the care may be present, and occasionally vision may be partially obstructed. This can be improved thetic medicine physician will all be held to an equal standard. A fail- by simply injecting a small amount of toxin into the lateral frontalis ure to fulfl such a duty may lead to loss of a lawsuit by the physician. If the jury accepts the suggestion that the doctor mismanaged the case Since brow depressors are generally weakened when treating gla- and that the negligence led to damages to the patient, then the physi- bellar lines, ptosis of the upper eyelid can occasionally result follow- cian will be liable. In the case of botulinum toxin injections, mistreat- ing improper injection technique in this region. Ptosis is caused by migration of toxin the jury believes an expert who testifes for the defendant doctor, then through the orbital septum weakening the levator palpebrae superi- the standard of care, in that particular case, has been met. It has been suggested that patients remain in an upright position the standard of care is a pragmatic concept, decided case by case, and for 3–4 hours following injection to lessen the risk of eyelid ptosis. Te physician injecting Tere is, however, no scientifc data to support this notion and this botulinum toxin is expected to do this in the manner of a reasonable author no longer provides such advice to his patients. A physician needs to perform a procedure in a manner that tion of the muscles under treatment may increase the uptake of toxin is considered by an objective standard as reasonable. Apraclonidine is an alpha2-adrenergic agonist, which dance with the manufacturer’s suggested dilution instructions, but causes Müller’s muscle to contract. It should be noted that apracloni- works well and gives optimal results, then this dilution would be con- dine is contraindicated in patients with documented hypersensitivity. Phenylephrine is contraindicated in patients with narrow-angle glau- It is important to note that where there are two or more recognized coma and in patients with aneurysms. If severe lower lid weak- even if one method turns out to be less efective than another method. If the lateral rectus is Finally, in many jurisdictions, an unfavorable result due to an “error 94 11. A court would sent a consensus among professionals on a topic involving diagno- have several options when such guidelines are ofered as evidence. Although the standard of care may vary from state lines would be shielded from liability to the same extent as one who to state in the United States, it is typically defned as a national stan- can establish that he or she followed professional customs. Using guidelines as evidence of professional witnesses articulate, in court, the standard of care. Te basis of the custom, however, is problematic if they are ahead of prevailing medi- expert witness testimony, and therefore the origin of the standard of cal practice. Te witness’s personal practice cal standard may be presumptive evidence of due care, but expert 2. Te practice of others that he has observed in his experience testimony will still be required to introduce the standard of care and 3. Medical literature in recognized publications establish its sources and its relevancy. Statutes and/or legislative rules Professional societies ofen attach disclaimers to their guidelines, 5. Courses where the subject is discussed and taught in a well- thereby undercutting their defensive use in litigation. Te American defned manner Medical Association, for example, calls its guidelines “parameters” instead of protocols intended to signifcantly impact on physician Te standard of care is the way in which the majority of the physi- discretion. If, in fact, the tain disclaimers stating that they are not intended to displace phy- expert personally does not practice like the majority of other physi- sician discretion. Such guidelines, in these situations, could not be cians, then the expert will have a difcult time explaining why the treated as conclusive. Although such It would seem then that in the perfect world, the standard of care a plaintif’s expert may also refer to clinical practice guidelines, the in every case would be a clearly defnable level of care agreed on by physician’s negligence can be established in other ways as well. Unfortunately, in the typical situation the methods include (1) examination of the physician defendant’s expert standard of care is an ephemeral concept resulting from diferences witness, (2) an admission by the defendant that he or she was neg- and inconsistencies among the medical profession, the legal system, ligent, (3) testimony by the plaintif, in a rare case where he or she and the public. In such a layperson could understand the negligence without the assistance of situation, recommendations, guidelines, and policies regarding vary- an expert. Even in some of these cases, how- cause of action against an aesthetic physician, must establish that his ever, factual disputes may arise because more than one such organiza- or her physician had a duty of reasonable care in treating him or her tion will publish conficting standards concerning the same medical and had in fact breached that duty. Adding to the confusion, local societies may publish their lead to some form of damages. A mere inconvenience to the plaintif, own rules applicable to a particular claim of malpractice. It is a legal fction to suggest that botulinum toxin induced complications are temporary and noth- a generally accepted standard of care exists for any area of practice. However, in those rare situations At best, there are parameters within which experts will testify. Te where a patient was not warned of a potential complication and the cosmetic physician’s best defense that he is acting in accordance with ensuing complication led to damages (such as the inability to work), the standard of care is to document appropriate risk assessment of the there may be legal implications from the botulinum toxin induced patient, provide appropriate medical record documentation, appro- complication. Because oped by specialty societies such as the American Academy of of negligent technique, her eyebrows were lifed in the so-called Dermatology, the American Society for Dermatologic Surgery, and mephisto pattern. Even though the deformity was treated to correc- the American Society of Aesthetic Plastic Surgery. Te Institute of tion some weeks afer the injection, she missed out on 2 weeks of work Medicine has defned such clinical guidelines as “systematically with its economic impact and associated embarrassment. She sued developed statements to assist practitioner and patient decisions her physician.

When performing splenectomy for trauma buy 100 mg zenegra with mastercard, it is not necessary to isolate and ligate the splenic artery as a first step (as described in Chap buy generic zenegra 100 mg online. Take a position on the patient’s right and retract the spleen Incision in a medial direction with the left hand generic zenegra 100 mg free shipping. In the unstable patient, make a midline incision from the Then divide the splenorenal, splenophrenic, and splenocolic xiphoid to a point well below the umbilicus. In an emergency situation the experi- patient, a midline incision is suitable for the patient with a enced surgeon can often perform much of this by blunt finger narrow costal arch. After the ligaments have been divided, slide the left subcostal incision, dividing the muscular layers with right hand behind the tail of the pancreas and elevate the tail electrocautery to speed the operation. A Kehr extension, of the pancreas together with the damaged spleen into the 97 Operations for Splenic Trauma 877 Fig. Pack the posterior abdominal wall vessels, insert Lembert sutures to invert this area of the with moist gauze pads. It is generally simple to divide these structures between hemo- stats or ligatures (Fig. Now deliberately dissect out each of the short gas- tric vessels and divide each vessel between Adson hemo- If the patient is hemodynamically stable and other injuries stats. Remove the spleen and then ligate each of the vessels have been managed or ruled out, splenic preservation may held by hemostats with 2-0 or 3-0 silk. In this case, fully mobilize the spleen as second ligature to the splenic artery for added security and to described above but take great care not to damage the cap- control the minor bleeding points around the tail of the pan- sule and worsen the injury. With this technique there need not be any haste to obtain hemostasis because early in the operation the surgeon can Selecting the Optimal Technique for Splenic control most of the bleeding by finger compression at the Preservation hilus of the spleen. Avulsion of Capsule; Superficial Injuries Carefully inspect the greater curvature of the stomach. If Iatrogenic injury to the spleen during the course of gastric there is any suspicion that the stomach wall has been injured surgery, hiatus hernia repair, or colon resection has consti- during the dissection or the ligation of the short gastric tuted the most common single indication for splenectomy in 878 C. Most of these injuries have involved avulsion of a relatively small patch of splenic capsule. Superficial injuries of this type are best treated by application of topical hemo- static agents (see below) rather than splenectomy. The argon beam coagulator is a noncontact device for splenic artery and vein, hemostasis is more difficult than is applying thermal energy. It is eminently suitable Stellate Fracture for repair by suturing after hemostasis has been obtained. This After exploring the depths of the fracture and removing clotted technique is described under Splenorrhaphy, below. Closing the capsule in this fashion generally controls bleeding Complete Transverse Fracture from superficial fractures. Alternatively, applying Avitene to When a transverse fracture of the spleen has divided the the stellate fracture may successfully control all but the arterial organ into two or more segments, it is necessary to determine bleeders. The efficiency of this topical agent may be enhanced the viability of each segment. Any splenic fracture that significantly involves the the nonviable segments and retain the viable portion of the hilus of the spleen generally requires partial splenectomy to spleen after achieving hemostasis. Be sure Applying Topical Hemostatic Agents to identify and ligate the hilar artery that supplied the ampu- tated segment of the spleen. Most topical hemostatic agents provide a framework for deposition of platelets, which accelerates formation of a Longitudinal Fracture blood clot. Severe blunt injuries may produce a longitudinal fracture in Consequently, it is necessary to slow down the bleeding from the long axis of the spleen (Fig. Because this fracture the surface of a damaged spleen by local pressure for a few may lacerate a large number of the transverse branches of the minutes. If the oozing surface is fairly smooth, apply a 97 Operations for Splenic Trauma 879 double sheet of oxidized cellulose gauze and cover it with a dry gauze pad. Then gently remove the gauze pad while taking care not to dislodge the sheet of oxidized cellulose, which should now be adherent to the raw surface. If the bleeding surface is irregular in nature, Avitene is a much better choice than hemostatic sheets. It is highly effec- tive for oozing surfaces due to traumatized capillaries and venous sinusoids. Use a forceps to apply enough Avitene to cover the entire bleeding surface for a thickness of 3–4 mm. If bleeding breaks through one portion of the Avitene, apply an additional layer of dry Avitene. If bleeding contin- ues to break through, remove the Avitene and pursue further efforts to reduce the rate of bleeding by applying hemostatic clips or suture-ligatures. If necessary, use strips or pledgets of Splenorrhaphy Teflon felt, omental pedicle, or even oxidized cellulose gauze; insert the sutures through these pledgets to protect the Mobilizing the Spleen splenic capsule when the suture is being tied. A linear sta- Do not try to repair the spleen without completely mobiliz- pling device may also be used to close the capsule of a small, ing the spleen and the tail of the pancreas by the technique normal spleen after partial splenectomy. Adequate exposure may Absorbable Mesh Wrap also require division of the lower short gastric vessels. Be When a spleen is the site of several fractures or the capsule is careful not to cause further injury to the spleen when divid- stripped from a significant part of the surface but the hilum is ing the splenic ligaments. Place a large gauze pad against the posterior tailoring the mesh and suturing it so it provides even pressure to abdominal wall in the area of the dissection and elevate the the damaged spleen may help achieve good hemostasis. Mark the excess, splenic artery and vein between the thumb and index finger remove it, and cut it to size, leaving at least a 2 cm border all at the hilus (Fig. With the mesh on a convenient surface away from the hilus that may have been lacerated by the trauma. This suture serves as a purse string to Suturing the Splenic Capsule tighten the mesh around the spleen, applying firm, even com- For fractures that have not penetrated the full thickness of pression to the splenic pulp without occluding the hilar vessels. Use a narrow-tipped suction device to taking care not to tighten it around the splenic artery and vein provide exposure and occlude bleeding arteries by accurately (Fig. If the mesh is not tight enough, plicate it with addi- applying small- or medium-size hemostatic clips, use 4-0 or tional sutures at a convenient location. Confirm that all bleeding 5-0 vascular sutures to control bleeding veins or arteries that has been controlled and replace the spleen in its bed. Control residual oozing of blood from the sinusoids by closing the capsule with interrupted sutures of 2-0 chromic catgut on a medium-size gastrointestinal atrau- Partial Splenectomy matic needle, as illustrated in Fig. In other cases, a Dividing the Spleen continuous suture of the same material may prove to be Temporarily occlude the splenic artery with a Silastic loop. When tying these sutures, take great care not to Then aspirate all blood clots from the area of injury, espe- apply force sufficient to tear the delicate splenic capsule. Release the splenic artery, observe for a line of demarcation, and mark it with electro- cautery along the capsule. Use a narrow-tipped suction device to expose the bleed- ing points in the line of the fracture. Apply small hemostatic clips to bleeding vessels and continue the dissec- tion until the traumatized section of the spleen has been entirely severed.

In fact the portion of thejejunum between the duodeno-jejunal flexure and the anastomosis should not be more than 6-9 inches order zenegra with amex. The loop of the jejunum buy genuine zenegra, which is kept very close to the posterior wall of the stomach order generic zenegra online, should be such that the proximal portion of the jejunum will be lying against the portion of the fold near lesser curvature of the stomach, while the distal portion of thejejunum will be lying against the portion of the stomach close to the greater curvature. Two Allis forceps are applied to the jejunum about 3 inches apart and an occlusion clamp may or may not be applied to hold the anastomotic site of the jejunum by the side of that of the stomach. A piece of swab soaked in warm sterile water is placed between the two guts just beneath the anastomosing site. All other viscera are returned to the abdomen and covered with two hot moist mops from both the sides, so that only the two portions of the gut held by occlusion clamps will be exposed. A continuous sero-muscular suture is passed through the serous and muscular coats of the stomach and jejunum using No. After completing the first row of posterior sero-muscular (Lembert) suture, the needle and catgut are left aside in a piece of gauze, so that they can be used again in the 4th row, i. With a knife, the wall of the stomach and the jejunum are incised about 5 mm away from the first row of sero-muscular suture for about 2 ‘/ inches. As soon as the mucous membrane is incised, the gastric and the jejunal juices should be sucked out so long as the incision ofthe mucous membrane is continued. Now a continuous posterior through-and-through stitch taking all the layers of the stomach and thejejunum is performed. This is continued as the anterior through-and-through suture (3rd row of suture) till the point, where the posterior through-and-through suture is reached. The last row of anterior sero-muscular suture is applied with the needle and catgut used for the posterior sero-muscular suture and continued a little beyond the point of commencement. The posterior wall of the stomach is sutured to the margin of the gap in the transverse mesocolon with a few interrupted sero-muscular sutures. Anterior gastro-jejunostomy This operation is seldom performed because of the possibility of the complication of regurgitant vomiting Only two conditions, where this operation is performed, are :— (a) Where dense adhesions will prevent access to the posterior wall of the stomach and (b) As palliative measure in gastric carcinoma, so that the gastro-jejunal anastomosis is not so easily involved by the extension of the growth. In this operation, the jejunum is brought round the transverse colon and applied to the anterior wall of the stomach. So the afferent loop is always kept long enough not to be compressed by the transverse colon. The anastomosis is made at the most dependent part of the stomach and horizontally. Jejuno-jejunal anastomosis between the afferent and efferent loops of the jejunum may be made only in case of carcinoma. If it is done in other cases, it will invariably lead to anastomotic ulcer as the alkaline juices of the duodenum and jejunum will not get an access to the gastro-jej unal anastomosis, but will be by-passed through the anastomosis between the afferent and the efferent loops. Pyloroplasty This operation is also a type of drainage operation as the preceding one. In uncomplicated duodenal ulcer, this operation along with vagotomy is probably the operation of choice. Being more physiological and as it maintains the normal anatomical configuration, this operation is gaining more and more popularity over the gastroenterostomy (gastrojejunostomy). In case of gastric ulcer this operation along with vagotomy may be performed, provided the ulcer is excised and biopsied. In peptic perforation, when the patient is a known sufferer of duodenal ulcer and when the patient’s condition is not too grave to perform this operation, pyloroplasty along with vagotomy is not only a life saving measure, but also a curative operation This operation is contra-indicated in case of pyloric stenosis and when the pyloroduodenal area is scarred, fixed and deeply placed in an obese abdomen. An incision is made through all the coats on the anterior wall of the pyloric canal midway between the greater and lesser curvatures starting from 3. If the ulcer is found very close to the incision, it should be encircled and excised along with the incision. A pair of tissue forceps is applied to the upper edge and one at the lower edge, both at the midpoints of the incision. These two pairs of forceps are now pulled apart so that the proximal and the distal ends of the incision approach to each other and the defect becomes vertical thus widening the pyloric canal. Now the defect is closed using an all-coats suture of 00 chromic catgut, leaving a vertical suture line. Weinburg’s modification is to close the defect with an all-coats suture using anon-absorbable suture material such as silk. Interrupted stitches are used and the needle is so inserted as to prevent invagination of the mucous membrane. Seromuscular suture, which generally invaginates the walls of the gut thus narrowing the pyloric canal, is not used. A seromuscular Lembert suture is used to unite the greater curvature of the stomach and the desending duodenum closing the angle below the pylorus. The anterior walls of the stomach and the duodenum are incised about 5 mm away from the suture line along an inverted horse-shoe shaped line. An all-coats stitch is used to unite the greater curve edge of the stomach to the left edge of the duodenal wall from above downwards. This stitch is continued around the comer to unite the right edge of the duodenum to the left edge of the stomach. The closure is completed with a seromuscular stitch to Partial gastrectomy invaginate the all-coats suture line. In patients with duodenal ulcer, with lower acid secretion, the distal 1 /3rd of the stomach may be excised. This operation goes by the name oiantrectomy, which is thus always combined with vagotomy to prevent recurrence of ulcer. The unscarred and mobile duodenum can easily be united to the proximal stomach remnant. In case of high lesser curve ulcer, it can be excised with a tongue of stomach, preserving longer greater curvature for the gastro-duoaenal anastomosis. This operation was described by Schoemaker This type of high gastric ulcer will also heal if a hemigastrectomy is performed below the ulcer, fol­ lowed by a Polya reconstruction; this i s Kelling-Medlener operation. When gastric and duodenal ulcers co-exist, Polya or Billroth I reconstruction give equally good result. A tongue of lesser curve can be excised to include a high gastric ulcer using either method. If the bleeding occurs from multiple gastric erosions that cannot be controlled by local measure such as under-running the bleeding points, gastric resection may be necessary. The erosions are usually localised to the distal stomach and can therefore be dealt with by distal gastrectomy and a Billroth I reconstruction. Polya gastrectomy has the theoretical advantage that the full width of the stomach is used for anastomosis, thus minimising the chance of subsequent stomal obstruction if the growth recurs in the gastric remnant. Cases are on record that gastric carcinomas often invade the duodenal bulb which should be excised and closed. The stomach and duodenum are thoroughly examined to know the exact details of the pathology. The stomach is drawn out of the wound and the probable extent of the resection is estimated. A hole is first made through the gastrocolic omentum in an avascular area to the left of the left gastro-epiploic vessels.

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