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However quality 140mg malegra fxt erectile dysfunction drug related, it is not advisable to dissect through a large distance of breast when trying to extract a fibroadenoma via Make no attempt to resuture the defect in the breast order generic malegra fxt line erectile dysfunction treatment dallas, as these one of these incisions purchase 140 mg malegra fxt with mastercard erectile dysfunction shake ingredients. For tumors more than a few centime- sutures often create a mass at the site of the repair. During the ters away from the areola, make an incision in the line of months and years following surgery, evaluation of the Langer directly over the tumor (Fig. These lines are patient’s breast on physical examination can be made essentially circular in nature in the skin overlying the breast, extremely difficult by the presence of a firm mass at the site each circle being concentric with the areola. The defect in the breast will fill with 110 Excision of Benign Palpable Breast Mass 981 Fig. Postoperative Care To apply even pressure on the operative site, request that the patient wear a supportive brassiere over a bulky gauze dress- ing continuously for the first postoperative week. Interim results from the fibro- be removed without creating a defect in the breast. Chassin† Excision of Ducts Ductography Ductography may be performed by inserting a tiny catheter Indications into the duct orifice and injecting a small amount of aqueous radiopaque medium. Single duct discharge with or without palpable mass Recurrent subareolar abscesses with or without associated Ductal Endoscopy mammary fistula This technique, if available, may prove useful in identifying the site of underlying pathology. Preoperative Preparation Operative Strategy Always perform a complete imaging workup, with mam- mography and ultrasound as appropriate. Single Duct Excision Versus Total Duct Excision If single (rather than total) ductal excision is planned, local- ize the involved duct by the following methods: When the indication for surgery is a bloody nipple discharge, the diagnosis is generally an intraductal papilloma. Careful Apply finger pressure at varying points along the outer mar- localization to a single duct allows precise excision, which is gin of the areola to determine which segment of the breast diagnostic in the case of carcinoma and therapeutic in the contains the offending duct (the finger pressure induces dis- case of an intraductal papilloma. If this is not accomplished at initial provides better preservation of sensation in the nipple- examination, apply collodion or skin glue to the surface of areolar complex and may permit breast feeding once healing the nipple to occlude all of the ducts temporarily and prevent has occurred. At subsequent examination a week later, recurrent subareolar abscesses generally requires complete remove the collodion and repeat the attempt to localize the ductal excision. Also, collodion may be applied to the surface of the nipple 1 week prior to operation to cause distension of the diseased duct. Prevention of Skin Necrosis with Ductal Excision Total excision of the mammary ducts requires elevation of the entire areola. Carver not to include more than 40–50 % of the circumference of the College of Medicine, University of Iowa, 200 Hawkins Drive, areola in order to avoid skin necrosis. Chassin incision confined to the skin of the areola is an excellent alter- native, particularly in women with large areolae. Strategic Approach to Breast Abscesses Many breast abscesses respond to aspiration and antibiotics and do not require incision and drainage.

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Until the surgeon is familiar with Splenectomy renders patients susceptible to the lifelong risk mobilizing and handling the organ discount 140mg malegra fxt mastercard erectile dysfunction treatment houston tx, it is best that the liga- of infectious complications best buy for malegra fxt best herbal erectile dysfunction pills. Dissection should occur about of adult splenectomized patients); but it can occur rapidly 10 mm away from the hilum where the vessels are less well and results in a more than 50 % mortality rate (Lynch and fixed and safer to dissect (see Chap malegra fxt 140 mg low cost erectile dysfunction after prostate surgery. Recognition of this syndrome has led to the is accessible above the pancreas, it can be clipped or tied in development and now universal acceptance of splenic pres- continuity. If a stapler is to be used to divide hilar vessels, do ervation as the treatment modality of choice whenever it is not place clips where the stapler is to be positioned to avoid safe and feasible. The importance of splenic preservation has been recog- nized for more than 20 years. The method of splenic preser- vation, however, has undergone a remarkable evolution from Laparoscopic Management of Splenic Cysts operative splenorrhaphy to nonoperative management (Pachter et al. Care must be taken to excise a sufficient portion of the primacy of the nonoperative approach to splenic trauma cyst wall to prevent recurrence. Whether nucleosis), selected patients with isolated stab wounds to the such partial restoration of reticuloendothelial function is suf- spleen, and neurologically impaired patients. As splenic autotransplantation can be performed with relative ease and has not to date been associ- Prognostic Indicators of Failure ated with significant complications, it seems reasonable to of Nonoperative Management continue employing this technique. In patients with splenic injuries who remain hemody- There are certain instances where more active intervention is namically stable but require operative intervention, a variety indicated despite the patient meeting all “conventional” cri- of techniques can be used to achieve splenic salvage. Irrespective of the Included in these techniques are splenorrhaphy, partial sple- patient’s hemodynamic stability, a shattered spleen envel- nectomy, mesh splenorrhaphy, topical hemostatic agents, oped by a significant perisplenic hematoma (Fig. It must be remembered that current literature suggests that splenorrhaphy can be nonoperative management of hepatic and splenic injuries achieved in at least 75 % of patients with a cumulative suc- differs greatly. Prompt surgical inter- Nonoperative Splenic Salvage vention and expeditious splenectomy, preferably with splenic autotransplantation, are warranted. Nonoperative management was, at best, applicable a patient who was injured in a motor vehicle collision, dem- to only 15–20 % of patients with blunt injuries. Current onstrating a contrast “blush” and a large perisplenic hema- data suggest an almost mirror-image reversal, with at least toma. Such a finding indicates extravasation of contrast 50–65 % of patients with blunt injuries and a small group material, signifying active bleeding in the splenic paren- of select patients with penetrating injuries being managed chyma. One should not be lulled into a false sense of security nonoperatively with success rates exceeding 90 %; only by the patient’s stable physiologic profile, however, as rapid 17–20 % undergo splenorrhaphy. The following criteria for nonoperative manage- of contrast from the lower pole of the spleen (same patient as ment have proven safe and effective in our hands: in Fig. Imaging may be used as a criterion for moving stable patients out of critical units sooner. Follow-up imaging may also phy in patients with stable postobservation courses seem be helpful for determining which patients may return to 95 Concepts in Splenic Surgery 865 splenectomy, and heterotopic splenic autotransplantation must be in the trauma surgeon’s armamentarium. Laparoscopy for Management of Splenic Trauma Laparoscopy is another tool available to the trauma surgeon dealing with the diagnosis and management of splenic trauma.

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It is performed as the first stage in the proce- Closure dure; if the rectum is so badly diseased that mucosectomy cannot be reasonably accomplished buy cheap malegra fxt 140 mg on line erectile dysfunction caused by hemorrhoids, the operative plan must A loop ileostomy (see Chap order malegra fxt 140 mg overnight delivery erectile dysfunction onset. It should be used whenever Good fecal continence can be maintained if the mucosa is there is the slightest doubt as to the integrity of the pelvic dissected away from the rectum up to a point no more than anastomoses discount malegra fxt 140 mg fast delivery erectile dysfunction pump demonstration. This amount of dissection can generally be accom- plished transanally with less difficulty in the adult patient Ileoanostomy than occurs when using the abdominal approach. To facilitate anastomosing the ileum or the ileal reservoir to Generally, careful electrocoagulation can accomplish the anus, it is helpful to flex the thighs on the abdomen to a this end. Otherwise, it will be neces- sary to insert sutures high up in the anal canal where trans- Abdominal Dissection anal manipulation of the needle is extremely difficult. Also, it is important to remove all of the diseased mucosa in this When performing the colectomy, transect the ileum just operation to eliminate the possibility of the patient develop- proximal to its junction with the ileocecal valve to preserve ing a rectal carcinoma at a later date. If a previous One method of achieving exposure with this anastomosis is ileostomy is being taken down, again preserve as much ter- to insert the bivalve Parks retractor with large blades into the minal ileum as possible. Then draw the ileum down, between the open blades of the retractor, to the dentate line. Insert two more Rectal Dissection sutures between the ileum and the posterior portion of the den- tate line. Remove the large When dissecting the rectum away from the sacrum, keep the blades from the retractor and replace them with small blades. Divide the Then carefully insert the blades of the Parks retractor into the mesenteric vessels near the point where they enter the rec- lumen of the ileum and open the retractor slowly. With the Parks retractor blades in place, continue to approx- In this way, the hypogastric nerves are preserved. This requires that the retractor be loos- the point of division as close to the rectum as possible to ened and rotated from time to time to provide exposure of the avoid dividing the parasympathetic nerves essential for nor- entire circumference of the anastomosis. Anteriorly, the dissection proceeds the underlying internal sphincter muscle together with the epi- close to the rectal wall posterior to the seminal vesicles and thelial layer of the anal canal when inserting these sutures. An alternative, more effective method of exposing the anastomosis is to use a Gelpi retractor with one arm inserted into the tissues immediately distal to the dentate line at about Division of Waldeyer’s Fascia 2 o’clock while the second arm of this retractor is placed at 8 o’clock. A second Gelpi retractor is inserted into the anus In the adult patient it is not possible to expose the levator with one arm at 5 o’clock and the second at 11 o’clock. If the diaphragm unless the fascia of Waldeyer is divided by sharp patient is properly relaxed, these two retractors ensure visi- dissection. This layer of dense fascia is attached to the ante- bility of the whole circumference of the cut end of the ano- rior surface of the sacrum and coccyx and attaches to the rectal mucosa at the dentate line.

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Decision to Perform Damage Control Damage Control in Trauma The decision to perform damage control rather than to pur- Always follow the basic principles of trauma surgery buy malegra fxt on line amex natural erectile dysfunction pills reviews. These sue definitive repair of all injuries depends upon physiologic include warming the operating room buy malegra fxt 140mg free shipping erectile dysfunction causes ppt, intravenous fluids cheap 140 mg malegra fxt fast delivery erectile dysfunction kidney stones, and stability of patient, other injuries, and the nature of damage ventilator circuit, having at least two large bore intravenous found on laparotomy. Physiologic criteria include acidosis, catheters in place and adequate (but not excessive) resuscita- hypothermia, and coagulopathy. The approach outlined here tion with warmed crystalloid, and ensuring ready availability works well for blunt trauma. First, obtain temporary control of bleeding and allow anesthesia to catch up with blood loss. Conversely, major splenic bleeding is easily and definitively managed by splenectomy. Rapid closure with a heavy running nonabsorbable suture provides hemostasis, prevents herniation of viscera, and facilitates liver packing. Without watertight closure of the diaphragm on the right, liver injuries may continue to bleed out a right-sided chest tube. There is no role for splenic repair in the set- ting of an unstable patient with multiple injuries. Have an assistant maintain bimanual compression of the liver to control bleeding as you mobilize the ligaments, including the falciform. Division of the falciform ligament makes it easier to pack the liver and helps prevent additional injuries caused by traction on the ligament. In less dire situ- ations, finger fracture with direct control of bleeders and bile Fig. If the bleeding can be controlled by bimanual compression, packing should Attain rapid control of hollow visceral injuries by closing work. Packs must be placed in such a manner as to avoid the hole with a skin stapler or with sutures or by resection compression on the inferior vena cava. For temporary closure during the right lobe against the retroperitoneum to the right of the exploration, Babcock clamps work well. Elevate the abdominal wall and costal margin and or stoma formation until the patient is more stable. It folded plastic drape directly on the liver and pack above this, contains the duodenum, pancreas, aorta, and vena cava as to facilitate atraumatic removal of packs at second laparot- well as many smaller named vessels such as the celiac, supe- omy. Have the anesthesiologist report any drop in blood rior and inferior mesenteric arteries, and the renal vascular pressure as you pack, and be prepared to adjust your packing pedicles. Hematomas in this area must be explored to iden- to relieve inferior vena cava compression.