Unbounded Medicine

Lakshmi is the hindu goddess of of wealth, fortune, love and beauty, the lotus flower and fertility. She is represented by an icon of a lady with four arms.

Lakshmi Tatma is a girl who is two years old but she was born with 8 limbs, because she is joined at the pelvis to what is, in fact, a headless, undeveloped twin (parasitic twin or to be more specific, ischiopagus cojoined twin).

This is surely an abnormal feature and it has attracted media attention worldwide.

The 24-hour-long surgery to remove the extra limbs of this Indian girl born with four arms and four legs was a success, doctors announced Wednesday.

A team of more than 30 physicians removed Lakshmi’s extra limbs, salvaged her organs, and rebuilt her pelvis area, Dr. Sharan Patil said from a hospital in the southern Indian city of Bangalore, India.

This surgical model is made of glass fiber and has abdominal and thoracic compartments separated. A selective bronchial intubation can be done in this model. It also has a structure that simulates a diaphragm. You can perform both laparoscopy and thoracoscopy.

The organs of a pig are placed within the model.

The model is intubated with an “orotracheal” tube

Abdominal view

Thoracic view

Laparoscopy view

A previously healthy 63 years old male underwent laparoscopic Nissen fundoplication. Pneumoperitonium was induced with CO2 at a pressure of 13 mmHg. 30 minutes later, he developed hypercarbia (44mmHg) and subcutaneous emphysema without hemodynamic instability, desaturation or fever. Other causes of hypercarbia was ruled out. The procedure was uneventful and completed successfully. Pneumoperitoneum was released. During surgery the patient underwent hyperventilation and the hypercarbia resolved.

Note the color of the skin and the emphysema

Note the color of the skin and the emphysema

Note the changes in the color of the skin

Images courtesy of Mariana Herrera Guerrero, M.D.

More of Subcutaneous emphysema here.

The english organization Marie Stopes International maintains a campaign to alert british citizens on the risks of acquiring venereal diseases or non-wished pregnancies when traveling to Mexico.

“What is more embarrassing, his hat or what he might give you? Make sure don’t come home with any unwanted holiday souvenirs”

This poster is very offensive and annoying. It’s an insult for my Country and it will frighten tourists. MFs, try to think before offend.

Welcome to the third edition of SurgeXperiences, the first carnival of surgery. I’m honored to bring you this surgical carnival.

This will be a practical and concise edition. The objective of blogs (in my point of view) is to answer questions as quickly as possible, so lets start with the HOW-TOs. Enjoy.

• How to classify fingertip injuries and amputations and how to treat them? This is a nice abstract in where we will learn how to close the wound, maximize sensory return, preserve length, maintain joint function, and achieve a satisfactory cosmetic appearance. This is a Must Read!
• How to survive surgical training when your boss is really mean? A touching and insightful story. Luckyly those times are changing.
• How must be your surgeon? How to make the perioperative experience a smooth one for patients, nurses and surgeons? Great tips for all of us. Don’t lose the floor.
• What are the complications of Mitral Valve Replacement? An excellent reminder.
• How to choose a rehabilitation center? What are their services, facilities, costs and credentials?
• How is the clinical presentation of severe pancreatitis? I love hard cases as this one.
• How much farther have we advanced in medicine since the days of trepanation? Do you know that people had holes drilled in their heads voluntarily and they state that this results in more energy and an increased feeling of consciousness and lessens repression?
• How a prosthetic robotic arm works? Nice videos!
• How a simple procedure (lateral sphicterectomy) can lead to a satisfyingly outcome for both the patient and the surgeon?
• How to interpret the new article that assures the relationship between breast implants and suicide rates?
• How to be thankful to a surgeon and how a surgeon can change your life? Charming story that guides me to always give the best of me.
• How an amebic brain abcess looks like? You will never forget to keep it as a differential.
• How a simple order can trigger a defense mechanism? Try to not give orders to therapydoc.
• Should mesalamine be stopped prior surgery? Why?
• How to manage those the difficult situations involving CPR? A very insightful view and nicely written.
• How to back in time for 3 decades and deny the link between AIDS and VIH? Do you think that the truth may prevail?
• What kind of role a military surgeon play in war zone? Sharing his thoughts and feelings about Air Force training.

Thank you for your time and participation. Make sure you read the next edition of SurgExperiences, created by Jeff Leow

I am pleased to announce that the new edition of SurgeXperiences is going to be hosted here at Unbounded Medicine next week. I’ll be accepting ALL your submissions.

Please feel free to post about anything related to surgery, like surgical procedures, mistakes during surgery of your training, lessons learnt, and tips, first operation done solo, memorable operations, memorable patients, jokes. I also accept patient posts.

You can send me your article via:

Blog Carnival Submission Form
Regular e-mail to: j o n m i k e l ( AT ) g m a i l . c o m.

This is how a Crohn’s disease looks in colonoscopy.

This is a case of a 67 years old male with history of chronic constipation (20 years) and chronic hemorrhoidal disease came to the office with rectal bleeding and a non-redicible anal mass.

On physical examination we found Grade IV hemorrhoidal disease.

We decide to perform a PPH procedure with an hemorrhoidal circular stapler (33 mm) kit.

Note the tissue removed.

This donut confirms the circular and complete resection of the defect.

On the postoperatory period the patient was in excellent condition without pain and without bleeding.

A previously healthy 27 years old female came to the emergency department with a chief complaint of one-month diffuse and intermitent abdominal pain, transitory relief with bowel movements, nausea without vomit, early saciety, postprandial fullness and weight loss of 4 kilos in 1 month.

On the physical exam, we found a 10×15 cm tumor in the left upper quadrant. The tumor is not fixed, it feels solid and well delimited. We did not find any other important data.

Lab work beteween normal ranges. We ordered plain abdominal film, chest x ray and later an abdominal ultrasound and a CT scan.

Rx

Ultrasound

CT Scan

With these findings, we decided to perform an exploratory laparotomy (left subcostal incision) and tumor resection.

Look the size of the tumor and its characteristics.

Note the splenic vein.

The tumor arises from the tail of the pancreas. It was impossible to dissect the spleen, so we had to cut it.

Pathology

Final diagnosis: Benign Solid Pseudopapillary Tumor of the Pancreas of 14 cm, and 1.66Kg.

Solid-pseudopapillary tumor (SPT) of pancreas is a very rare (about 450 cases have been described in the world literature) neoplasm of low malignant potential and unknown origin. It generally occurs in young women and the prognosis is usually good after complete surgical removal.

SPT is also know as Fratz’s tumor

A 68 year old female patient came to the E.D. with a chief complaint of sudden, severe epigastric pain, retching without vomitus and distention of the upper abdomen.

The patient was alert, very anxious, and in severe pain.
blood pressure of 160/120; pulse of 126; respiratory rate of 24; normal temperature; SatO2 of 96% without O2 supplement.
She had a distended upper abdomen and epigastric tenderness without rebound or guarding.

A plain film of the abdomen was ordered and showed gas-filled, grossly dilated stomach.

Pass of nasogastric tube was unsuccessful.

A laparotomy was mandatory.

The patient survived the surgery but 6 months later, she died by causes nonrelated to the surgery

In 1904, Borchardt described the classic triad of gastric volvulus: severe epigastric pain, retching without vomiting, and inability to pass a nasogastric tube.

On January 25th, a car crash took place in Nebraska and Shannon Malloy (a previously healthy 30 year old woman) was seriously injuried. Her skull became separated from her cervical spine, this is what is called internal decapitation.

“I remember the impact and then I had no control over my head… I wasn’t focused so much on the pain. I just kept thinking, ‘I have to stay alive,’” said Shannon.

5 screws were drilled into Shannon’s neck and 4 more were drilled into her head to keep it stabilized. Then a thing called a halo (rods and a circular metal bar around her head) was attached for added support. It’s not exactly a pain-free procedure.

Shannon Malloy still has a long, costly recovery ahead. A fund has been set up in Malloy’s name at Wells Fargo banks. You can make donations at any location under the “The Benefit of Shannon Malloy.”

via

Artist Koen Hauser is a specialist in digital picture manipulation. This collection is called Modische Atlas der Anatomie.

Lovely work I said.

Via

Neurosurgery is about to change with the arrival of Neuro Arm, a new robot system developed by specialists of The Calgary University.

This device was designed by Garnette Sutherland, a neurosurgeon who worked the last 6 years to make the device that frees the surgeons of the possible faults caused by the human hand.

“Many of our microsurgery techniques come from the 60s, and have put to the surgeons the lack of the exactitude, precision, skills and resistance,” explained the professor of neurosurgery.

“Neuro Arm shows a spatial resolutions that allows neurosurgeons to operate with such precision tha we could speak of a cellular level.”

It is designed to be operated by a neurosurgeon from a workstation, the robot operates with a system of realtime images, offering a detail without precedent, and a better control of the equipment.

The surgical tests of Neuro Arm in the human patient are in process, and we hope that the first surgery with this device could be this summer,” added Sutherland.

This surgical device was designed and made in collaboration with MDA, a well-known company to participate with the NASA in the development of the robotic arm Canadarm2, used in the space shuttles. The project began in 2001, had a cost of 2 million dollars, mainly provided by B.J. and Don Seaman.

“The best surgeons can work in a space of 1/8 of inch, whereas this robot does possible to work in a space of the wide one of a hair,” explained Don Seaman.

Byron and Lincoln Ryman were born within a minute of each other, first Byron (3lb 6oz) was precisely three times bigger than his brother.

Eleven weeks premature, both boys were given a little chance of survival - particularly Lincoln, weighing only 1lb 2oz at birth.

But yesterday this twins, now they are five weeks old, are doing well, thanks to the dedicated staff at the Royal Hospital for Women in Sydney.

This is called twin-to-twin transfusion, where one of the blood flow of one of the babies goes from the smaller to the larger twin.

“Lincoln’s chances of survival, I considered, were less than 30 per cent because he was so small.”

But after their birth, both brothers showed an “exceptional will to live,” said Dr Mishra.

“Lincoln initially had a lot of breathing problems and then he had heart problems, so an operation was carried out when he was still about 600g (1lb 5oz).

“But Byron also needed a little bit of help with his breathing before he began to gain proper weight and now he is doing well.

“We’re now watching both boys carefully, particularly little Lincoln, but we hope that he’ll soon start gaining weight much more quickly and get nearer and nearer his brother,” said Dr. Mishra.

Via

Its benefits include treatment of ulcerative colitis, irritable bowel syndrome, colon cancer and Crohn disease.

The compounds of blue agave (the cactus used for making tequila) showed nice results in studies performed at the University of Guadalajara in Mexico.

This development could be the first step in better treatments for ulcerative colitis, irritable bowel syndrome and other conditions involving the colon.

The deliver of drugs in to the colon has been a challenge for the doctors dealing with colon and rectal diseases.

Many drugs are destroyed by acids at the stomach. This could be avoided by the compounds of tequila, a type of polysaccharide known as fructans (a fructose polymer). This compound resists the destruction in the stomach and could let that drugs reach the colon without problems.

“This study showed that the agave fruit is not good just for making tequila, but it’s good because of its medicinal value. Agave’s fructan is the ideal natural transporter of drugs”, said Guillermo Toriz.