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11-8 Readings Knee Replacement, Hemorrhoids

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  Knee Replacement (Arthroplasty) Reasons for knee replacement  –  1) persistent pain (due to OA), 2) immobility that interferes with daily life. Joint replacement aims to remove the affected parts of the joint and insert artificial components to stop pain and improve mobility Inflammation and loss of cartilage  –  cause stiffness, joint deformity, restricted movement Partial  –  unicompartmental, involving the end of just one bone, either tibia or femur. Total  –  the ends of both bones (often the patella) are renewed. Arthroplasty Step by Step -   Use titanium or cobalt/chromium to replace ends of the long bones of the knee -   High-density plastic liner (polyethylene) which sits on the tibia to separate the two -   Held in place by “bone cement” such as polymethylmethacryla te  –  dries quickly. o   Cemented are quicker healers than screws/bolts 1.   Put pt to sleep. 2.   Inject leg muscle with relaxant to reduce tension in leg. Place tourniquet to thigh to stop blood flow to knee. 3.   Make incision down front of knee from 8-12in. (Quadriceps may need to be cut to allow manipulation of patella). 4.   Flex knee to 90 o . Retractors placed. 5.   Remove damaged surface of femur with bone saw. Don’t let saw get above 113 o F (long term damage to bone may occur)/ Holles are drilled into the lower end of the cut femur for placement of new prosthesis. 6.   Damaged surface of tibia is removed. Hole drilled down into the top of the prepared tibia to accept peg on the base plate. 7.   Resurfacing of patella may be necessary. 8.   Temporarily position tibial and femoral components to ensure stability and alignment. Both with knee bent and straight. 9.   Refit metal components using bone cement. 10.   Let down tourniquet and asses range of motion. 11.   Clean joint. Close joint capsule and skin wound repaired with stiches or clips. 12.   Drain and dress as necessary. Knee replacements last about 10-20 years. Complications include increased risk of blood clots in legs. Reduced by early mobilization, compression stockings, intermittent compression pump during and after surgery and blood thinning medications. After knee replacement  –  avoid high-impact exercises such as running and jumping. Walking, swimming, and cycling are ok. Acute compartment syndrome -   Increased pressure within an osteofascial compartment that can lead to ischemic necrosis. -   Pain, paresthesias, paralysis, pressure, pain on passive movement, pallor (cyanosis) -   Complications  –  necrosis of muscle, nerve damage, contractures, myoglobinuria -   Tx: Bivalve and split casts, removing constricting dressings, place extremity at heart level. o   Perform fasciotomy if pressure >40mmHG within 4 hours if possible Unhappy triad  –  lateral knee injury resulting in ACL tear, MCL tear and medial meniscus injury!  Hemorrhoidectomy/PPH Engorgement of the nevous plexi of the rectum, anus or both. With protrusion of the mucosa, anal margin or both. SSx; anal mass/prolapse, bleeding, itching, pain External = PAINFUL! Causes: constipation, straining, portal HTN, pregnancy Internal/External  –  dentate line (junction of the rectum *columnar epithelium* with the anus *squamous epithelium*) Locations: Left lateral Right posterior Right anterior Degree Classification -   First Degree: hemorrhoid that does not prolapse -   Second Degree: hemorrhoid that prolapses with defecation, but returns on its own -   Third Degree: hemorrhoid that prolapses with defecation or any type of Valsalva maneuver and required active manual reduction (EAT FIBER!) -   Fourth Degree: hemorrhoid that prolapses and cannot be reduced Treatment -   High fiber diet, anal hygiene, topical steroids, sitz baths -   Rubber band ligation (in most cases anesthetic is not necessary for internal hemorrhoids) -   Surgical resection for large refractory hemorrhoids Complications -   Exsanguination (bleeding) -   Pelvic infection -   Incontinence  –  sphincter injury -   Anal stricture Contraindication for hemorrhoidectomy  –   Crohn’s disease  Must R/O colon cancer Procedure for Prolapse and Hemorrhoids (PPH) ethicon -   Clinical trial results comparing Procedure for Prolapse and Hemorrhoids to conventional hemorrhoid surgery have shown that patients who have the PPH procedure may experience:less pain; a quicker recovery period; less overall complications; need for less postoperative pain medication -   Using a hemorrhoidal circular stapler device , the procedure for prolapse and hemorrhoids procedure essentially lifts up, or repositions the mucosa, or anal canal tissue, and reduces blood flow to the internal hemorrhoids. These internal hemorrhoids then typically shrink within four to six weeks after the procedure. The PPH procedure results in less pain than traditional hemorrhoidectomy procedures because it is performed above the area where a person would feel pain, or dentate line inside the anal canal. The advantage is that this hemorrhoid treatment method affects few nerve endings , while traditional hemorrhoidectomy procedures are performed below dentate line, affecting many sensitive nerve endings. -   PPH is indicated for patients with o   Second degree hemorrhoids  after failure of multiple rubber band ligation o   Third and fourth degree hemorrhoids   o   Rectal mucosal prolapse -   PH Hemorrhoid Surgery Risks and Complications o   As with any surgical procedure, there are risks that accompany PPH:    If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall resulting in inflammation or infection.    The internal muscles of the sphincter may be damaged, resulting in short-term or long-term dysfunction, such as severe pain or incontinence. Reduces the prolapse of hemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. The prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining hemorrhoidal tissue is stapled. This restores the hemorrhoidal tissue back to its srcinal anatomical position. The introduction of the Circular Anal Dilator  causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator. The Purse-String Suture Anoscope  is then introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a  purse-string suture around the entire anal circumference . The Hemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is then tied with a closing knot. The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler. With moderate traction on the purse-string, a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help promote hemostasis. Firing the stapler releases a double staggered row of titanium staples through the tissue . A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.  Herniorrhaphy, Ventral with Mesh Ventral hernias occur in the midline along the linea alba, usually between the xiphoid and umbilicus -   Incisional hernia  –  weakness or defect in the abdominal wall that occurs at a site of prior surgical incision o   MC type of ventral hernias! 5% of abdominal surgeries end with ventral hernias o   RF  –  inadequate fascial closure, wound infection, midline incision, obesity, preggo, ascities, malnutrition, elderly, peritoneal dialysis, steroids and chemotherapy -   Epigastric hernia  –  herniation through a defect in the linea alba above the umbilicus o   MC in men, may be multiple Ventral Hernia Repair (Laparoscopic) Certain risk factors predispose patients to develop incisional hernias, such as obesity, diabetes, respiratory insufficiency (lung disease), steroids, wound contamination, postoperative wound infection, smoking, inherited disorders such as Marfan's syndrome and Ehlers-Danlos syndrome, as well as poor surgical technique. The principle of surgical repair entails the use of prosthetic mesh  to repair large defects in order to minimize tension on the repair. A tension free repair has a lesser chance of hernia recurrence. Traditionally, the old scar is incised and removed, and the entire length of the incision inspected. Generally, there are multiple hernia defects other than the one(s) discovered by physical examination. The area requiring coverage is usually large and requires much surgical dissection. A prosthetic mesh is used to cover the defect(s), and the wound closed. This is a major surgical procedure and often complicated. Infection rates following repair may be as high a 7.0%. Recurrence can be up to 5%, or higher, depending on the patient's preoperative risk factors. While the use of prosthetic mesh has decreased the number of recurrences, it has also been implicated in increased infection rates, adhesion or scar formation of the abdominal contents to the anterior abdominal wall leading to intestinal obstruction and fistula formation . However, overall, recovery is usually excellent and patients return to normal activity within a matter of weeks. The laparoscopic repair of ventral hernias was designed to minimize operative trauma to the patient. As mentioned, these are often complicated repairs requiring large incisions and extensive tissue dissection. The principles governing a laparoscopic ventral hernia repair are based on those of open Stoppa ventral hernia repair. A large piece of prosthetic mesh is placed under the hernia defect with a wide margin of mesh outside the defect (see figure). The mesh is anchored in to place with eight full thickness sutures and secured to the anterior abdominal wall with a varying number of tacs, placed laparoscopically. A patient is a candidate for laparoscopic incisional hernia repair if they are medically able to undergo general anesthesia. Also, the defect must allow the surgeon to place the laparoscopic trocars in such positions that repair are ergonomically possible. In some very large or giant hernias, the abdominal wall is distorted to such a degree that it is impossible to safely place laparoscopic trocars. Ancillary studies, such as CT scan of the abdomen and pelvis are helpful in making this decision. Patients are also given a bowel preparation to evacuate the colon and decrease the number of intestinal bacteria prior to surgery. Patients are admitted the same day of their surgery. Following the procedure and recovery from anesthesia, they are taken to a hospital room where they spend the night. We encourage our patients to move as quickly as possible. It is extremely important to be active early in order to stave off some of the complication seen postoperatively, such as pneumonia, deep venous thrombosis and pulmonary embolism (clots in the legs that break off and go the lungs). Postoperative pain is variable, and can be considerable during the first 24 hours. As such, patients are given I.V. narcotics as needed, and are changed to oral analgesics the next day. Generally, most patients stay in the hospital 1 or 3 days following surgery. Patients are then seen, by the surgeon, one to two weeks after discharge. There is no dietary restriction. Activity level is restricted by the patient's comfort level. However, it is generally not advisable to engage in any strenuous exercise or heavy lifting for several weeks, to allow the hernia repair to heal.
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