Preoperative dose of antibiotic

When vancomycin is used as a preoperative prophylactic antibiotic, it should be administered within ______ minutes of the start of surgery.

A) 15
B) 30
C) 60
D) 120
E) At the time of incision

Answer and Discussion

The answer is D.
Ideally, a preoperative dose of antibiotic should provide a sufficient antibiotic serum level throughout the surgery to combat organisms most likely to cause a site infection. It is recommended that the first dose be timed to occur within 60 minutes before the surgical incision is made. If a fluoroquinolone or vancomycin is chosen for prophylaxis, the first dose should be administered within 120 minutes of the start of surgery. If the surgery involves the use of a tourniquet (e.g., hip or knee arthroplasty), the antibiotic infusion should be completed before inflation of the tourniquet. For most surgeries, it is recommended that use of prophylactic antibiotics end within 24 hours after surgery.

Mindmap for Appendicitis

Revise appendicitis faster with this mindmap!

Click here for enlargment

Management of a case of scrotal pain and swelling testis

A 5 year old presents to your office complaining of scrotal pain and you note swelling of the left testis. Appropriate management at this time includes

• A) continued observation
• B) elevation of the scrotum and ice therapy
• C) ultrasound evaluation
• D) doppler stethoscope evaluation
• E) CT scan of the pelvis

The answer is C. 

Testicular torsion should be suspected in patients who complain of acute scrotal pain and swelling. Torsion of the testis is a surgical emergency because the likelihood of testicular damage increases as the duration of torsion increases.

Associated conditions that may resemble testicular torsion, such as torsion of a testicular appendage, epididymitis, trauma, hernia, hydrocele, varicocele, and Henoch-Sch?nlein purpura, in general do not require immediate surgical intervention. Testicular torsion is most common in neonates and postpubertal boys, although it can occur in males of any age. Henoch-Schonlein purpura and torsion of a testicular appendage typically occur in prepubertal boys, whereas epididymitis most often develops in postpubertal boys.

The cause of an acute scrotum can usually be made based on a careful history, a thorough physical examination and appropriate diagnostic tests. The onset, character, and severity of symptoms must be determined. The physical examination should include inspection and palpation of the abdomen, testis, epididymis, scrotum, and inguinal region. Urinalysis should always be performed. Scrotal imaging with Doppler color flow ultrasound is necessary when the diagnosis remains unclear. Once the correct diagnosis is established, prompt surgical evaluation should be performed.

A “spectacle” view of both testes with colour Doppler ultrasound

Indication and Technique of Buried Intradermal Sutures

Indication:

Buried Intradermal Sutures technique is useful for wide, gaping wounds and when it is difficult to evert the skin edges. When buried intradermal sutures are placed properly, they make skin closure much easier. The purpose of this stitch is to line up the dermis and thus enhance healing.
It is termed buried as the knot needs to be as deep into the tissues as possible so that it does not come up through the epidermis and cause irritation and pain.

Technique:

-By using a cutting needle and absorbable material Start just under the dermal layer and come out below the epidermis.
You are going from deep to more superficial tissues.

-Now the technique becomes a bit challenging. You need to enter the skin on the opposite side at a depth similar to where you exited the skin on the first side, just below the epidermis. To do so, you should position the needle with the tip pointing down and pronate your wrist to get the correct angle. It will help to use the forceps (in the other hand) to hold up the skin. The needle should come out of the tissues below the dermis. Try to get as little fat in the stitch as possible; it does not contribute to the suture.

-Finnaly Tie the suture.

Atypical "Rodent Ulcer" Basal Cell Carcinoma

These lesions are moist ulcers which may not have the characteristic rolled, translucent border of a nodular Rodent Ulcer or Basal Cell Carcinoma BCC. Often, they are much larger than the pre-auricular lesion seen here, and represent neglected lesions.

The typical basal cell carcinoma appears as a small, pearly, dome-shaped nodule with small visible blood vessels (telangiectasias).

Subcuticular (or Intradermal) Suturing

Demonstration of subcuticular or intradermal suturing technique for wound closure in the operating room.

How to do Vertical Mattress Suturing ?

Demonstration of vertical mattress suturing technique for laceration repair or wound closure in the operating room.

How to do Horizontal Mattress Suturing ?

Demonstration of horizontal mattress suturing technique for laceration repair or wound closure in the operating room.

Madelung's Disease (benign symmetric lipomatosis)

A 45-year-old man presented with a 3-year history of a painless, soft, and slow-growing swelling of the neck, upper trunk, upper back, and shoulders (Panels A and B). The patient had a history of heavy alcohol consumption and was a nonsmoker. Laboratory blood analysis showed minor elevations in aspartate aminotransferase (71 U per liter), alanine aminotransferase (49 U per liter), and total cholesterol (235 mg per deciliter [6.08 mmol per liter]). Triglycerides were very elevated at 1020 mg per deciliter (11.52 mmol per liter).
Magnetic resonance imaging revealed diffuse, nonencapsulated fatty deposits in the mediastinum and in the subcutaneous and deeper fascial compartments of the neck, upper trunk, and back (Panel C, arrows). A clinical diagnosis of Madelung's disease was made.

Madelung's disease (also known as benign symmetric lipomatosis, the Launois–Bensaude syndrome, and multiple symmetric lipomatosis) is a rare disorder of unknown cause. In reported case series, up to 90% of patients have a history of chronic alcoholism, and there is a strong male predominance. Since the patient was asymptomatic, no surgical treatment was proposed. He was started on lipid-lowering therapy and referred to an alcohol detoxification program.

The 5 W's of post-operative fever

Wind---pneumonia, atelectasis at 1st 24- 48 hours
Water---urinary tract infection at Anytime after post op day 3
Wound---wound infections at Anytime after post op day 5
Wonderdrugs---especially anesthesia
Walking---walking can help reduce deep vein thromboses and pulmonary embolus usually occures at Day 7-10

See this video :

Lap dermoid cystectomy

a large size glove can be used as an endobag as is shown in this case of lap dermoid cystectomy.careful dissection.of the dermoid,enclosing it in a glove/endobag and removal are the features of this case.

Keloids of the Auricle

Keloid formation of the auricle's ear lobe is a rare complication of ear ring use. It occurs more commonly in African Americans than Caucasians. Treatments is surgical excision followed by repeated steroid injections.

Cellulitis PIC

Cellulitis: Severe bilateral inflammation and swelling of the legs.











Acute inflammation is clearly seen in the image on the left. The picture on the right is of a
normal foot for comparison.

Complementary ultrasound to mammography ; Why?

Breast cancer can lie hidden from mammography in women with dense breast tissue, and thus the role of ultrasound is implemented to evaluate the texture and anatomical structures within the breast. Women most likely to have dense breasts are younger, premenopausal women and postmenopausal women who are taking hormone replacement therapy.

Breast ultrasound is used as a complementary examination to mammography in the following situations:

* Evaluation of dense breast tissue.
* Evaluation of a mass demonstrated on mammography.
* Guidance of biopsy needle or needle localization (see cyst aspiration image)

Absess Drainage

Appendicitis Picture

Appendicitis is an inflammation of the appendix, a finger-like glandular piece of tissue that connects to the beginning of the large intestine, usually at the lower right side of the abdomen. In older children, the classic symptoms of appendicitis are abdominal pain, fever, and vomiting. Abdominal pain usually begins in the center of the abdomen, around the area of the navel ("belly button"). Later, the pain may move downward and to the right - to an area called McBurney's point, roughly corresponding to the location of the appendix in the lower right portion of the abdomen.
For appendectomy and some notes in mangement:

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Compartment Syndrome Animation - Everything You Need to Know

This video describes in detail the anatomy relevant to compartment syndrome as well as the causes, diagnosis and description of techniques for fasciotomy used in different anatomical locations. This educational program also provides information related to the diagnosis and treatment of chronic exertional compartment syndrome.

Fluorescent thyroid scan in thyroiditis

Fluorescent thyroid scan in thyroiditis. The normal thyroid scan (left) allows identification of a thyroid with normal stable (127I) stores throughout both lobes. A marked reduction in 127I content is apparent throughout the entire gland involved with Hashimoto's thyroiditis (right).

Surgical drains & it`s types

At the beginning we use drains to:
1- Evacuate establish collections of pus, blood or other fluids (e.g. lymph)
2- Drain potential collections
They are often made from inert silastic material and induce minimal tissue reaction
.Red rubber drains induce an intense tissue reaction allowing a tract to form

# Arguments for their use include:
* Drainage of fluid removes potential sources of infection
* Drains guard against further fluid collections
* May allow the early detection of anastomotic leaks or haemorrhage
* Leave a tract for potential collections to drain following removal



# Arguments against their use include:
* Presence of a drain increases the risk of infection
* Damage may be caused by mechanical pressure or suction
* Drains may induce an anastomotic leak
* Most drains abdominal drains infective within 24 hours

Types :- * Drains can be:

• Open or closed


• Active or passive

Open drains


* Include corrugated rubber or plastic sheets
* Drain fluid collects in gauze pad or stoma bag
* They increase the risk of infection

Closed drains

* Consist of tubes draining into a bag or bottle
* They include chest and abdominal drains
* The risk of infection is reduced

Active drains

* Active drains are maintained under suction
* They can be under low or high pressure

Passive drains

* Passive drains have no suction
* Function by the differential pressure between body cavities and the exterior

Lipoma arborescens (what`s it !!!)

Lipoma arborescens is a rare case affecting the synovial linings of the joints and bursae, with 'frond like' depositions of fatty tissue. They account for less than 1% of all lipomatous lesions.

Clinical presentation
Clinically presented by painless joint swelling, frequently with effusion, typically in the 5th - 7th decades. Usually these lesions are sporadic, however they can be seen in the setting of osteoarthritis, collagen vascular disorders or previous trauma.

The most common site of involvement is suprapatellar bursa of knee joint, and the disorder is usually unilateral . Occasional reports of hip, shoulder, wrist elbow are also reported. Other joint involvement is uncommon. Involvement of tendon sheath is even rarer.

Treatment and prognosis
The condition is benign and is cured by synovectomy. Recurrence is uncommon

For MRI images (of ankle involvement):

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