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R. Grobock. Wheaton College, Wheaton Illinois.

Te orbicularis oculi muscle is much more expansive than appears on the surface purchase female viagra 50 mg with mastercard women's health exercises at home, extending superiorly and inferiorly beyond the orbital rim in an “aviator glasses” shape buy 50mg female viagra mastercard menstruation large blood clots, and occasionally laterally as far as the temporal hairline purchase 50mg female viagra visa menstruation length. This sometimes necessitates a second row of toxin injections more lateral from the lateral orbital rim to have the desired efect. Te nose lengthens and the tip droops, with retrac- tion of the columella, and alar base widening with superior excursion. Te periorbital complex typically shows signs of aging in the third decade of life with skin color and consistency changes. This early chronological senescence is not unexpected as the thin skin of the periorbital region is exposed to the stress of blinking an average of 1200 times per hour. Additionally, expansion of the inferolateral (middle age) and superomedial (advanced age) orbital rims, results in a volumetric increase of the bony orbit relative to its contents. Similar applications can be applied to those around the periorbita has been mostly for the improvement in the individuals with lower eyelid asymmetry with comparable dosing. While this has been quite efec- tive for improving facial appearances and delivering a more restful T e Beautiful Nose and Botulinum Toxin persona, other efects, now quite evident, with toxin use in this region Nasal enhancement is one of today’s most sought-after yet chal- include the changes to the position of the lateral (tail of the) eyebrow lenging cosmetic procedures. Understanding the local anatomy while injecting be found in its Phi proportions as well as the gentle transition botulinum toxin can deliver even greater aesthetic efects when the between its aesthetic units. Almost exclusively the domain of der- injector performs a more in-depth pre-injection assessment to deter- mal fillers, successful non-surgical nasal enhancement relies on mine eyelid fssure asymmetry. Of particular note is a pleasing nasal length position should not be underestimated. Tey frequently relay that it had ing for small bundles of each muscle to contract separately with been evident in photographs but that they were unaware of noninva- separate synergistic and counteracting functions. Te levator muscle and Muller’s muscle are both upper lid lus myrtiformis (depressor septi nasi muscle and musculus digas- elevators while the major lid depressors are certain regional com- tricus septi nasi labialis muscle) located at the base of the columella ponents of the orbicularis oculi muscle. Local chemical efects can can reduce unwanted tip depression creating a more open nasola- be seen with adrenergic agents such as naphazoline, antazoline, bial angle. When instilled onto the ocular surface, they have adrenergic secondary efects on Muller’s muscle and cause temporary contraction and upper eyelid elevation. Teir utility has become common in some forms of “small eyes” including botulinum toxin-induced lid ptosis. Similarly, upper eyelid elevation with the creation of “round eyes” can be achieved by reducing the efective force of the upper eyelid depressors (orbicularis oculi) through pre- cise chemodenervation. Surgical Anatomy Pearls: Tere has also been confusion as to where the most efective placement is and what that dose should be. Again, understanding the details of the periorbital anatomy will shed light on this. Te fbers of the orbicularis muscle at the lateral periorbita are more vertical hence contraction will cause the formation of “crow’s feet” and lateral brow depression. This results in a hyperkinesis Gummy Smile and Lip Asymmetries (similar to a Spock brow) of the alar portion of the transverse nasalis A gummy smile (greater than 2 mm of gingival show), in its mild form muscle (ofen referred to as the posterior dilator naris muscle) and may be considered cute in the young, but can ofen be distracting in lower lateral procerus, both of which elevate and rotate the drooping the adult. Te perioral complex consists of interdigitating lip elevators tip toward ideal Phi proprotions (Figure 8. Numerous anatomical variants of gummy smile authors’ experience that the major arterial branches appear to be have been described,33–38 however, the authors have found that for the located under creases in the overlying skin. This concept of surface purposes of injection therapy, three basic types exist, as defned by the topography being related to underlying structures has been well intended location of toxin injections: those that target the confuence of established. Other patients expose exces- to be somewhat stratifed in that superfcial fbers contribute more to sive gingiva by a rolling under of the upper lip vermilion with smil- pursing while deeper fbers more for lip position and support against ing, without a shortening of the ergotrid, resembling a roll-up blind. This explains the rationale behind deeper Chemodenervation in these instances should be directed symmet- injections when treating the “roll-up blind” form of gummy smile, rically at the deeper fbers of the orbicularis oris muscle under the with the caveat that the patient may experience some temporary white roll of the upper lip (Figure 8. Lip and smile A common request of patients seeking aesthetic facial improvement asymmetries secondary to uneven pull of mimetic muscles (e. While sofening unsightly marionette lines, relaxing these depres- measured masticatory function is dramatically decreased over several sor muscles leads to an elevation of the corner of the mouth through months44, patients do not report any difculty chewing hard food, the anatagonistic action of the levator anguli oris and zygomaticus change in facial expression, or speech disturbances; and any initial (major and minor) muscles. Of Beautifully proportioned lips exhibit horizontal vermilion show cautionary note is that instillation of toxin merely superfcially can from commissure to commissure equal to the distance from medial pupil to medial pupil (Phi of the intercanthal distance) (Figure 8. Te opposite should be avoided by excessive neuromodulation of the zygomaticus major in an attempt to eradicate upper cheek crow’s feet lines. Surgical Anatomy Pearls: Te risorius muscle originates in a fan- like distribution from the anterior fascia of the masseter and parotid gland to insert horizontally in the modiolus of the periorbital region. In the majority of Asians, the modiolus is actually located below the level of the oral commissure. Injection is performed subder- mally 1 cm below the intersection of a horizontal line drawn from the tragus to the commissure and a vertical line drawn along the anterior masseteric border (Figure 8. Te advantage of nonsurgical lower face contouring by reducing undesirable unilateral or bilateral masseter muscle hyper- trophy is self-evident in its simplicity, predictability, and avoidance of Figure 8. In cases of lower facial contouring, the injection specialist must appreciate that there must be an aesthetic endpoint for slimming—a so-called sweet spot beyond which further narrowing may actually detract away from beauty. Certainly, Liew’s Angle of Beauty applies45, and is the hallmark of the ideal vertical facial angle as seen in many noted beautiful faces globally. Additionally, the concepts of sym- metry, balance, and harmony are nowhere more critical than in the lower face. Golden proportions in the female dictate that an attrac- tive lower profle is typifed by a transcommissure distance of 1. Posterior cheek enlargement secondary to benign parotid gland hypertrophy, causing squaring of the lower face, can likewise be Figure 8. Clinical diferentiation from masseter hypertrophy relies on both careful palpation during maximal bite and the pres- ence of blunting of the gonial angle of the mandible by the tail of (a) (b) the gland. Surgical Anatomy Pearls: Te mentalis muscle extends from its mandibular origin deep beneath the mental crease upward in a lead to a disfguring “herniation” of the deeper masseter through the caulifower-like projection to insert into the dermis of the chin. Furthermore, some laxity Tight chins can be relaxed into more pleasing appearance both in of the mandibular skin envelope due to loss of volume support can profle and width by the relaxation of the ofending muscle with occur in the more mature patient with poor skin tone. Simultaneous sofening of a deep labiomental crease can eral investigators have empirically noted compensatory temporalis be efected. Te second most obvious sign is “no the submandibular and parotid glands (where indicated), the platys- appearance of the neck”—a more mature woman wearing a scarf or a mal bands, and necklace lines. Levi modifed its application across the upper neck in a procedure he coined the Nefertiti lif for redefning and accentuating the jawline. Paying attention to the little changes that have made your patients lose their youthful propor- tioned appearance is critical—we have a tendency to see but not observe. Te role of botulinum toxin in the aesthetic arena has evolved dra- matically since its original introduction for the treatment of dynamic Figure 8. Plast of the aesthetic injection specialist should remain the creation of a Recon Surg 2001; 108(5): 1118–26. Facial diversity and infant preferences for attrac- tron microscopic studies on wrinkles in aged persons’ skin.

If none of the above associated signs is present buy cheap female viagra on line menopause yoga, one should consider hemorrhoids buy discount female viagra 50mg line pregnancy 27 weeks, anal fissure buy female viagra 100mg mastercard breast cancer research foundation, tabes dorsalis, or bladder neck obstruction as the most likely cause. If these tests fail to detect the cause, an urologist must be consulted for cystoscopy and intravenous or retrograde pyelography. The patient loses control of the bladder when he or she coughs, laughs, or sneezes and consequently leaks small amounts of urine. In postmenopausal women, there is often an atrophic vaginitis due to the deficiency of estrogen. You can ask the patient to cough during a vaginal examination, and the urine will trickle out. If that does not establish the diagnosis, have the patient drink a lot of water and not void until he or she returns to the office. Then you can have him or her cough in the recumbent or erect position, and the urine will be released. In the Q-tip test, a Q-tip is inserted in the tip of the urethra, and the patient is asked to cough or strain. The Q-tip will move at least 30 degrees above the horizontal in cases of stress incontinence. However, purple striae of the abdomen, especially when they are associated with moon facies or a buffalo hump, should immediately call to mind Cushing’s syndrome. If the patient is a child, acute epiglottitis, acute laryngotracheitis, foreign body, congenital laryngeal stridor, laryngismus stridulus, and a retropharyngeal abscess should be considered. If the patient is an adult, myasthenia gravis, bulbar and pseudobulbar palsy, recurrent laryngeal palsy, pharyngitis, laryngotracheitis, carcinoma of the larynx or trachea, angioneurotic edema, foreign bodies, thyroid disorders, and disorders of the mediastinum should be considered. The presence of stridor of acute onset would suggest acute epiglottitis, acute pharyngitis, laryngotracheitis, angioneurotic edema, retropharyngeal abscess, laryngismus stridulus, and foreign body. The presence of fever would suggest acute laryngotracheitis, diphtheria, subacute thyroiditis, retropharyngeal abscess, and mediastinitis. On ear, nose, and throat examination, the clinician may find pharyngitis, acute epiglottitis, a foreign body, tenderness of the thyroid suggesting thyroiditis, and thyroid masses. Neurologic abnormalities may be found in myasthenia gravis, bulbar and pseudobulbar palsy, bilateral recurrent laryngeal nerve palsy, and comatose states. Direct laryngoscopy can now be done in the office with the fiberoptic laryngoscope. An ear, nose, and throat specialist should be consulted before ordering expensive diagnostic tests. Intermittent stupor should suggest epilepsy, chronic illicit drug use, transient ischemic attacks, migraine, and insulinoma. The presence of focal neurologic signs may mean cerebral vascular disease, advanced brain tumor, cerebral abscess, encephalitis, subdural hematoma, central nervous system lues, Wernicke’s encephalopathy, and subarachnoid hemorrhage or meningitis. The presence of nuchal rigidity would suggest a subarachnoid hemorrhage or meningitis, but it could occasionally indicate an intracerebral hemorrhage. Besides alcohol, uremia, diabetic acidosis, and liver failure may be suggested by a characteristic odor to the breath. A cerebral vascular disease may need further investigation, including carotid duplex scan and cerebral angiography. If they are heard with the stethoscope in a patient with abdominal disturbance, they are of pathologic significance. When there are associated hyperactive and/or high-pitched bowel sounds, intestinal obstruction should be considered. When there are hypoactive bowel sounds, paralytic ileus or peritonitis should be considered. Succussion sounds coming from the chest are because of hydropneumothorax or hemopneumothorax. Other rare causes of succussion sounds are acute gastric dilatation, chronic pyloric obstruction, subdiaphragmatic abscess, and pneumoperitoneum. The diagnostic workup will be determined by associated symptoms and signs (vomiting, page 352; abdominal pain, page 16; abdominal mass, page 24). Following the algorithm, you ask about convulsive movements, incontinence, or tongue lacerations following these episodes and there are none of these signs. Examination shows a normal pulse, no murmurs or cardiomegaly, and the conjunctivae are not pale. On further questioning the patient tells you, she gets numbness and tingling of her lips and fingers just before she passes out. The husband confirms that the patient has rapid deep breathing during these attacks confirming your suspicions of hyperventilation syndrome. The presence of convulsive movements should suggest convulsions, and the differential diagnosis of this is discussed in page 108. The presence of a slow or absent pulse would suggest heart block, vasovagal syncope, and carotid sinus syncope. The presence of a normal pulse rate would suggest anemia, aortic stenosis, aortic insufficiency, and cyanotic congenital heart disease. The presence of a rapid pulse would suggest the various types of ventricular and supraventricular tachycardias, including auricular fibrillation and flutter, and it should also suggest heat exhaustion or heat stroke. The presence of a rapid regular pulse should suggest supraventricular or ventricular tachycardia, heat exhaustion, or heat stroke. Carotid sinus massage can help distinguish supraventricular tachycardia from sinus tachycardia. The presence of a heart murmur should suggest aortic stenosis, aortic insufficiency, and cyanotic congenital heart disease. The presence of focal neurologic signs should suggest cerebral vascular insufficiency, hypoglycemia, and transient ischemic attacks. Several blood pressure recordings in the recumbent and upright positions should be made. If hypoglycemia is suspected, a 72-hour fast and a tolbutamide tolerance test should be done. A serum prolactin can be drawn to distinguish hysterical seizures from true epilepsy. In addition, other cardiovascular studies, such as echocardiography and His bundle, may need to be done. Exercise tolerance testing is useful when the syncope seems to be exercise induced. An upright-tilt test is helpful when vasodepressor syncope is suspected, especially when combined with isoproterenol infusion. A cardiologist or neurologist should be consulted before ordering expensive diagnostic tests. In patients suspected of having seizures, a therapeutic trial of an anticonvulsant may be indicated. For suspected postural hypotension a therapeutic trial of 20 mg of hydrocortisone daily may confirm the diagnosis. A cardiologist may suggest a trial of an antiarrhythmic agent for a patient with a suspected tachyarrhythmia. This finding would help confirm the diagnosis of sinus tachycardia and lead to a consideration of fever, thyrotoxicosis, shock, anemia, myocardial infarction, and other disorders as the cause of the tachycardia.

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Some surgeons also insert a small piece of rolled-up Gelfoam Encourage ambulation the day of operation buy female viagra 50mg visa 4 menstrual stages. This roll buy female viagra line womens health 7 day eating plan, Prescribe analgesic medication preferably of a nonconstipat- which should not be more than 1 cm in thickness 50 mg female viagra with visa menstrual sea sponge, serves to ing type. After discharge, limit the use of cathartics because passage of a well formed stool is the best guarantee the anus will not become stenotic. In patients with severe chronic constipation, dietary bran and some type of laxative or stool softener is necessary following discharge from the hospital. Order warm sitz baths several times a day, especially follow- ing each bowel movement. Discontinue intravenous fluids as soon as the patient returns to his or her room and initiate a regular diet and oral fluids as desired. If the patient was hospitalized for the hemorrhoidectomy, he or she is generally discharged on the first or second post- operative day. Complications Serious bleeding during the postoperative period is rare if complete hemostasis has been achieved in the operating room. However, if bleeding is brisk, the patient should prob- ably be returned to the operating room to have the bleeding Fig. Conventional versus LigaSure hemorrhoidec- procedure when the operative site has healed completely. A paralytic agent is recommended prior to the “critical 3 minutes” when the sta- pler will be closed. This avoids Valsalva and straining which Preoperative Preparation could lead to bleeding and avulsion. Place the patient in the prone jackknife position with soft support of the shoulders, Diagnostic studies: anoscopy and visualization of patient hips, and knees. The hips should be higher than any other straining on the commode (colonoscopy, defecagraphy, body part in this position in flexion with 30° Trendelenburg. Without the nerve Pitfalls and Danger Points block, placing the retractor may be difficult and may cause injury, since the internal sphincter is contracted at rest Inadequate protection of the anal canal with the retractor Perform digital rectal exam before placing the anal retractor leading to placement of staple line too close to the dentate with obturator. Take great care to assure the retractor covers line and postop pain the dentate line completely and circumferentially before Inadvertent full thickness transection rather than mucosal securing it in place. At the posterior midline, pay particular attention to the placement of the fenestrated obtu- rator and the placement of sutures to avoid suturing the ante- rior wall of the rectum instead of the intended posterior wall. While closing the stapler, carefully palpate the posterior vaginal wall in female patients to avoid catching it in the jaws of the stapler. During the “critical 3 minutes,” avoid patient Valsalva; otherwise, the mucosa may be avulsed leading to profuse Fig. This must be corrected by manually suturing the mucosal defect for hemostasis and may lead to stenosis if circumferential. Operative Technique Anal Dilation and Placement of the Retractor Purse String Suture Placement and Transection of the Rectal Mucosa Use local anesthetic to place a pudendal nerve block bilaterally with or without a perianal block by palpating the Once the fenestrated obturator is in proper position, the purse ischial tuberosity, directing the needle in that direction, aspi- string suture is placed with mucosal bites using 2-0 Prolene rating, and then injecting, followed by injecting in the direc- suture beginning at the anterior midline and progressing in tion of the anus in a fanning motion into the subcutaneous quadrants (Fig. Perform a digital rectal exam and place the anal obturator rather than simply turn it clockwise. At the posterior midline, pay particular should be replaced with the fenestrated obturator to facilitate attention to the placement of the fenestrated obturator and the placement of sutures to avoid suturing the anterior wall of the rectum instead of the intended posterior wall. Complete the purse string by ending the stitch where it started without over- lap. An extra stitch may be placed 180° opposite the purse string knot to assure the purse string is secure and even circumferen- tially. Then bring out the two suture ends through the eyelets of the stapler using the hook. While maintaining distal traction on the suture, start to close the stapler by allowing the stapler to enter the anus rather than pulling the mucosa to the stapler (Fig. Once the marker is centered in the green window of the handle, hold it in position for 60 s. If additional sutures have been placed, visually inspect the staple line circumferentially until hemostasis is deemed acceptable. If the patient is unable to void within 6 h of the procedure, place a Foley catheter for 24 h. Sitz baths will aid in pelvic muscle relaxation and decrease pain, as well as improve hygiene. Complications Postoperative hemorrhage occurs with increased abdominal pressure or Valsalva with straining. If this does not abate with conservative measures, it is necessary to return to the operating room for an exam under anesthesia and hemosta- sis. Postoperative pelvic sepsis is the most feared postopera- tive complication of any hemorrhoidal procedure. The patient will complain of a possible foul-smelling mucous discharge and failure of jaws of the stapler. It is imperative during these “critical 3 minutes” the to the dentate line or stapling the anoderm. Then expect discomfort, a sensation of distention, or a perception remove the safety and fire and hold the stapler in position for of the need to defecate during recovery. At this point, release the stapler handle and turn This can lead to stenosis or contracture of the healing 1 full turn to partially open the anvil. Open the anvil and cut the rectal mucosa to pass it ecation and can be treated with dilation or stricturoplasty. Staples by themselves are not pain- ful, but a malpositioned or partially open staple can induce Inspection for Hemostasis discomfort, especially with defecation, and therefore, should and Removal of Retractor be removed. Fecal incontinence may result from anal dilation, even Replace the fenestrated obturator in the anal canal, and use though the anal sphincter itself is not cut or directly injured. Any bleeding from Removing a portion of the internal hemorrhoids and mucosa 656 S. A Incontinence of solid stool is rare with normal preoperative 17-year follow-up of a prospective, randomized trial. Closed vs open hemorrhoidec- review on the diagnosis and treatment of hemorrhoids. Hemorrhoids, anal fissure, and carcinoma of the retroperitoneal sepsis after hemorrhoid injection sclerotherapy: colon, rectum, and anus during pregnancy. Randomized clinical trial of micronized open vs closed day-case haemorrhoidectomy. Survey of hemorrhoidectomy prac- the treatment of chronically bleeding internal hemorrhoids. Chassin† Indications Pitfalls and Danger Points Drainage of any anorectal abscess is indicated as soon as the Failure to diagnose anorectal sepsis and to perform early diagnosis is made. There is no role for conservative man- incision and drainage agement because severe sepsis can develop and spread Failure to diagnose or control Crohn’s disease before fluctuance and typical physical findings appear.

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It is essential that the line of staples cross the cut edge of the serosa and underlying mucosa buy discount female viagra pregnancy jewelry. This both the anterior and posterior terminations of the anastomotic stitch has the advantage of inverting a smaller cuff of tis- staple line to avoid gaps in the staple line order discount female viagra on line menstruation on full moon. Fire the stapler order female viagra 100mg on-line pregnancy 7 weeks 4 days, and sue than does the Lembert or Cushing technique and may excise the redundant bowel flush with the stapling device using therefore be useful when the small bowel lumen is exceed- Mayo scissors. When inserted properly the seromucosal Carefully inspect the staple line to be sure each staple has suture inverts the mucosa but not to the extent seen with formed a proper B. If feasible, cover the everted mucosa by the mesenteric suture line to minimize the possibility of it becoming a nidus of adhesion formation. Chassin† Indications Enter the abdomen through a scar-free area and carefully dissect the bowel from the underside of the abdominal Enterolysis is indicated for acute cases of complete small wall. The additional exposure gained by doing the easy dissection first facilitates work in the more difficult parts. Work on the collapsed region Preoperative Preparation (distal to the obstruction) first, if possible, and keep the dilated proximal bowel in the abdomen as long as possible. After all adhesions have been freed, repair any injured seg- Initiate fluid and electrolyte resuscitation. Pitfalls and Danger Points Documentation Basics Inadvertent laceration and spillage of the contents of the • Note findings intestine is a hazard of this procedure. Failure to identify and • Presence or absence of obstruction relieve all points of obstruction can occur unless the entire small bowel is dissected free. Operative Technique Operative Strategy Incision and Bowel Mobilization Dissect carefully and patiently to avoid spillage of intesti- A long midline incision is preferable. Bacterial overgrowth occurs rapidly when the ous midline incision, start the new incision 3–5 cm cephalad contents stagnate. Massive distension with thinning of the to the upper margin of the scar so the abdomen can be entered bowel makes it much more likely to occur and more serious through virgin territory. To avoid this mishap, dissection soon as the peritoneum is entered, air flows into the perito- should be done carefully and patiently. The basic dissection strategy consists in entering the At the same time, dissect away any adherent segments of abdominal cavity through a scar-free area. Access to the peritoneal cavity through an unscarred area often gives the surgeon an opportunity to Whereas the content of the normal small intestine is sterile, assess the location of adhesions in the vicinity of the antici- with intestinal obstruction, the stagnation of bowel content pated incision. After the free abdominal cavity is entered and results in overgrowth of virulent bacteria with production of any adherent segments of intestine are freed, the remainder toxins. When these substances spill into the peritoneal cavity, of the incision is carefully done. Metzenbaum scissors can generally then be insinu- ated behind the various layers of avascular adhesions to incise them (Fig. If the left index finger can be passed underneath a loop of bowel adherent to the abdominal wall, it helps guide the dissection. The aim is to free all the intes- tine from the anterior and lateral abdominal wall, first on one side of the incision and then on the other, so the anterior and lateral layers of parietal peritoneum are completely free of intestinal attachments (Fig. Once the intestine has been freed, trace a normal-look- ing segment to the nearest adhesion. If possible, insert an index finger into the leaves of the mesentery, separating the two adherent limbs of the intestine. By gently bringing the index finger up between the leaves of the mesentery, the adherent layer can often be stretched into a fine, filmy membrane, which is then easily divided with scissors Fig. Chassin the left index finger or closed blunt-tipped curved between the thumb and index finger without damaging the Metzenbaum scissors underneath an adhesion to delineate serosa of the bowel. If this principle is always followed, the dif- Operative Intestinal Decompression ficult portion of a dissection becomes easy. Avoid tackling a dense adherent mass directly; if the loops of intestine If the diameter of the small bowel appears to be so distended going to and coming from the adherent mass are dissected that closing the incision would be difficult, operative decom- on their way in and on their way out of the mass of adhe- pression of the bowel makes the abdominal closure simpler sions, a sometimes confusing collection of intestine can be and may improve the patient’s postoperative course. Decompression may also lessen the risk of inadvertent lac- In the case of an acute small bowel obstruction, frequently eration of the tensely distended intestine. When this occurs, be careful not to 270-cm-long tube with a 5 ml balloon at its tip, for this pro- permit the distended bowel to leap out of a small portion of cedure. It may be passed through the patient’s nose by the the incision, as it may be torn inadvertently in the process. If anesthesiologist or introduced by the surgeon through a possible, first deliver the collapsed bowel (distal to the point Stamm gastrostomy. It is then passed through the pylorus of obstruction), and then trace it retrograde up to the point of with the balloon deflated. The adhesion can then be divided under direct and the tube milked around the duodenum to the ligament of vision and the entire bowel freed. Meanwhile, inter- Free the remainder of the bowel of adhesions, from the mittent suction is applied to aspirate gas and intestinal con- ligament of Treitz to the ileocecal valve. Caution should be exercised when milking the tube task by delicate dissection with Metzenbaum scissors, alter- through the intestine, as the distended bowel has impaired nately sliding the scissors underneath a layer of fibrous tissue tensile strength and can easily be torn. This can relatively few adhesions, the Baker tube may be removed at be done more efficiently if the left index finger can be insinu- the conclusion of the decompression and a nasogastric tube ated in such a way as to circumscribe the adherent area or if substituted for postoperative suction. In very rare situations, the index finger can be brought between the leaves of mesen- for example, when the patient has required multiple laparot- tery separating the adherent bowel, thereby placing the adhe- omies for adhesions or where the bowel has sustained exten- sion on stretch and making it visible (Fig. In some sive serosal damage, the Baker tube may be left in place for cases there are adhesions of a cartilaginous nature, especially 2–3 weeks to perform a “stitchless plication” (see Chap. Again, by doing the easy dissection Repair of Damage to Bowel Wall first, the difficult parts become easier. Small areas of intestine from which the serosa has been avulsed by dissection require no sutures for repair if the sub- Relaparotomy for Early mucosa has remained intact. This is evident in areas where Postoperative Obstruction some muscle fiber remnants remain. Otherwise, when only thin mucosa bulges out and the mucosa is so transparent that We most often reenter the same incision, usually in the mid- bubbles of fluid can be seen through it, the damage is exten- line, to reexplore the postoperative abdomen. Large postoperative day, some sharp dissection may be necessary areas of damage should be repaired transversely by one or to enter the abdomen. To divide adhesions in these cases, many of the loops of Extensive damage requires bowel resection with anastomo- bowel can be separated by inserting the index finger between sis by sutures or stapling. By elevating the finger, If a segment of bowel is of questionable viability, replace the adhesion can be stretched between the bowel segments. Reevaluation in 10–15 min often reveals that the 44 Enterolysis for Intestinal Obstruction 407 bowel has regained some color, tone, and peristalsis In the very rare situation when a Baker tube must remain indicative of recovering perfusion. Our policy is to avoid filling both After decompressing the bowel, replace it in the abdominal nostrils with intestinal tubes. If there has been any spillage, thoroughly irrigate the cases to insert the long Baker tube through a newly con- abdominal cavity with large volumes of warm saline solution. Postoperative Care Complications Nasogastric suction may be required postoperatively until evi- dence of bowel function returns.

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