Remote and Rural Surgery

FRCS (Gen Surgery): A Road to Success.
1
st
Edition, Doctors Academy Publications, Cardiff, UK,December 2013
Remote and rural surgery
Pradip K Datta
213
Diagnoses
Match the following diagnoses with the clinical scenarios that follow bearing in mind that there may be more than one scenario for one
particular diagnosis.
1. Abdominal aortic aneurysm (AAA)
2. Abdominal trauma
3. Acute closed loop large bowel intestinal obstruction
4. Acute haematemesis and melaena
5. Acute retention of urine
6. Ankle fracture
7. Arterial embolus
8. Extradural haematoma
9. Faecal peritonitis
10. Stone in middle 1/3 of ureter
Clinical features
The reader should presume that the following scenarios occur in a remote and rural district general hospital in a small town in mainland UK. The
hospital has a 24 hour A & E department with the usual radiological facilities including a CT scanner with teleradiology connection to the regional
/ tertiary centre. There are facilities for video-conferencing. There is no radiologist on site and no intensive care unit. The town has a commercial
airport. The nearest regional / tertiary centre is 110 miles by road.
A. A 28-year-old woman while horse riding in the countryside was thrown off her horse which was frightened by a tractor. The horse
landed on the right side of her chest and abdomen. On admission to the A & E department she is confused and complains of
severe abdominal pain. On examination she has a rigid and tender abdomen with the following findings:
This is an unusual chapter. It is a part of the syllabus. It does not deal with any specific specialty in the usual sense of the word. It gives
an idea of how best to look after a patient in an emergency situation under challenging circumstances. The philosophy and culture of
working in a remote and rural area is different to that of practising surgery in the usual district general or teaching hospital. The real
challenge of surgical practice in a remote and rural area such as the Scottish Highlands and Islands is to be aware of ones own
limitations. A good and safe remote and rural surgeon is one who knows when he or she does not know and is not backward in seeking
help and advice on the phone. The surgeon should be able and safe in certain emergency situations which may well require expertise
outwith ones comfort zone.
Another additional factor is support staff. It is common for trainee surgical staff to be quite junior. This requires the service provided
to be mainly consultant based. At the same time the support paramedical and nursing staff are quite senior and experienced. An
intensive care unit may not be available. The range of surgical services provided will have to take into account these factors.
The surgeon practising in such a location will not have specialist help readily available for emergency cases. Good judgement and a wide
range of skills and expertise will be a necessity. The former is particularly important to decide when a patient can wait to be transferred
as opposed to a situation where time is of the essence and the patient needs surgical intervention at the receiving hospital. The
maintenance of the range of skills is difficult when working in this sort of an area with a limited population. It is possible that in due
course the surgeon might get de-skilled in a particular surgical procdure. Adherence to local protocols with regard to the management
of cancers may require patients to be transferred to regional hospitals. On the other hand, certain cancers can easily be treated locally
after discussion in a MDT (multidisciplinary team) meeting by video-conferencing.
Accident and Emergency department cover is mandatory which means that ability for emergency orthopaedic management is a requirement
of such posts. Good communication between the surgeon in the peripheries and his/her counterpart in the regional/tertiary hospital is
absolutely paramount if the patient living in a remote and rural area is to receive the best possible surgical treatment. Never should the
surgeon from the referring hospital ask the trainee to speak to the receiving hospital. The consultant surgeon must always personally do
the referral and speak to the unit receiving the patient.
The chapter contains scenarios of several specialties and how best to manage certain situations, both elective and emergency. This is a
part of the examination syllabus and hence questions may be asked in any of the oral examinations where a scenario will be given and
the candidate is asked what he or she would do under the circumstances in a remote and rural area.
REMOTE AND RURAL SURGERY
Pradip K Datta
Introduction
214
Pradip K Datta
1
st
Edition, Doctors Academy Publications, Cardiff, UK, December 2013
O
2
saturation 90%
Respiratory rate 32/min
BP 90/50 mm Hg
Capillary refill time 5 seconds
B. A fit 35-year-old man sustained a fall while hill walking. He sustained an obvious fracture of his ankle and had to be stretchered
off the hillside. He did not sustain any other injuries.
C. A 68-year-old woman complains of severe generalised lower abdominal pain of six hours duration. In recent months she has been
constipated having to take laxatives for a satisfactory bowel action. On examination she is toxic, hypotensive with tachycardia and
generalised lower abdominal tenderness with rigidity and marked rebound tenderness.
D. A 70-year-old woman complains of sudden onset of very severe pain in her left lower limb from the mid-thigh downwards. The
limb is pale, feels cold and she has very little feeling and unable to move the leg. About 6-weeks-ago she had a myocardial infarct.
E. A 55-year-old man, a known chronic alcoholic, has been admitted with severe haematemsis and melaena. His BP is 90 mm Hg,
pulse 128/min and is cold and clammy. He has distended veins around his umbilicus.
F. A 72-year-old man complains of abdominal pain radiating to the back of about a weeks duration. The pain is throbbing in nature.
Abdominal examination reveals a pusatile mass in his epigastrium which is tender.
G. A 65-year-old woman has had gradual abdominal distension associated with colicky abdominal pain for the past five days during
which time she has had no bowel action. Over the last few months she has suffered from increasing constipation. On examination
her abdomen shows distension in the peripheral part with tenderness over the right iliac fossa.
H. A 70-year-old man complains of severe lower abdominal pain not having passed any urine for over 12 hours. He has had symptoms
of bladder outflow obstruction for almost a year. The night before he was in a party where he imbibed a considerable amount of
alcohol. On examination he has a large mass in his suprapubic region.
I. A fit 28-year-old man while climbing a Munro (Scottish mountain > 3000feet) missed his footing and fell a few hundred feet. He
was brought unconscious to the A & E department. His spine has been stabilised in a spinal frame. His Glasgow Coma Score is
12 and has a dilated pupil on the right which is reacting to light.
J. A 32-year-old woman complains of severe pain in her left loin radiating to her left lumbar region and left iliac fossa. The pain is
so severe that she is writhing around and unable to get comfortable in any position. She complains of frequency of micturition.
Pradip K Datta
215
1
st
Diagnoses matched with clinical features and images
Answer to question 1 : F
Abdominal aortic aneurysm (AAA)
Questions
1. What does tenderness indicate?
2. What are the x-ray findings?
3. What are you going to do?
Answers
1. Clinically this patient has an AAA. Tenderness indicates that there may be impending leak/rupture of the aneurysm. Leak of the
aneurysm posteriorily is much more common than rupture into the peritoneal cavity. This is because in the vast majority of
AAAs the anterior part is occupied by clot; hence posterior leak is much more common thereby the patient having a better
chance of urvival.
2. The plain abdominal x-ray in the lateral view shows a large calcified soft tissue mass in front of the lumbar vertebrae. It shows the
typical anterior scalloping of the lumbar vertebral bodies. This appearance is due to the erosion caused by the pulsatile aneurysm
which is the reason for throbbing backache as the principal symptom.
3. This patient should have an intravenous access with crystalloids and transferred immediately by air ambulance to the regional
vascular unit after a consultant-to-consultant telephone call referral. While waiting for the arrival of the air ambulance, it would
be prudent to save time by cross-matching six units of blood and sending it with the patient. An indwelling catheter is inserted.
Scalloping of
anterior part
of bodies of
lumbar vertebrae
from erosion
of AAA
Large calcified
soft tissue
shadow of AAA
anterior to
lumbar
vertebrae
Figure 22.1 : Plain x-ray of abdomen lateral view showing: large calci-
fied
soft tissue shadow of AAA anterior to lumbar vertebrae; scalloping
of anterior part of bodies of lumbar vertebrae from erosion of AAA.
216
Pradip K Datta
1
st
Answer to question 2 : A
Abdominal trauma
Questions
1. What is the condition the patient is suffering from? Describe your immediate management in the A & E department.
2. What is your definitive management considering the patient is unstable inspite of efficient resuscitation?
Answers
1. The patient is suffering from hypovolaemic shock. Shock is defined as acute circulatory failure resulting in impaired tissue perfusion.
This patient should be immediately resuscitated according to the ATLS protocol of Airway, Breathing and Circulation (ABC).
With regard to her airway she should be on oxygen with a mask and bag at 15 L/min; her breathing may be laboured one
should look for chest movements, listen for breath sounds and feel for the position of the trachea; circulation should be taken
care of by two wide bore cannulae blood is sent for FBC, U & Es, serum amylase, clotting studies, grouping and cross matching
and infusion of crystalloid commenced.
The anaesthetist who should be involved right at the start will send blood for arterial blood gases (ABGs) and may decide on
intubating the patient as the patient is confused a symptom of hypoxia. Once intubated, CXR and abdominal x-rays are done.
With the type of injury, the team should bear in mind the possibility of haemothorax, pneumothorax, cardiac tamponade and liver
injury. The patient may require the insertion of an intercostal drain.
By this time cross-matched blood should be available. Consideration should be given to the use of O negative blood. If the
expertise is available, FAST is carried out to look for liver damage. This should normally be followed by contrast-enhanced CT
scan of the abdomen and chest. However, as this patient is unstable, the patient has to be taken to theatre without a CT scan.
2. Ideally this patient requires to be treated in a regional centre as she will require ICU management and the surgical expertise of
the hepatobiliary team. However, as the patient is unstable, she is not suitable for transfer at this time and will require exploration
in the local hospital. She is already intubated and with an intercostal chest drain on the right side. She should be taken to theatre
for a laparotomy.
Although a rooftop incision is ideal for liver exploration, a midline incision is made to save time. If necessary a tranverse extension
can be made in the form of a T to right or left depending upon whether liver or spleen needs exploration. This patient has the
effects of a crush injury on the right side and will probably have extensive capsular liver lacreations. Pringles manoeuvre may be
attempted but may not be possible in actual practice because of the bleeding. Haemostasis is secured by packing. Advantage is
taken of the natural contour of the diaphragm to pack using large abdominal packs which are placed above, below and behind the
liver. The packing must be done judiciously so as not to produce excessive pressure to prevent necrosis of liver tissue and
abdominal compartment syndrome. The abdomen is closed with tension sutures or as a laparostomy. (For further details of
treatment of liver injuries, please refer to Chapter 7)
Once the patient is deemed stable enough on the ventilator, she is transferred to the regional hepatobiliary centre where a second
laparotomy would be done after 48 hours.
Pradip K Datta
217
1
st
Answer to question 3 : G
Acute closed loop large bowel intestinal obstruction
Questions
1. Explain the clinical situation and your immediate management.
2. What are the x-ray findings?
3. What should be the definitive management?
Answers
1. This patient has most probably a stensoing carcinoma of the lower descending colon or rectosigmoid causing intestinal obstruction.
She has a competent ileocaecal valve resulting in a closed-loop obstruction. This causes the back pressure to be concentrated on
the caecum. If the obstruction is not relieved in time, the caecum may perforate with disastrous consequences. A tender caecum
usually denotes impending perforation and surgical intervention is indicated as soon as possible.
The patient should be given adequate analgesia, all routine blood tests (FBCs and U & Es) are done and an indwelling catheter
inserted. Plain abdominal x-rays are carried out.
2. Although routinely supine and erect films of the abdomen are taken, the supine film gives more information and is much less
uncomfortable for the patient. The erect film merely shows fluid levels whereas the supine film shows gross distension of the
caecum, transverse colon, splenic flexure and descending colon (Figure 22.2) and is thus much more informative. There is very
little air in the sigmoid colon and no air in the rectum. This denotes an obstruction in the rectosigmoid. The conclusion is acute
closed loop large bowel obstruction from a possible rectosigmoid carcinoma.
3. Ideally in any obstruction of a hollow tube, be it intestines, ureter or common bile duct, it is mandatory to find out the site and
cause of obstruction. For definitive management this patient should be transferred to the regional centre where an urgent
contrast CT scan would give the answer. Transfer is all the more advisable if facilities and expertise for temporary stenting is
available in the regional unit offered by the team of colorectal surgeon and radiologist. The patient can then have a planned one-
stage resection with end-to-end anastomosis in due course. The other alternative of one-stage resection may be on offer in the
regional unit with on table colonic irrigation. The third alternative is to do a two-stage procedure: initial Hartmanns operation
with reversal a few months later.
If on clinical grounds this patient is unsuitable for transfer or examination shows an extremely tender caecum denotimg imminent
perforation, the patient should be operated upon in the original hospital. A Hartmanns procedure should be the operation.
However, if at operation the caecum is found to be almost at the point of bursting, then a subtotal colectomy (or extended right
hemicolectomy) with ileosigmoid (or ileorectal) anastomosis is done. This has the advantage of being a one-stage procedure. The
disadvantage is that the patient will have diarrhoea for a few months postoperatively.
Supine
Erect
Massively distended caecum, transverse
colon and descending colon
Multiple fluid levels
Figure 22.2 : Plain x-ray of abdomen.
218
Pradip K Datta
1
st
Answer to question 4 : E
Acute haematemesis and melaena
Questions
1. Give in detail your immediate management.
2. What is the definitive management?
Answers
1. The most important immediate management is resuscitation. This should ideally be a team effort between the surgical unit and the
anaesthetist. Resuscitation is started on the ATLS principles. The airway may have to be cleared of blood clots and oxygen started
and oxygen saturation determined with a pulse oximeter. Simultaneously intravenous access is obtained by two wide bore
cannulae and the patient is started on crystalloids. Blood is sent for FBC, U & Es, clotting studies, LFTs and grouping and cross-
matching. An indwelling urinary catheter is inserted; a CVP line is inserted to help monitor the adequacy of preload.
Once stable, a detailed history is taken from the patient with regard to ingestion of drugs such as NSAIDs, PPIs and alcohol intake.
The vital signs are monitored including capillary refill time. An OGD is arranged urgently. This should be carried out by the most
experienced endoscopist who may be the physician. On endoscopy, in view of the patients history and the presence of caput
medusa, there will be gastro-oesophageal varices. Even if these are seen many of these patients bleed from a coincidental peptic
ulcer. Thorough examination of the stomach and duodenum is carried out.
Once the cause of the bleeding is diagnosed, it is treated: rubber band ligation for varices and adrenaline injection for peptic ulcer.
For longterm definitive treatement the patient should be referred to the regional centre once the patient is stable. For details of
treatment please see chapter 1.
Pradip K Datta
219
1
st
Answer to question 5 : H
Acute retention of urine
Questions
1. What is your immediate management? What are the precipitating causes for such an emergency?
2. What is your subsequent management?
Answers
1. This patient will be in agony from his acute retention of urine. At the outset he should be given 100 mg of pethidine and
immediately catheterised under strict aseptic conditions. This would result in drainage of 1.5 to 2 litres of urine with instantaneous
relief. Some elderly men who already have lower urinary tract symptoms (LUTS) from bladder outflow obstruction (BOO) may go
into acute retention when there may be some cause that triggers the onset of this unpleasant emergency. These are:
Acute fissure-in-ano
Constipation
Medication eg, diuretics, anticholinergics, antihistamines
Excessive alcohol intake
Delayed micturition
The usual underlying pathology is benign prostatic hypertrophy (BPH).
2. If there is a precipitating cause (see above), this is corrected. Urinary tract infection, if present, is treated and the patient is then
given a trial without catheter after 48 to 72 hours. Almost 25% of them will void normally. Even if the patient is passing urine
normally, measurement of post-micturition residual urine by ultrasound is advisable to make sure that the patient is emptying his
bladder satsifactorily before being discharged. If trial without catheter is unsuccessful, the catheter is re-inserted and the patient
referred to the urologist in the regional centre for further management.
On occasions the passage of a catheter may be unsuccessful. This may be because of one of three reasons: an urethral stricture,
the catheter getting curled up within an elongated prostatic urethra as a result of gross lateral lobe enlargement, obstruction from
a large median lobe. In that case a suprapubic cystostomy under local anaesthetic is carried out. If the surgeon is experienced in
the use of a catheter introducer, this may be tried prior to spurapubic cystostomy (see chapter 26). The patient is then referred to
the urologist.
220
Pradip K Datta
1
st
Answer to question 6 : B
Ankle fracture
Questions
1. Looking at the x-ray, what mistake do you think has been made in the immediate management? Describe the initial management.
2. What is the definitive management?
3. After the definitive management, 24 hours later the patient has very severe pain in the affected limb. What would you suspect and how
would you deal with this?
Answers
1. The mistake that has been made is that this x-ray should not have been carried out. On arrival, this patients ankle should have
been reduced under sedation and placed in a back slab; x-ray of the foot is then taken. Nothing is gained by doing an x-ray when
such a patient arrives in the A & E department with a grossly deformed ankle from an obvious fracture dislocation. Delay in
reduction may result in neurovascular compromise and encourage the formation of skin blisters.
2. The x-rays are transmitted through teleradiology and the patient is discussed with the orthopaedic unit in the regional centre for
internal fixation. Transfer need not be carried out immediately because operation would be performed after the swelling has
settled down. This may take 48 to 72 hours.
3. This patient has developed limb compartment syndrome. If the patient has developed this on returning to the original peripheral
hospital, the plaster should be removed and posterior fasciotomy should be performed at least at two sites. Time should not be
lost in considering transfer or doing compartment pressure studies. (Plese refer to Chapter 27 question and answer 18)
Figure 22.3 : Fracture dislocation of ankle.
Pradip K Datta
221
1
st
3. This patient needs an urgent femoral embolectomy. The patient is immediately given 5000 i.u of heparin intravenously and i.v
access obtained. Whilst ideally the procedure is done by a vascular surgeon, this operation should well be within the capability of
any general surgeon. Precious time may be lost in trying to transfer the patient thereby putting the limbs viability in jeopardy.
Following full informed consent, the patient is taken to theatre and the procedure carried out under local anaesthesia with the
anaesthetist in attendance. The patient is given oxygen and intravenous sedation. The region of the upper part of the femoral
artery within the femoral triangle is infiltrated with 0.5% lignocaine. A longitudinal incision is made over the femoral artery just
below the midinguinal point. A self-retaining retractor is inserted; the common femoral, superficial femoral and deep femoral
(profunda femoris) arteries are dissected and controlled by rubber slings. Depending upon the site of the embolus, the femoral
artery may or may not be pulsating. The patient is given another 5000 units of iv heparin and the three arteries are controlled
using bulldog clamps.
A longitudinal arteriotomy is made at the junction of the 3 arteries. A Fogarty embolectomy catheter (with the balloon already
tested) is passed first either proximally or distally depending upon where the embolus is expected. The clot is removed and back
flow will be seen. Once adequate backflow occurs and no further clot extracted, the artery is flushed with heparinised saline. A
small piece of vein is taken from one of the superficial veins and used as a patch to close the arteriotomy with 5/0 prolene. The
wound is then closed.
The patient is fully heparinised and 3 to 4 days later commenced on warfarin. She should remain on warfarin maintaining an INR
in the region of 2.5 to 3 for at least six months. Postoperatively one should be on the look-out for compartment syndrome or
recurrent embolus. The regional vascular unit is now consulted and consideration given to transfer the patient.
When acute thrombosis is the diagnosis, the patient should be transferred to the regional vascular unit. Here an angiogram would
be carried out and a decision would then be made whether to attempt thrombolysis or immediately perform a surgical bypass
procedure. This depends upon the protocol of the vascular team (surgeon and interventional radiologist).
Answer to question 7 : D
Arterial embolus
Questions
1. What are the classical features of an arterial embolus?
2. What is the difference in the presentation between an embolus and acute thrombosis?
3. What is the management of this patient and how would it differ from acute thrombosis?
Answers
1. The typical presentation is that of a patient who would have had a myocardial infarct, four to six weeks ago, and complains of
sudden onset of severe pain in her leg from mid-thigh distally for a few hours. This is accompanied by loss of movement in the
knee and ankle joint, loss of sensation, pale skin, paraesthesia and no arterial pulses. The presentation can be summariesd as the
6 Ps: pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold. The patient would have atrial fibrillation.
2. The patient with acute thrombosis would always be a heavy smoker who has intermittent claudication with recent decrease in the
claudication distance. In the immediate past rest pain would have supervened and the patient unable to walk, the history lasting
a few days. On examination the limb feels uniformly cold, there is guttering of the veins and no peripheral pulses. In an embolus the
history is much more acute lasting a few hours whereas in thrombosis the history is acute-on-chronic and the duration is a few
days (Table 22.1).
Symptoms Embolus Thrombosis
Pain Sudden & severe Not as sudden & severe
Duration In hours In days (2 to 3 days)
Past history Recent MI Long term IC
Cardiac signs AF Chronic ischaemia
5 Ps Very obvious Not as obvious
Table 22.1: Acute Limb Ischaemia: differences between embolus and acute thrombosis
Treatment Embolectomy +
Anticoagulation
Bypass surgery, may be preceded by
attempt at thrombolysis
MI = myocardial infarction, IC = intermittent claudication, AF = atrial fibrillation
222
Pradip K Datta
1
st
Answer to question 8 : I
Extradural haematoma
Questions
1. What is your immediate management?
2. Because of weather conditions the patient cannot be transferred either by road or air. What are you going to do?
Answers
1. This patient is resuscitated according to the ATLS protocol. His airway should be clear and he is started on oxygen; intravenous
access is obtained. The anaesthetist should be alerted and the patient will be made ready for intubation. A CT scan is done to
confirm the diagnosis and the images are transmitted to the regional centre for confirmation. The patient is started on mannitol
and an indwelling urinary catheter inserted.
2. Because of the inclement weather, the patient cannot be transferred by air ambulance. After consulting the regional neurosurgical
unit, arrangements should be made to perform a burr hole. The surgeon must make sure that the relevant instruments are
available and in working order Hudsons brace, skull perforator, burr and bone rongeur. Once anaesthetised, the affected side is
doubly checked and shaved. The site of the incision is infiltrated with lignocaine and adrenaline to elevate the layers of the scalp
and reduce bleeding.
The longitudinal incision, 5 to 7 cm long should start at the lower border of the mid-point of the zygomatic arch and extend
upwards to overlie the pterion. Once down to the periosteum, a self-retaining retractor is inserted. The burr hole is then
commenced first by using the perforator and then the burr. On entering the inner table, the hole is now enlarged by using a bone
rongeur. A pulsating blue haematoma will be seen. This is evacuated by irrigation and suction, the latter used with great caution
and kept well away from the brain. Ideally the torn middle meningeal artery is ligated or coagulated. The ideal is not always
achievable. The bleeding point, torn middle meningeal artery, is accessed at the foramen spinosum which is plugged with bone wax.
The wound is closed with an extradural vacuum drain.
This patient will need to be ventilated in a side room until circumstances permit transfer to the regional neurosurgical unit. Here
the CT scan would be repeated followed by a formal craniotomy depending upon the patients progress. Quite often the haematoma
is a semi-solid jelly and is not easy to evacuate through a burr hole. Hence a formal craniotomy is ideal.
Pradip K Datta
223
1
st
Answer to question 9 : C
Faecal peritonitis
Questions
1. What is your immediate management?
2. What is your definitive management?
Answers
1. This is a very ill patient who is in septic shock. All attention is given towards thorough resuscitation. The patient is put on oxygen
by mask, intravenous access obtained and indwelling catheter inserted. After bloods have been sent for culture, FBC, U & Es,
ABGs, the patient is started on broad spectrum antibiotics cephalosporins, metronidazole and gentamicin (provided renal
function is normal). A CVP line is inserted. The patient is given adequate amount of crystalloids, the effect closely monitored by
clinical signs, urinary output and CVP reading. An erect chest x-ray is taken to look for gas under the right dome of diaphragm
(Figure 22.4) and for any pulmonary disease.
2. This patient probably has faecal peritonitis from perforated diverticular disease or perforated colonic carcinoma. She will need
emergency surgery.
Postoperatively she will need care in the ICU almost certainly requiring ventilation for some time during her recovery from
septic shock.
In this situation the surgeon needs to talk first to his anaesthetist regarding the possibility of operating at the receiving hospital
and the pros and cons of such an undertaking. This should be a joint decision. Then the surgeon should speak to the surgical
consultant on call in the regional hospital and discuss the possibility of transfer straightaway or after surgery. Once the telephone
conference between the surgeons and anaesthetists is over and whatever decision taken, the patients family should be informed
in a frank, honest and sensitive manner. If the decision has been taken to operate in the receiving hospital, this patient will require
a Hartmanns resection with thorough peritoneal lavage, closure of the linea alba and peritoneum and leaving the abdominal wall
open for secondary closure.
This particular case is not so much a surgical challenge. The real challenge is one of tripartite communication between the
surgeons and anaesthetists at the two hospitals and the patients family.
Gas under right
dome of
diaphragm
Figure 22.4: Erect plain abdominal x-ray.
224
Pradip K Datta
1
st
Answer to question 10 : J, P
Stone in middle 1/3 of ureter
Stone in middle 1/3
of left ureter
Figure 22.5 : IVU: Delayed 3 hour film showing: right kidney has ex-
creted; delayed excretion from left kidney from stone in middle 1/3 of
ureter; left hydronephrosis and hydroureter.
Questions
1. What is the emergency management?
2. What is the ideal definitive management?
3. The patient does not wish to be transferred for minimal access surgery because he knows somebody who had a bad experence from such a
procedure following transfer to the regional centre. What are you going to do?
Answers
1. Please refer to Chapter 26 question and answer 2.
2. The ideal definitive management should be minimal access surgery by an urologist. Please refer to Figures 26.3 a and b.
3. The stone is larger than 0.5 cm in diameter and needs surgical intervention. This is ideally carried out at the index admission. The
patient should undergo an open ureterolithotomy. This procedure should be well within the capability of any general surgeon.
Considering that minimal access surgery is the gold standard, the general surgeon would probably have greater experience of
open ureterolithtomy that an urologist.
The patient is x-rayed on the way to the operating theatre (or ideally on the operating table prior to being anaesthetised) to make
sure that the stone is still mpacted at the middle 1/3 of the ureter. Once anaesthetised, the patient is tilted slightly to the right with
a sandbag under the loin to open up the space between the 12
th
rib and the iliac crest.
A transverse skin incision is made midway between the 12
th
rib and the anterior superior iliac spine. The three adominal muscles
are cut or split in the direction of the fibres until the peritoneum is reached. Care is taken not to open the peritoneum. The
peritoneum is pushed forward to enter the retroperitoneal space. The dilated ureter will be seen to cling to the peritoneum. It is
carefully dissected off the peritoneum.
Two stay sutures are applied to the dilated part of the ureter proximal to the tone and a longitudinal incision made in between. A
stone-removing forceps is introduced and the stone removed. An ureteric catheter is inserted and the distal ureter washed out;
the catheter is passed down into the bladder just to make sure that there are no stone fragments obstructing the distal ureter. The
ureterotomy is then closed with two or three interrupted absorbable sutures which should not include the mucosa. A suction
drain is inserted and the wound closed.

Remote and Rural Surgery

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Remote and Rural Surgery

Caricato da

Copyright:

Formati disponibili

FRCS (Gen Surgery): A Road to Success.

Potrebbero piacerti anche