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Emotional demons Imagine you’re on a boat out at sea. You’re alone, except for a pack of scary demons hiding below the deck. As long as you keep floating around on the open sea, they stay below deck and you feel okay—for the most part.  Except for that nagging feeling that there are frightening creatures just out of sight. When you decide you’ve had enough of floating around and turn the tiller to head toward shore, the demons come rushing up from below, gnashing their teeth and waving their razor-sharp claws at you. “You have to stay out on the open sea!” they roar at you. “We’re going to slice you up with our razor-sharp claws if you don’t turn away from the shore!” Frightened and intimidated, you turn your boat around and head back out to open sea. Slowly, the demons shuffle back under the deck. For a while, floating aimlessly again on the open sea is okay. At least you have some peace and don’t need to worry much about the demons lurking close by. But...

Overview Craniotomy is a cut that opens the cranium. During this surgical procedure, a section of the skull, called a bone flap, is removed to access the brain underneath. The bone flap is usually replaced after the procedure with tiny plates and screws. A craniotomy may be small or large depending on the problem. It may be performed during surgery for various neurological diseases, injuries, or conditions such as brain tumors, hematomas (blood clots), aneurysms or AVMs, and skull fractures. Other reasons for a craniotomy may include foreign objects (bullets), swelling of the brain, or infection. Depending on the reason for the craniotomy, this surgery requires a hospital stay that ranges from a few days to a few weeks.   What is a craniotomy? Craniotomy is any bony opening that is cut into the skull. A section of ...

Modified Radical Mastectomy Arm on the affected side is extended on a side table. The patient is draped and the affected breast and axilla are exposed. Drawing incision line (an optimal wound closure without any redundant skin must be taken into account) Skin incision and formation of upper flap Proceed cranially towards the pectoralis fascia just below the clavicula and laterally until the lateral margin of the pectoralis major muscle Formation of lower flap from medial to lateral Continue laterally until the latissimus dorsi muscle has been reached Dissection of the breast from medial to lateral including pectoralis major 's fascia Follow the lateral margin of the pectoralis major muscle and opening clavipectoral fascia Identification of upper axillary margin (=axillary vein) Dissection of axillary top (along axillary vein) Identify and preserve thoracodorsal nerve/vessels Identify and preserve long thoracic nerve Finalize axillary dissection and rem...

Mucosal advancement Flap, Step by step Position patient in lithotomy position Place the intra-anal retractor Identify fistula site Canulate and brush the fistula tract (or flush with hydrogen peroxide,or both) Excise the intra-anal fistula site (elliptical shape) Create a wide flap by extending the proximal anorectal wall upwards Close the internal fistula opening with absorbable suture Further dissect the flap above the fistula including a thin layer of internal sphincter Prepare the advancement flap and optimize the size before suturing Complete the repair with single sutures Mucosal advancement flap for treatment of anorectal fistula General information For classification and diagnosis of perianal fistulas MRI is the most appropriate diagnostic tool The majority of patients with perianal fistula show epithelialization of the fistula tract, that might prevent closure of the tract. Curettage of perianal fistulae must therefore be considere...

Tension free mesh repair, step by step Skin incision about 1.5 cm above and parallel to Inguinal ligament. Ligation of the superficial epigastrivc vein (do not coagulate) Opening Scarpa's fascia Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve. Isolate spermatic cord Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers Isolate hernia sac and/or preperitoneal lipoma Repositioning hernia (do not ligate!) Lipoma can be ligated In case of a large lateral hernia (scrotal) the hernia sac can be transected and proximally ligated. The distal part can remain in situ however needs to be left open widely. Suture mesh with Prolene. First suture through the lateral rectus border just cranially to the pubic tubercle. Proceed along inguinal ligament with large steps and small bites. Tie a knot when the internal ring has been reached...

Appendectomy by laparotomy, step by step Skin incision at McBurney's point Opening Scarpa's fascia Opening aponeurosis Atraumatic spreading of muscle fibers Identify and opening of peritoneum Identify cecum and appendix Deliver cecum and appendix Identify and ligate appendiceal artery Crush appendix at base Ligate and remove appendix at base If desired place a purse string suture around base of appendix Closing peritoneum Closing aponeurosis Skin closure Thats all...CHILL ;-) Acute Appendicitis, General remarks Classification Acute appendicitis has 6 types: 1. catarrhalis appendicitis; slightly red 2. phlegmonous: moderate inflammation and ischaemia 3. gangrenous: (partial) necrosis 4. perforated 5. appendicular mass 6. appendicular abscess ...

Blood obtained through skin puncture (capillary blood) differs from blood that is obtained through venipuncture. When analyzing the major characteristics of capillary blood, such as pH, PCO 2 , PO 2 and oxygen saturation, freely flowing capillary blood is actually more similar to arterial than to venous blood. On the other hand, due to the method of collection, capillary blood is contaminated with interstitial and intracellular fluids, which will influence the analytic values obtained from these samples. It is for this reason that capillary blood is not recommended for coagulation testing. Differences also exist between venous and capillary blood analyte concentrations (see table below). This is by no means an exhaustive list, and since the data were taken from two different studies, does not include identical analytes for both specimen types, i.e. plasma and serum. Differences in Composition of Capillary and Venous Blood Specimen