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 then you begin to notice other boats heading toward shore. You remember that you have plans to go ashore to see things you want to see and do things you want to do. As your hand moves toward the tiller to change course, you hear the muffled sounds of roaring and growling below.
Your hand trembles above the tiller. How can you reach shore with those threatening demons ready to pounce at the least movement of the rudder?

Letting the demons decide our course

This scenario is a metaphor for the struggle many of us have with the painful emotions that get in the way of the life we want to lead. When we try to take control of the helm in our lives, we can be intimidated by our emotional demons and continue instead to float aimlessly through life.
Suppose you value being in a loving relationship, but every time you begin pursuing ways to meet a potential partner, you become overwhelmed by the demons of Anxiety and Doubt. You might try arguing with your demons, telling them that they’re irrational or wrong or stupid.
But this only feeds the demons and causes them to grow.
You might decide the demons are just too powerful and give up on your path of finding a partner. Your anxiety and doubt may diminish, only to be replaced by loneliness and restlessness as you float away from your cherished value.
Or, perhaps you value creating community and helping society. You feel a strong sense of purpose and meaning when you take action to steer in that direction. Yet thoughts of volunteering or taking a leadership position in your community are met with monstrous demons of Grief and Anger over the death of your adult child several years ago.
“I can’t help anyone when I’m so mixed up myself,” you might think, turning your ship around to head back out to open sea and leaving your important values behind you on the shore. The Anger and Grief demons trundle to the stern of the ship, not even bothering to go below deck.

The truth about demons

There is something important you need to know about these demons.
They can’t hurt you.
They appear nasty and can be loud and aggressive, gesturing with their sharp claws and growling with their deep voices. But the truth is, they can’t touch you. They can get right next to you and scream threats in your ear, but they can’t harm you.
As long as you believe their threats, they are in charge of the boat and you are left floating in an open, dreary sea. But when you see them for what they are, you can take back control of the tiller and sail anywhere you like.
The demons are real. It’s important to acknowledge that fact. But once you recognize that you can steer your boat despite their unwelcome presence, you will start to see the demons for what they are.
With your hands firmly on the helm, you’ll start to notice that the demons aren’t as big and ugly as you thought. And, even though they gather around to intimidate you into changing your course, it will become apparent that all they can do is hiss and roar and growl. They can’t hurt you with their claws that once seemed huge and razor-sharp but now appear to be merely overgrown fingernails.
So with the now-normal-sized demons around you, you set sail for developing a loving relationship or creating community or being kind to others or making a difference in the world or being tolerant or practicing any of the other values you hold close. After a while, your demons realize you’re not paying much attention to them, so they grumble their way to the back of the boat as you sail on in the direction you want to go.

Making room for your emotional demons

Realizing that your painful emotions can’t tear you to shreds and keep you from going where you want to go is an important first step. Learning how to allow them to just be, rather than fighting them or letting them push you in a non-valued direction, is a productive second step. Here are some ideas about how to do that.
1. Soften, expand, allow.
Sitting in a quiet place, close your eyes or gaze softly at an area on the floor in front of you. Take a few gentle, deep breaths and allow your mind to settle. Become aware of the painful emotion(s) that you’re struggling with. Try to locate this feeling in your body. Is it in your neck? Your stomach? Your back?
When you get a sense of where the feeling is located, take a breath in, and as you breathe out, imagine softening around the feeling. You may be accustomed to resisting the feeling, so softening may be new to you. Just imagine the outer edges of the feeling relaxing and growing soft.
Now as you inhale, see the area around the feeling expanding, giving room and space to the feeling. Allow the feeling to just be.
Your mind will want to take over during this exercise. That’s natural. Just let the thoughts go by like leaves floating down a stream and return to allowing your feeling to just be within you.
Remember that this exercise isn’t about feeling better or getting the feeling to go away. It’s about learning to allow the emotion so that you can continue on your path toward a richer and more meaningful life.
2. Be compassionate.
In your quiet place, visualize your feeling. Realize that, in a way, it is trying to help, perhaps to protect you or keep you safe. Create some compassion for your feeling. Imagine holding it close and soothing it, letting it know that it is okay and all will be well.
3. Remember that your feeling is normal.
Feelings—even feelings we don’t like—remind us that we are human and that we really care about something. Our painful feelings result from what author Russ Harris calls “the reality gap:” the space between what we want and what we have.
4. Healing hand.
Place your hand over the area in your body where you feel this emotion strongly. Imagine that your hand is sending warm, healing energy to the feeling. You’re not trying to get rid of the feeling. You’re just holding it gently and sending it healing warmth.

Remember that this is a practice and that the demons on your boat have been threatening and intimidating you for a long time. It may take awhile for you to accept them and create more space for them rather than trying to make them be quiet or go away. Be patient and compassionate with yourself as you set your course for the shore.

Craniotomy Steps & Basic info

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 skull, called a bone flap, is removed to access the brain underneath. There are many types of craniotomies, which are named according to the area of skull to be removed (Fig. 1). Typically the bone flap is replaced. If the bone flap is not replaced, the procedure is called a craniectomy.

Figure 1. Craniotomies are often named for the bone being removed. Some common craniotomies include frontotemporal, parietal, temporal, and suboccipital.

Craniotomies are also named according to their size and complexity. Small dime-sized craniotomies are called burr holes or keyhole craniotomies. Sometimes stereotactic frames, image-guided computer systems, or endoscopes are used to precisely direct instruments through these small holes. Burr holes or keyhole craniotomies are used for minimally invasive procedures to:

• insert a shunt into the ventricles to drain cerebrospinal fluid (hydrocephalus)
• insert a deep brain stimulator to treat Parkinson Disease
• insert an intracranial pressure (ICP) monitor
• remove a small sample of abnormal tissue (needle biopsy)
• drain a blood clot (stereotactic hematoma aspiration)
• insert an endoscope to remove small tumors and clip aneurysms

Large or complex craniotomies are often called skull base surgery. These craniotomies involve the removal of a portion of the skull that supports the bottom of the brain where delicate cranial nerves, arteries, and veins exit the skull. Reconstruction of the skull base is often necessary and may require the additional expertise of head-and-neck, otologic, or plastic surgeons. Surgeons often use sophisticated computers to plan these craniotomies and locate the lesion. Skull base craniotomies can be used to:

• remove or treat large brain tumors, aneurysms, or AVMs
• treat the brain following a skull fracture or injury (e.g., gunshot wound)
• remove tumors that invade the bony skull

There are many kinds of craniotomies. Ask your neurosurgeon to describe where the skin incision will be made and the amount of bone removal.

Steps Of Craniotomy

There are 6 main steps during a craniotomy. Depending on the underlying problem being treated and complexity, the procedure can take 3 to 5 hours or longer.
 
Step 1: prepare the patient
No food or drink is permitted past midnight the night before surgery. Patients are admitted to the hospital the morning of the craniotomy. With an intravenous (IV) line placed in your arm, general anesthesia is administered while you lie on the operating table. Once asleep, your head is placed in a 3-pin skull fixation device, which attaches to the table and holds your head in position during the procedure (Fig. 2). Insertion of a lumbar drain in your lower back helps remove cerebrospinal fluid (CSF), thus allowing the brain to relax during surgery. A brain-relaxing drug called mannitol may be given.

Figure 2. The patient’s head is placed in a three-pin Mayfield skull clamp. The clamp attaches to the operative table and holds the head absolutely still during delicate brain surgery. The skin incision is usually made behind the hairline (dashed line).

 
Step 2: make a skin incision
After the scalp is prepped with an antiseptic, a skin incision is made, usually behind the hairline. The surgeon attempts to ensure a good cosmetic result after surgery. Sometimes a hair sparing technique can be used that requires shaving only a 1/4-inch wide area along the proposed incision. Sometimes the entire incision area may be shaved.  
 
Step 3: perform a craniotomy, open the skull
The skin and muscles are lifted off the bone and folded back. Next, one or more small burr holes are made in the skull with a drill. Inserting a special saw through the burr holes, the surgeon uses this craniotome to cut the outline of a bone flap (Fig. 3). The cut bone flap is lifted and removed to expose the protective covering of the brain called the dura. The bone flap is safely stored until it is replaced at the end of the procedure.

Figure 3. A craniotomy is cut with a special saw called a craniotome. The bone flap is removed to reveal the protective covering of the brain called the dura.


Step 4: expose the brain
After opening the dura with surgical scissors, the surgeon folds it back to expose the brain (Fig. 4). Retractors placed on the brain gently open a corridor to the area needing repair or removal. Neurosurgeons use special magnification glasses, called loupes, or an operating microscope to see the delicate nerves and vessels.

Figure 4. The dura is opened and folded back to expose the brain.

 
Step 5: correct the problem
Because the brain is tightly enclosed inside the bony skull, tissues cannot be easily moved aside to access and repair problems. Neurosurgeons use a variety of very small tools and instruments to work deep inside the brain. These include long-handled scissors, dissectors and drills, lasers, ultrasonic aspirators (uses a fine jet of water to break up tumors and suction up the pieces), and computer image-guidance systems. In some cases, evoked potential monitoring is used to stimulate specific cranial nerves while the response is monitored in the brain. This is done to preserve function of the nerve and make sure it is not further damaged during surgery.  
 
Step 6: close the craniotomy
With the problem removed or repaired, the retractors holding the brain are removed and the dura is closed with sutures. The bone flap is replaced back in its original position and secured to the skull with titanium plates and screws (Fig. 5). The plates and screws remain permanently to support the area; these can sometimes be felt under your skin. In some cases, a drain may be placed under the skin for a couple of days to remove blood or fluid from the surgical area. The muscles and skin are sutured back together. A turban-like or soft adhesive dressing is placed over the incision.

Figure 5. The bone flap is replaced and secured to the skull with tiny plates and screws.

Recovery

The recovery time varies from 1 to 4 weeks depending on the underlying disease being treated and your general health. Full recovery may take up to 8 weeks. Walking is a good way to begin increasing your activity level. Start with short, frequent walks within the house and gradually try walks outside. It’s important not to overdo it, especially if you are continuing treatment with radiation or chemotherapy. Ask your surgeon when you can expect to return to work.

 

What are the risks?

No surgery is without risks. General complications of any surgery include bleeding, infection, blood clots, and reactions to anesthesia. Specific complications related to a craniotomy may include:

• stroke
• seizures
• swelling of the brain, which may require a second craniotomy
• nerve damage, which may cause muscle paralysis or weakness
• CSF leak, which may require repair
• loss of mental functions
• permanent brain damage with associated disabilities

Steps Of Modified Radical Mastectomy..MRM

Modified Radical Mastectomy

1. Arm on the affected side is extended on a side table. The patient is draped and the affected breast and axilla are exposed.
2. Drawing incision line (an optimal wound closure without any redundant skin must be taken into account)
3. Skin incision and formation of upper flap
4. Proceed cranially towards the pectoralis fascia just below the clavicula and laterally until the lateral margin of the pectoralis major muscle
5. Formation of lower flap from medial to lateral
6. Continue laterally until the latissimus dorsi muscle has been reached
7. Dissection of the breast from medial to lateral including pectoralis major 's fascia
8. Follow the lateral margin of the pectoralis major muscle and opening clavipectoral fascia
9. Identification of upper axillary margin (=axillary vein)
10. Dissection of axillary top (along axillary vein)
11. Identify and preserve thoracodorsal nerve/vessels
12. Identify and preserve long thoracic nerve
13. Finalize axillary dissection and remove all level I and II lymph nodes (for a complete oncologic resection it is sometimes necessary to cut the intercostobrachial nerve)
14. Remove axillary content en bloc with the breast
15. positioning of two drains (axilla-lower flap and upper flap)
16. Woundclosure, avoid any redundant skin

Some people are old at 18 and some are young at 90. Time is a concept that humans created.

Anorectal fistula.... Mucosal advancement Flap, Step by Step

Mucosal advancement Flap, Step by step

1. Position patient in lithotomy position
2. Place the intra-anal retractor
3. Identify fistula site
4. Canulate and brush the fistula tract (or flush with hydrogen peroxide,or both)
5. Excise the intra-anal fistula site (elliptical shape)
6. Create a wide flap by extending the proximal anorectal wall upwards
7. Close the internal fistula opening with absorbable suture
8. Further dissect the flap above the fistula including a thin layer of internal sphincter
9. Prepare the advancement flap and optimize the size before suturing
10. 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 considered an essential step in the surgical treatment of perianal fistula.
• Closure of the primary fistula opening using a biological anal fistula plug and anal flap advancement result in similar fistula healing rates in patients with high transsphincteric fistulae. These 2 strategies are superior to seton placement and fibrin glue.
• Given the low morbidity and relative simplicity of the procedure, the anal fistula plug is a viable alternative treatment for patients with high transsphincteric anal fistulas.

Treatment options

• A drainage seton. A safe option to provide adequate drainage. Surrounding tissue will get the opportunity to heal for future treatment. This option does not cure the fistula.
• Lay-open. The fistula is cut open. With this technique there is a risk of cutting to much sphincter tissue (depending on the position of the fistula) which can impair the sphincter's function leading to incontinence. Therefore this option is not suitable for high fistulas (e.g. crossing the entire anal sphincter). At least 2/3 of the sphincter should remain after the procedure.
• Cutting seton. A tied seton is tightened over time, resulting in gradually cutting through the sphincter. This technique can be used until the fistula is completely cured, or can be left in place until the fistula tract is lowered to a level allowing a safe lay-open technique. This technique can sometimes cause incontinence.
• Fistula plug. With this technique the fistula is plugged with a small stretched cone (plug) made of porcine small intestine submucosa. The plug is biodegradable allowing the fistula to heal almost physiologically. Success rates are reported up to 80%.
• Fibrin glue. In this technique the fistula tract is injected with biodegradable glue. However the anal fistula plug treatment shows better results when compared to fibrin glue injection.
• Mucosal advancement flap. In this technique the internal fistula opening is excised and covered with a flap of mucosal tissue. This technique can be combined with a fistula plug. 

Inguinal Hernia...Tension free mesh repair, step by step

Tension free mesh repair, step by step

1. Skin incision about 1.5 cm above and parallel to Inguinal ligament.
2. Ligation of the superficial epigastrivc vein (do not coagulate)
3. Opening Scarpa's fascia
4. Opening external aponeurosis following fibre direction. Avoid damage to the ilioinguinal nerve.
5. Isolate spermatic cord
6. Identify genitofemoral nerve (genital branche), this runs dorsal and parallel to the spermatic cord, underneath the cremaster muscle fibers
7. Isolate hernia sac and/or preperitoneal lipoma
8. Repositioning hernia (do not ligate!)
9. Lipoma can be ligated
10. 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.
11. 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.
12. Tie a knot when the internal ring has been reached (preferably an Aberbeen knot)
13. Create a new internal ring by attaching the lower edge of the upper part of the mesh to inguinal ligament.
14. Secure upper part with single sutures. Beware of the iliohypogastric nerve.
15. Close the external aponeurosis and create new external ring
16. Close Scarpa's fascia
17. Skin closure (intracutaneous resorbable)
18. Infiltrate wound with local anaesthesia

Inguinal Hernia

Risk factors
Positive family history, prolonged increased abdominal pressure (COPD, constipation, prostatism, peritoneal dialysis), aortic abdominal aneurysm, smoking.

Examination
Basically only physical examination; groin mass cranially from Poupart's ligament. Differentiate between a lateral or medial hernia with physical examination is unreliable. Describe testicles, contralateral side and reducibility. Further test are rarely necessary but in doubt a herniography, US or MRI can be considered.

Differential diagnosis
Femoral hernia, varicosis, lymph node, aneurysm, abscess, soft tissue tumor.

Treatment
Asymptomatic hernia; consider conservative treatment
Symptomatic hernia; planned surgery
Incarcerated hernia; acute surgery

Surgical technique
Unilateral; Mesh-repair.Extensive research has been done for the Lichtenstein's and the endoscopic technique. Lichtenstein's technique is recommended.
Bilateral; Mesh-repair. Lichtenstein or endoscopy if enough expertise is available. When endoscopically treated, the TEP is superior to the TAPP.
Recurrent hernia; Technique depends on earlier treatment. In case of an earlier anterior approach, a pre-peritoneal mesh or TEP should be performed. In case of an earlier posterior approach, an anterior mesh or TAPP should be performed.

 
Antibiotics
Antibiotic prophylaxis does not prevent the occurrence of wound infection after groin hernia surgery and should therefore not routinely be given. Prophylactic antibiotics is only recommended in high risk patients.

Appendectomy by laparotomy, step by step

Appendectomy by laparotomy, step by step

1. Skin incision at McBurney's point
2. Opening Scarpa's fascia
3. Opening aponeurosis
4. Atraumatic spreading of muscle fibers
5. Identify and opening of peritoneum
6. Identify cecum and appendix
7. Deliver cecum and appendix
8. Identify and ligate appendiceal artery
9. Crush appendix at base
10. Ligate and remove appendix at base
11. If desired place a purse string suture around base of appendix
12. Closing peritoneum
13. Closing aponeurosis
14. 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

Treatment

In case of an acute appendicitis, an appendectomy should be performed, either by laparotomy or by laparoscopy. Fertile females should get a laparoscopy, to exclude any gynaecologic pathology. An appendicular mass should be treatment with medicine and other conservative measures (e.g. rest, no enteral nutrition)
Abscesses should be drained.

Antibiotics

All patients with an acute appendicitis should receive antibiotics. Normally the patient receives a single dose of antibiotics against gram-positive, gram-negative an anaerobes organisms. This treatment should be continued for 5 days in case of gangrenous and perforated appendicitis. In children a total of three days is sufficient.

Wondclosure

The skin can be closed entirely, and does not cause more wound-site infections compared to an approximating stitch. This also accounts for a perforated appendicitis.


 

Differences in Composition of Capillary and Venous Blood Specimen

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, PCO₂, PO₂ 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