Brain Abcess

Introduction 

A brain abscess is a pus-filled swelling in the brain caused by an infection. It is a rare and life threatening condition.

It happens when bacteria or fungi enter the brain tissue.

Symptoms of a brain abscess include:

• Headache – which is often severe and cannot be relieved by taking painkillers
• Changes in mental state such as appearing very confused
• Weakness or paralysis on one side of the body
• A high temperature (fever) of or above 38C (100.4F)
• Seizures (fits)

What causes a brain abscess?

There are three main ways that a brain abscess can develop:

• An infection in another part of the skull, such as an ear infection, sinusitis or dental abscess, spreads directly into the brain
• An infection in another part of the body, such as the lung infection pneumonia, spreads into the brain via the blood
• Trauma, such as a severe head injury, that cracks open the skull allowing bacteria or fungi to enter the brain

Although in around 1 in 7 cases the source of the infection remains unknown.

Treating a brain abscess

A brain abscess is regarded as a medical emergency. This is because the swelling caused by the abscess can disrupt the blood and oxygen supply to the brain. There is also a risk that the abscess may burst (rupture). If left untreated, a brain abscess can cause permanent brain damage and can be fatal.

A brain abscess is usually treated using a combination of antibiotics (or in some cases, antifungals) and surgery. Dr. B C Shah will usually open the skull and drain the pus from the abscess or remove the abscess entirely.

The sooner the condition is diagnosed and treated the lower the chance a person has of developing long-term complications.

Complications

Any damage to the tissue of the brain can result in long-term complications, such as:

• Brain damage – which can range from mild to severe
• Epilepsy – where a person has repeated seizures (fits)

Who is affected

Brain abscesses tend to only be significant problem in parts of the world where access to antibiotics is limited.

Brain abscesses can occur at any age, but most cases are reported in people aged 40 or younger. They are more common in men than women. It is not clear why this should be the case.

Outlook

Because of advances in diagnostic and surgical techniques, the outlook for people with brain abscesses has improved dramatically. Nowadays, deaths only occur in an estimated 1 in 10 of cases. Many people make a full recovery.

Symptoms of a brain abscess

The symptoms of a brain abscess can develop quickly or slowly.

In around two-thirds of people, symptoms are present for two weeks or less before they escalate to the point where the person needs to be admitted to hospital.

Common symptoms include:

• Headache - the headache is often severe, located in a single section of the head and cannot be relieved with painkillers
• Changes in mental state, such as confusion or irritability
• Problems with nerve function, such as muscle weakness, slurred speech or paralysis on one side of the body
• A high temperature (fever) of or above 38C (100.4F) 
• Seizures (fits)
• Nausea and vomiting
• Stiff neck
• Changes in vision, such as blurring, greying of vision or double vision (because of the abscess putting pressure on the optic nerve)

When to seek medical advice

Any symptoms that suggest a problem with the brain and nervous system, such as slurred speech, muscle weakness or paralysis, or seizures occurring in a person who had no previous history of seizures should be treated as a medical emergency.

Any symptoms that suggest a worsening infection, such as fever and vomiting, should be reported to Dr. B C Shah immediately.

Causes of a brain abscess

An abscess is a pus-filled swelling caused by infection with either bacteria or fungi.

The abscess is created by your immune system as a defence mechanism. If the immune system is unable to kill an infection, it will try to limit its spread. Your immune system will use healthy tissue to form a wall around the source of infection to stop the pus infecting other tissue.

The routes for brain infection

Infections of the brain are rare because the body has evolved a number of defences to protect this vital organ. One of these is the blood-brain barrier, which is a thick membrane that filters out impurities from blood before allowing it into your brain.

However, in some people, for reasons not always entirely clear, germs can get through these defences and infect the brain.

The three most common routes for germs to enter the brain are:

• Germs have already infected one of the nearby cavities in the skull (such as the ears or nose) and go on to infect the brain.
• Germs have already infected another part of the body, get into the bloodstream, bypass the blood-brain barrier and then infect the brain.
• Germs pass through the skull and enter the brain after the skull is damaged, for example after being hit by a blunt object or after a gunshot wound.

Though in around 1 in 7 cases no obvious cause for the infection can be found.

The causes of a brain abscess are explained in more detail below.

Germs from another infection in the skull

In up to a half of cases, the brain abscess occurs as a complication of a nearby infection in the skull, such as:

• A persistent middle ear infection (otitis media)
• Sinusitis (an infection of the sinuses, which are the air-filled cavities inside the cheekbones and forehead)
• Mastoiditis (an infection of the bone behind the eye)

This used to be a major cause of brain abscesses, but because of improved treatments for infections, a brain abscess is now a rare complication of these kinds of infection.

Germs invading the brain through the bloodstream

Infections spread through the blood are thought to account for around 1 in 4 cases of brain abscesses.

People with a weakened immune system have a higher risk of developing a brain abscess from a blood-borne infection. This is because their immune system may not be capable of fighting off the initial infection.

You may have a weakened immune system if you:

• Have a medical condition that weakens your immune system, such as HIV or AIDS
• Receive medical treatment known to weaken the immune system, such as chemotherapy
• Have an organ transplant and take immunosuppressant drugs to prevent your body rejecting the new organ

The most commonly reported infections and health conditions that may cause a brain abscess are:

• Cyanotic heart disease, a type of congenital heart disease (a heart defect present at birth) where the heart is unable to carry enough oxygen around the body (this lack of a regular oxygen supply makes the body more vulnerable to infection) 
• Pulmonary arteriovenous fistula – a rare condition in which abnormal connections develop between blood vessels inside the lungs; this can allow bacteria to get into the blood and then into the brain,
• Lung infections, such as pneumonia or bronchiectasis
• Infections of the heart, such as endocarditis
• Skin infections
• Infections of the abdomen, such as peritonitis (an infection of the lining of the bowel)
• Pelvic infections such as infection of the lining of the bladder (cystitis)

Germs invading the brain after a head injury

Direct trauma to the skull can also lead to a brain abscess and is thought responsible for 1 in 10 cases.

The most commonly reported causes include:

• Skull fracture caused by penetrating injury to the head
• Gunshot or shrapnel wound

In rare cases, a brain abscess can develop as a complication of surgery.

Diagnosing a brain abscess

An initial assessment will be made based on your physical symptoms and medical history, such as whether you have had a recent infection or a weakened immune system.

Blood tests 

Blood tests will be carried out to check for the presence of infection. A high level of white blood cells in your blood indicates the presence of a serious infection.

Scans

If a brain abscess is suspected, the diagnosis can be confirmed using a brain scan.

Computerised tomography (CT) scan

A computerised tomography (CT) scan involves a series of X-rays taken of your body at different angles. This produces a detailed image of the inside of your body.

A CT scan can often detect the presence of the abscess and any associated swelling inside the brain.

Magnetic resonance imaging (MRI) scan

A magnetic resonance imaging (MRI) scan uses strong magnetic fields and radio waves to produce a detailed image of the inside of your body.

A MRI scan can provide a more detailed image than a CT scan so is sometimes used if the results of the CT scan are inconclusive. 

CT-guided aspiration

If an abscess is found, Dr. B C Shah can use a CT scan to guide a needle to the site of the abscess and remove a sample of pus for further testing. This is known as CT-guided aspiration. The sample of pus should indicate the type of germ causing the abscess.

Treatment with broad-spectrum antibiotics will usually begin as soon as possible, even before a CT-guided aspiration is carried out, because it can be dangerous to wait for the results.

Broad-spectrum antibiotics can be used against a wide range of bacteria. They will be used before a specific diagnosis is made because there is a high chance they will be effective if the infection is caused by bacteria.

If the test reveals the abscess is caused by a fungus, the treatment plan can be changed and antifungal medication given.

Treating a brain abscess

Treatment for a brain abscess will depend on the size and number of brain abscesses present. A brain abscess is a medical emergency, so you will need treatment in hospital and will stay there until your condition is stable.

Medication

Surgery will be avoided if thought too risky or if an abscess is small and could be treated by medication alone.

Medication is recommended over surgery if you have:

• Several abscesses
• A small abscess (less than 2cm)
• An abscess deep inside the brain
• Meningitis (an infection of the protective membranes that surround the brain) as well as an abscess
• Hydrocephalus (a build-up of fluid on the brain)

You will normally be given antibiotics or antifungal medication through a drip (directly into a vein). Dr. B C Shah will aim to treat the abscess and the original infection that caused it.

Surgery

If the abscess is larger than 2cm, it is usually necessary to drain the pus out of the abscess.

There are two surgical techniques for treating a brain abscess:

• Simple aspiration
• Craniotomy

Simple aspiration involves using a CT scan to locate the abscess and then drills a small hole known as a burr hole into the skull. The pus is then drained through the hole and the hole sealed.

A simple aspiration takes around one hour to complete.

Open aspiration and excisions are usually carried out using a surgical procedure known as a craniotomy.

Craniotomy

A craniotomy may be recommended if an abscess does not respond to aspiration or reoccurs at a later date.

During a craniotomy, Dr. B C Shah will shave a small section of your hair and then remove a small piece of your skull bone (a bone flap) to gain access to your brain.

The abscess will then be drained of pus or totally removed. A CT-guided localisation system may be used during the operation, which allows Dr. B C Shah to more accurately locate the exact position of the abscess.

Once the abscess has been treated, the bone is replaced. The operation usually takes around three hours which includes recovery from the general anaesthetic (where you are put to sleep).

Complications of a craniotomy

As with all surgery, a craniotomy carries risks, but serious complications are uncommon.

Possible complications of a craniotomy are:

• Swelling and bruising around your face, which is common after a craniotomy. This will die down after the operation.
• Headaches. These are common after a craniotomy and may last several months, but should eventually settle down.
• A blood clot in the brain (further surgery may be required to remove it).
• Stiff jaw. During a craniotomy, Dr. B C Shah may need to make a small cut to a muscle that helps with chewing. The muscle does heal, but can become stiff for a few months, causing your jaw to feel stiff. Exercising the muscle by regularly chewing sugar-free gum should help relieve the stiffness.
• Movement of the bone flap. The bone flap in your skull may feel like it moves and you may experience a clicking sensation. This can feel strange, but it is normal and not dangerous. It will stop as the skull heals.

The site of the cut (incision) in your skull can become infected, although this is uncommon. You are usually given antibiotics around the time of your operation to prevent infection.

Recovering from surgery

Once your brain abscess has been treated, you will probably stay in hospital for several weeks so your body can be supported while you recover. 

You will also receive a number of CT scans, to make sure the brain abscess has been completely removed.

Most people will then need a further 6 to 12 weeks rest at home before they are fit enough to return to work or full-time education.

After treatment for a brain abscess, avoid any contact sport where there is a risk of injury to the skull, such as boxing, rugby or football.

Complications of a brain abscess

Possible complications of a brain abscess are outlined below.

Brain damage

Brain damage can range from mild through moderate to severe.

Mild brain damage can result in:

• Headaches
• Memory problems

Moderate brain damage can result in:

• Changes in mood such as feeling restless or agitated
• Problems with tasks that require high-level thinking such as planning and decision making
• Difficulties with balance and coordination – the medical term for this is ataxia

Severe brain damage can result in:

• Weakness in certain parts of the body
• And in the most serious of cases – coma or persistent vegetative state

Mild to moderate brain damage often improves with time. Severe brain damage is likely to be permanent.

Brain damage is more of a risk when the diagnosis of a brain abscess was delayed and treatment did not begin quickly enough. Brain abscesses can now be diagnosed very easily with a CT or MRI scan, so the risk of serious brain damage is now low.

Epilepsy

A common complication of brain abscesses is epilepsy, a condition that causes repeated fits or seizures. Epilepsy is a long-term condition and symptoms can usually be controlled using medication..

Meningitis

In some cases, especially those involving children, a brain abscess can develop into bacterial meningitis, a life-threatening infection of the protective membranes that surround the brain.

Symptoms of meningitis include:

• Severe headache
• Vomiting
• High temperature (fever) of 38ºC (100.4ºF) or over
• Stiff neck

Someone with bacterial meningitis will require urgent treatment in hospital; usually an intensive care unit (ICU).

Antibiotics will be used to treat the underlying infection. These will be given intravenously (through a vein in the arm).

At the same time a person may also be given:

• Oxygen
• Intravenous fluids (through a vein)
• Steroids or other medication to help reduce the inflammation (swelling) around the brain

Belly Button

Often female patients come with belly button pain or pain around belly button. There are many causes. Commonest cause is muscle stretching. In India its generally common in females  because of multiple pregnancies, obesity, poor muscle tone & lifting heavy weight. The navel gets so stretched that it starts to tear and the contents which are suppose to be inside start protruding out. The belly button everts & protrudes out This is called herniation. Often due to obesity this protrusion is not recognized and the patients continues to experience pain and not realize the swelling in the belly button. Gradually these small defects grow to bigger defects. Most of these muscle defects in and around the navel can be repaired laparoscopically. Its a short procedure. The defect if very small can simply be closed by few stitches  A synthetic material (mesh) is often used to reinforce the repair. This minimizes the chance of recurrence. So please report to your doctor if you experience a belly button or navel pain. One easy was to check if you are developing a hernia is by placing your tip of finger on your belly and coughing in standing position. If there is an expansile impulse or feeling that something is protruding out, there are chances that you may be developing an umbilical hernia. Report to your doctor. If diagnosed early, it can be repaired very easily. To prevent suchumbilical (paraumbilical) hernia avoid lifting very heavy weights, do regular exercises especially after delivery and avoid obesity.

Breast infection in infants

Baby L_____ S_____, one month old female infant was brought to me by her aunt with a huge left breast abscess. The mother was too terrified to come inside my clinic & the father was also outside consoling the mother. It started as a small boil. They had taken her to pediatrician who gave them local ointment and oral antibiotics. However, it did not subside. IT grew very quickly and the child started to have fever. It was extremely painful and the child was constantly crying. The baby was being massaged by a servant. The possible reason is that many times such masseur, who are most often untrained try manipulation the delicate neonatal breast to express a clear or cloudy (milk-like) substance from nipple (also called witch's milk). This causes potential damage & bleeding inside which gets infected or possibly it causes cracks in the nipple thro which the bacteria enter inside. The main worry of the relatives & parents was – will she have a normal breast development or is her left breast completely destroyed?

I removed the pus from the infant baby's left breast under anesthesia. Subsequently she underwent daily dressings. The nipple restored back to normal and the wound healed very soon. I assured the parents that she will have normal breast. Nature is great!

Adult breast is common especially in lactating mothers but neonatal breast abscess is not so common.

Percutaneous Endoscopic Gastrostomy PEG

What is a PEG?

PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. This brochure will give you a basic understanding of the procedure – how it's performed, how it can help, and what side effects you might experience.

How is the PEG performed?

Dr. B C Shah will use a lighted flexible tube called an endoscope to guide the creation of a small opening through the skin of the upper abdomen and directly into the stomach. This procedure allows him to place and secure a feeding tube into the stomach. Patients generally receive an intravenous sedative and local anesthesia, and an antibiotic is given by vein prior to the procedure. Patients can usually go home the day of the procedure or the next day.

Who can benefit from a PEG?

Patients who have difficulty swallowing, problems with their appetite or an inability to take adequate nutrition through the mouth can benefit from this procedure.

How should I care for the PEG tube?

A dressing will be placed on the PEG site following the procedure. This dressing is usually removed after one or two days. After that you should clean the site once a day with diluted soap and water and keep the site dry between cleansings. No special dressing or covering is needed.

How are feedings given? Can I still eat and drink?

Specialized liquid nutrition, as well as fluids, are given through the PEG tube. If the PEG tube is placed because of swallowing difficulty (e.g., after a stroke), there will still be restrictions on oral intake. Although a few PEG patients may continue to eat or drink after the procedure, this is a very important issue to discuss with your physician.

Are there complications from PEG placement?

Complications can occur with the PEG placement. Possible complications include pain at the PEG site, leakage of stomach contents around the tube site, and dislodgment or malfunction of the tube. Possible complications include infection of the PEG site, aspiration (inhalation of gastric contents into the lungs), bleeding and perforation (an unwanted hole in the bowel wall). Dr. B C Shah can describe for you symptoms that could indicate a possible complication.

How long do these tubes last? How are they removed?

PEG tubes can last for months or years. However, because they can break down or become clogged over extended periods of time, they might need to be replaced. Dr. B C Shah can easily remove or replace a tube without sedatives or anesthesia, although Dr. B C Shah might opt to use sedation and endoscopy in some cases. Dr. B C Shah will remove the tube using firm traction and will either insert a new tube or let the opening close if no replacement is needed. PEG sites close quickly once the tube is removed, so accidental dislodgment requires immediate attention.

Hemorroidectomy

What are hemorrhoids?

Hemorrhoids are veins, normally present in and around the anus and lower rectum, that have become swollen due to stretching under pressure. These are very common in both men and women, and about half the population have hemorrhoids by age 50. Hemorrhoids are also common in pregnant women due to the pressure of the fetus in the abdomen, as well as hormonal changes, which cause hemorrhoidal vessels to enlarge. The process of childbirth also puts severe stress of these vessels.

Hemorrhoids are either internal (inside the anus) or external (under the skin around the anus).

What causes hemorrhoids?

Hemorrhoids may develop as a result of repeated straining during bowel movements, pregnancy, heredity, aging, and chronic constipation or diarrhea.

What are the symptoms of hemorrhoids?

The following are the most common symptoms of hemorrhoids. However, each individual may experience symptoms differently. Symptoms may include:

• Bright red blood present on the stool, toilet paper, or in the toilet bowl
• Irritation and pain around the anus
• Swelling or a hard lump around the anus
• Itching

The symptoms of hemorrhoids may resemble other medical conditions or problems. Always consult your doctor for a diagnosis.

How are hemorrhoids diagnosed?

The presence of blood in the stool can be indicative of other digestive disorders, including colorectal cancer, so thorough evaluation and proper diagnosis is important.

Diagnosing hemorrhoids may include:

• Physical examination: This is done to check the anus and rectum and look for swollen blood vessels that indicate hemorrhoids.
• Digital rectum examination (DRE): The doctor inserts a gloved, lubricated finger into the rectum to check for abnormalities.
• Anoscopy: A hollow, lighted tube useful for viewing internal hemorrhoids is inserted into the anus.
• Proctoscopy: A lighted tube, which allows the doctor to completely examine the entire rectum, is inserted into the anus.
• Sigmoidoscopy: A diagnostic procedure that allows the doctor to examine the inside of a portion of the large intestine, and is helpful in identifying the causes of diarrhea, abdominal pain, constipation, abnormal growths, and bleeding. A short, flexible, lighted tube, called a sigmoidoscope, is inserted into the intestine through the rectum. The scope blows air into the intestine to inflate it and make viewing the inside easier.
• Colonoscopy: A procedure that allows the doctor to view the entire length of the large intestine, and can often help identify abnormal growths, inflamed tissue, ulcers, and bleeding. It involves inserting a colonoscope, a long, flexible, lighted tube, in through the rectum up into the colon. The colonoscope allows the doctor to see the lining of the colon, remove tissue for further examination, and possibly treat some problems that are discovered.

Treatment for hemorrhoids

Specific treatment for hemorrhoids will be determined by your doctor, based on:

• Your age, overall health, and medical history
• Extent of the condition
• Your tolerance of specific medicines, procedures, or therapies
• Expectations for the course of the condition
• Your opinion or preference

Medical treatment of hemorrhoids is aimed at relieving symptoms and may include the following:

• Sitting in plain, warm water in the tub several times a day
• Ice packs to reduce swelling
• Application of hemorrhoidal creams or suppositories

Dr. B C Shah may also recommend increasing both fiber and fluids to soften stools. A softer stool lessens pressure on hemorrhoids caused by straining. Good sources of fiber include fruits, vegetables, and whole grains. Bulk stool softeners or fiber supplements, such as psyllium (Metamucil) or methylcellulose (Citrucel), may also be recommended.

In some cases, it is necessary to treat hemorrhoids surgically. Several surgical techniques are used to remove or reduce internal and external hemorrhoids. These include the following:

• Rubber band ligation: A rubber band is placed around the base of the hemorrhoid inside the rectum to cut off circulation to the hemorrhoid. The hemorrhoid then gradually shrinks and withers away within a few days.
• Sclerotherapy: A chemical solution is injected around the blood vessel to shrink the hemorrhoid.
• Electrical or laser coagulation or infrared photo coagulation: Techniques that use special devices to burn hemorrhoidal tissue.
• Hemorrhoidectomy: A surgical procedure that permanently removes the hemorrhoids.

HYDROCELECTOMY

WHAT IS A HYDROCELE, A SPERMATOCELE, AND AN EPIDIDYMAL CYST?

A hydrocele is an abnormal fluid collection between the outer tissue layers of the testicle. These tissue layers naturally secrete fluid and when this fluid is not reabsorbed, as it usually would be, a fluid collection or hydrocele forms. The cause of most hydroceles is unknown, although some may be related to trauma, infection, or past surgery.

A spermatocele is a cyst-like sac that is usually attached to the epididymis, the tube that sits behind the testicle and stores sperm. The sac of a spermatocele is filled with sperm. The exact cause of a spermatocele is unknown but it is thought that injury and obstruction may play a part in their formation.

An epididymal cyst is much the same as a spermatocele. However, the sac attached to the epididymis is a true cyst and is filled with cystic fluid and not sperm.

WHAT IS A HYDROCELECTOMY, SPERMATOCELECTOMY AND AN EPIDIDYMAL CYSTECTOMY?

A hydrocelectomy is an operation to treat a hydrocele. An incision is made in the scrotum and the testicle containing the hydrocele is lifted out. The sac is then removed and the remaining tissue edges are stitched back. The tissue edges then heal onto themselves and the surrounding vessels naturally reabsorb any fluid produced.

A spermatocelectomy is an operation to remove a spermatocele from the epididymis of a testicle. An incision is made in the scrotum and the testicle with its attached spermatocele is lifted out. The spermatocele is then removed from the epididymis and any bleeding areas are sealed off.

An epididymal cystectomy is an operation to remove the cyst from the epididymis. The operation is performed in exactly the same way as a spermatocelectomy.

After all three types of surgery, once the operation is complete, the wounds are stitched closed with dissolving stitches that dissolve slowing in the weeks following surgery. No wound drains are usually required.

Hydrocelectomy, spermatocelectomy and epididymal cystectomy are usually not performed unless the hydrocele, spermatocele or epididymal cyst are causing pain or social embarrassment. All three operations are usually simple day stay procedures and complications are rare. Haematoma (blood clot collection), wound infection, abscess, and recurrence, are all very uncommon complications and success rates for surgery usually approach 100%.

YOUR CONSENT

We need your permission for your operation to go ahead. Before you sign the consent form it is important that you understand the risks and effects of the operation and anaesthetic. These will be discussed with you by Dr. B C Shah and the nurse, should you have any questions, Dr.B C Shah would be happy to answer these.

If you would like any testicle tissue returned to you for personal reasons, please discuss this with your family and inform Dr. B C Shah before your operation.

ABOUT YOUR ANAESTHETIC

You will NOT be allowed to eat or drink anything for at least six hours before your surgery. This includes chewing gum and sweets.

Before your operation you will be able to discuss the type of anaesthetic with your anaesthetist, who will see you prior to your operation.

There are two main types of anaesthetic used for this surgery; • General Anaesthetic: You will be asleep throughout the operation and remember nothing of it.

Regional Anaesthetic e.g. Spinal, Epidural or Caudal: A needle is placed into your back and a solution is injected that will numb your body from the waist down. You will be awake but you maybe sleepy and you will not feel the operation.

Feel free to discuss these options and your questions with the anaesthetist.

You must not drive any vehicle or operate any machinery for 24 hours after having an anaesthetic. You will have to arrange for someone to drive you home if you go home within 24 hours of your surgery.

YOUR OPERATION

On admission you will be informed of your approximate time of surgery and prepared for theatre by your nurse.

Any shave of the surgical site is done in theatre once you are asleep.

You may be given some tablets before theatre. These are charted by your anaesthetist and may include tablets for tension, nausea and pain prevention.

You will be escorted to theatre where you will be transferred to the theatre table. Anaesthetic staff will then insert a drip in your arm and will attach various monitoring devices.

Once you have been completely prepared and given your anaesthetic, surgery will begin. The operation usually takes about 30 minutes to perform.

When the operation is completed you will go to the recovery room for a short while where you will be cared for until you are ready to be transferred to the ward.

AFTER SURGERY

Dr. B C Shah will check your blood pressure, pulse and your wound routinely.

You may still have the drip in your arm so you get enough fluid until you are drinking. You can usually eat and drink when you return to the ward.

You may have a scrotal support in place, which is a special pair of underpants that support the scrotum. These underpants help prevent bleeding and keep you comfortable.

Once you have recovered from your anaesthetic you will be able to be up and about, but you must take things very quietly in order to avoid causing any bleeding or bruising at the operation site.

Our aim is to keep you as comfortable as possible, so please tell Dr. B C shah if you have any pain or discomfort so you can be given the appropriate care. At all times, your nurse is there to help you, please ring your bell if you need assistance and your nurse is not nearby.

GOING HOME

Once you are up and about, eating and drinking and you have passed urine you will be able to return home. This may be later on your operation day or the following morning.

Before leaving the ward you will be given a discharge information letter which contains helpful information for when you get home.

Dr. B C Shah will give specific instructions about caring for your wound. You can shower daily to wash your wound but avoid soap and powders directly on the wound until it has healed. The area should be kept clean and dry and you will be given some dressings to take home that are to be placed over the wound to collect any slight ooze.

You will be given appointment to return to see Dr.B C Shah. The appointment is usually about 6 weeks after your operation.

ONCE HOME

If you were a daystay patient, it is important to take things quietly for the rest of the day as the anaesthetic can still have some effects on your body.

You should wear your scrotal support or your own supportive underpants for as long as you need for comfort after your surgery.

Your wound should heal within about 3 to 5 days. During this time your wound may ooze very slightly. However, if your wound continues to ooze or you have any signs of an infection such as a red, hot, swollen, or painful wound please contact Dr. B C Shah as soon as possible.

You should avoid any heavy lifting, straining or strenuous activity for 2 to 3 weeks after your surgery. This includes things such as any digging and strenuous sports as these activities can cause the stitches below the skin to pull apart.

Before discharge Dr. B C Shah will inform you about taking mild pain relievers, should you have any pain or discomfort after you return home.

This is routinely a straightforward operation, after which most patients have a speedy recovery and experience little pain.

While you are in hospital we will do everything we can to make your stay as comfortable as possible. The nursing and medical staff are always available to help with whatever needs you have. If you are worried about anything before or after your surgery, or if you have any further questions or would like more information, please do not hesitate to ask Dr. B C Shah who will be more than happy to help.

Exploratory Laparotomy

By definition, an exploratory laparotomy is a laparotomy performed with the objective of obtaining information that is not available via clinical diagnostic methods. It is usually performed in patients with acute or unexplained abdominal pain, in patients who have sustained abdominal trauma, and occasionally for staging in patients with a malignancy.

Once the underlying pathology has been determined, an exploratory laparotomy may continue as a therapeutic procedure; sometimes, it may serve as a means of confirming a diagnosis (as in the case of laparotomy and biopsy for intra-abdominal masses that are considered inoperable). These applications are distinct from laparotomy performed for specific treatment, in which Dr. B C shah plans and executes a therapeutic procedure.

With the increasing availability of sophisticated imaging modalities and other investigative techniques, the indications for and scope of exploratory laparotomy have shrunk over time. The increasing availability of laparoscopy as a minimally invasive means of inspecting the abdomen has further reduced the applications of exploratory laparotomy. Nevertheless, the importance of exploratory laparotomy as a rapid and cost-effective means of managing acute abdominal conditions and trauma cannot be overemphasized.

Indications

Four primary indications for an exploratory laparotomy are noted, as follows.

Acute-onset abdominal pain and clinical findings suggestive of intra-abdominal pathology requiring emergency surgery

In these conditions, exploratory laparotomy is carried out both to diagnose the condition and to perform the necessary therapeutic procedure.

Peritonitis

Patients with clinical features of peritonitis may have pneumoperitoneum on erect chest and abdominal radiographs. They usually have a perforated viscus, most commonly the duodenum, stomach, small intestine, cecum, or sigmoid colon. Exploratory laparotomy is done first to determine the exact cause of pneumoperitoneum, followed by the therapeutic procedure. In the absence of pneumoperitoneum, appendicular perforation and intestinal ischemia are possible diagnoses; a high index of suspicion for possible intestinal ischemia should be maintained.

Intestinal obstruction

Patients with vomiting, obstipation, and abdominal distention are likely to have intestinal obstruction. Abdominal radiographs in these patients may reveal dilated intestinal loops and air-fluid levels. Hernia, especially an incarcerated inguinal hernia, should be ruled out as a possible cause of the obstruction.

Intra-abdominal collections

Patients with pain in the abdomen and fever may have intra-abdominal collections. These are usually detected by means of ultrasonography or computed tomography (CT) and can often be managed percutaneously. A persistently high aspirate or the presence of enteric contents may suggest perforation, and laparotomy may be required to control the source.

Abdominal trauma with hemoperitoneum and hemodynamic instability

Hemodynamically unstable trauma patients with hemoperitoneum should undergo exploratory laparotomy without any delay. They are likely to have intraperitoneal bleeding after injury to the liver, spleen, or mesentery. They may also have associated intestinal perforations that call for emergency repair.

Chronic abdominal pain

Availability of good imaging facilities have restricted the use of exploratory laparotomy in these conditions; however, when limited facilities are available, exploratory laparotomy becomes an important diagnostic tool. These patients may have intra-abdominal adhesions, tuberculosis, or tubo-ovarian pathology.

Staging of ovarian malignancy and Hodgkin disease

The role of surgical staging in Hodgkin disease is controversial, and recommendations are restricted to patients who may be considered for primary radiotherapy as the sole modality of treatment.

Contraindications

The primary contraindication for exploratory laparotomy is unfitness for general anesthesia. Peritonitis with severe sepsis, advanced malignancy, and other comorbid conditions may render patients unfit for general anesthesia.

Technical Considerations

Exploratory laparotomy is sometimes a good diagnostic tool. However, anticipation of the diagnosis is necessary, and a hasty exploration should be avoided if the center is not well equipped to perform the therapeutic procedure that will be necessary if the suspected condition is confirmed.

Nontherapeutic laparotomy is associated with significant long-term morbidity, including adhesive intestinal obstruction and incisional hernia. Consequently, exploratory laparotomy should be performed in accordance with standard protocols and guidelines for laparotomy.

The authors have found that in equivocal cases of acute abdomen, diagnostic peritoneal lavage (DPL) is often helpful in determining the need for exploratory laparotomy. If DPL findings are positive, then an exploratory laparotomy is performed; if DPL findings are negative, the patient is closely monitored.

Periprocedural Care

Preprocedural Planning

The patient's physiologic status at laparotomy is an important determinant of outcome. Accordingly, whenever possible, efforts should be made to optimize the patient's general condition. This includes correction of fluid and electrolyte imbalances, blood transfusions, and bronchodilator nebulizations as required.

Before the procedure, a nasogastric tube and an indwelling urinary catheter are inserted to decompress the stomach and the urinary bladder. Decompression of the stomach reduces the risk of aspiration of gastric contents during induction of anesthesia. The risk of such aspiration is high in these patients because of the emergency nature of the procedure and because of paralytic ileus. Decompression of the bladder reduces the risk that the bladder may be injured as the midline incision is extended inferiorly for better exposure.

Equipment

Exploratory laparotomy is performed in an operating room (OR). The OR should contain anesthetic equipment, overhead lights, electrodiathermy equipment, and suctioning systems. A standard laparotomy tray is usually sufficient for an exploratory laparotomy.

If vascular intervention is anticipated, vascular instruments may be required. If major abdominal organ resection may be needed, appropriate instruments, facilities, and expertise should be available. Similarly, abdominal trauma necessitates major abdominal surgery, for which appropriate infrastructure and expertise are required.

Patient Preparation

Patient preparation includes adequate anesthesia and appropriate patient positioning.

Anesthesia

Exploratory laparotomy is performed with the patient under general anesthesia. Patients who are anesthetized for emergency surgery are at higher risk for aspiration of gastric contents. Adequate care must be taken to empty the stomach before induction. Rapid-sequence induction considerably reduces the risk of aspiration.

Positioning

The patient is placed in the supine position, with the arms abducted at right angles to the body. The lithotomy position may be employed instead when a pelvic pathology is suspected and a simultaneous vaginal or rectal intervention is necessary.

Technique

Exploratory Laparotomy

After appropriate preparation (see Periprocedural Care), exploratory laparotomy is performed as follows.

Midline incision and opening of peritoneum

A vertical midline incision is the best choice: it affords a rapid entry into the peritoneum and is relatively bloodless and safe.The incision may be made in the upper, middle, or lower midline, depending on the anticipated pathology, and may be extended in either direction if necessary. Exposure of the peritoneum should never be compromised in an attempt to keep the incision small.

The skin is incised with a surgical knife. The incision is then deepened through the subcutaneous fat. Electrodiathermy in coagulation mode provides a bloodless access through this layer. The linea alba is identified as a glistening layer deep to the subcutaneous tissues.

Upper midline incision. Incision is deepened through subcutaneous tissue to expose linea alba.

The orientation of the fibers on the linea alba is appreciated; these fibers are directed medially and inferiorly from either side, and the midline is identified as the axis where they criss-cross. This is opened carefully by means of electrodiathermy or heavy Mayo scissors .

Linea alba is divided to reveal preperitoneal fat.

Abdominal incision is completed to reveal intra-abdominal organs.

Every effort must be made to avoid injury to the intraperitoneal contents. This can be done by lifting the peritoneum in 2 straight artery forceps placed close to each other at right angles to the incision. Use careful palpation to ensure that no bowel or omentum is picked up in the artery forceps. In reoperations, extreme care is necessary because the underlying bowel may be adherent to the parietal peritoneum. In these cases, the peritoneum is opened in a virgin area, preferably by extending the incision appropriately.

Exploration of abdominal cavity

The steps of exploration depend on the initial findings and are governed by the principles of systematic survey and priority for life-saving maneuvers.

Massive hemoperitoneum suggests 2 things. First, the patient may have a major source of bleeding. Second, the presence of blood within the peritoneum interferes with adequate exploration. The ideal strategy is to lift the small bowel and its mesentery out of the peritoneal cavity, to rapidly suction the blood within the peritoneum, and to place laparotomy pads in the 4 quadrants of the peritoneum. Once this is done, each pad is carefully removed to allow inspection of each quadrant.

Identification of the source of bleeding is much easier in the absence of massive hemoperitoneum. Common sources include injuries to the liver (see the image below) or spleen, ruptured ectopic pregnancies, mesenteric tears, hollow visceral injuries, aortic aneurysms, and splenic or hepatic artery aneurysms. Once the source of bleeding is identified, necessary corrective measures must be taken.

Liver laceration in traffic accident victim who presented with hemoperitoneum.

If enteric contents are the finding, they are suctioned out with a sump suction catheter, and the source of the enteric contamination is sought. This search must be performed systematically, starting from the stomach. The anterior aspect of the stomach is inspected for a perforation, followed by the duodenum.

Subsequently, the small bowel is inspected carefully, starting from the duodenojejunal flexure.

Each segment of the intestine is held up by Dr. B C Shah, and all surfaces are inspected. Any slough on the serosal surface is gently separated to allow identification of an underlying perforation (see the image below).

Laparotomy in patient with peritonitis. Image shows perforated duodenal ulcer.

If no source of enteric contents is found in the small intestine, the appendix and then the colon are examined. Any perforation found in the intestine is controlled. Methods of controlling the source include direct repair, buttressed repair, resection, and anastomosis or exteriorization of the perforation with stoma formation. The choice between the different options depends on the site of perforation, the suspected pathology, the extent of the disease, and the patient's physiologic status.

In patients with intestinal obstruction, possible findings on exploratory laparotomy include adhesive intestinal obstruction, a single intraperitoneal band with intestinal compression or torsion, and tumors (see the images below).

Laparotomy in patient with intestinal obstruction. Intraoperatively, single peritoneal band causing intestinal obstruction was found.

Laparotomy in patient with acute intestinal obstruction. Sigmoid volvulus with gangrene was found intraoperatively.

Multiple omental deposits in patient with disseminated carcinoma of stomach.

Multiple metastatic deposits over small bowel in patient with colonic malignancy.

Staging laparotomy should include a thorough search for foci of malignancy, splenectomy, wedge and core liver biopsies, and sampling of retroperitoneal lymph nodes. In premenopausal women, oophoropexy is performed in anticipation of radiotherapy.

Completion and closure

Placement of drains after an exploratory laparotomy is still a subject of debate. The evidence currently available is inadequate to support routine drain placement. Patients with extensive contamination may benefit from drains in the subhepatic space and the pelvis.

Once the procedure is completed, the abdominal wall is closed. Before closure, however, the instrument and pad counts must be double-checked. Dr. B C Shah should manually inspect the peritoneum for any retained pads or instruments, even if scrub nurse has found the count to be correct.

Closure is carried out with either nonabsorbable suture material (eg, polypropylene) or a delayed absorbable suture material (eg, polydioxanone) in either a continuous suture or interrupted sutures. The standard approach is to place sutures about 1 cm from the edge of the incised linea alba, maintaining a distance of 1 cm between successive bites.

Sometimes, the Smead-Jones closure technique (ie, single-layer mass closure) may be employed to close the abdomen if the abdominal wall is plastered and separate layers are unavailable as a result of previous operations. This technique makes use of figure-eight sutures.

At times, closure may be rendered difficult by an edematous or distended bowel. In such circumstances, forced closure may have adverse postoperative outcomes in the form of impaired ventilation, intra-abdominal hypertension, pain, and dehiscence. Laparostomy and delayed closure may be a better option in such cases.

Complications of Procedure

An exploratory laparotomy is associated with the same complications that are associated with any laparotomy. Immediate complications include the following:

• Paralytic ileus
• Intra-abdominal collection or abscess
• Wound infections
• Abdominal wall dehiscence
• Pulmonary atelectasis
• Enterocutaneous fistula

Delayed complications include the following:

• Adhesive intestinal obstruction
• Incisional hernia