By E. Hogar. Agnes Scott College.

After you have removed the sequestrum: (1) If the tissues are not too tight order cheapest famvir, close the wound lightly and insert a drain in its lower part buy famvir with amex. Apply a posterior slab or a long leg cast with the ankle in neutral order 250 mg famvir fast delivery, and the knee in 20 of flexion. Mark a window in it while it is still soft, cut out the window with a knife, or with a plaster saw 2days later when it is hard. If you have left a deep trough in the front of the tibia which is slow to granulate and epithelialize, graft it. Apply a long leg cast with a walking heel, then encourage early weight bearing with as normal a gait as possible. If there is a very large skin defect in the tibia which is Approach the fibula between the peroneal muscles anteriorly, slow to heal, consider making relieving incisions about and the soleus posteriorly. Use the lateral position with the affected Hold them in place with sutures or strapping. Use the appropriate part of an incision which starts 5cm below the head of the fibula, and curves gently posteriorly If a large part of the tibia has been destroyed, and down towards the lateral malleolus. Reflect short skin inadequate involucrum has formed, try to get the fibula flaps anteriorly and posteriorly. Later, an of the fibula, because the common peroneal nerve winds operation in which a length of the fibula is moved across round it. The transposed piece of the If you are working on the middle of the fibula, incise fibula can hypertrophy greatly. The peroneal vessels are close to the medial involucrum had formed, or side of the fibula, so strip the muscles carefully. The calcaneus is a completely cancellous bone which Make a longitudinal incision exactly in the middle of the never forms an involucrum and seldom an isolated heel. You cannot remove it from inside its periosteum, so strip this away from the soft tissues of the heel and remove the bone completely, either as a single piece or in several smaller ones. Start in the midline, stay close to bone and reflect everything you meet medially and laterally. In this way you will avoid important structures, especially the plantar nerves entering from the medial side of the foot. Hold the ankle in a neutral position with a gutter plaster splint held with a crepe bandage. As the wound heals, start walking with crutches; later progress to full weight- bearing. The edges of the scar will turn deeply inwards and split the heel into two cushions. If you apply a below knee cast and treat with an antibiotic for 3wks the infection will probably settle without surgery, but degenerative arthritis may follow. When sequestra do form in the skull, it is usually because a burn has destroyed the blood supply to the outer diplo. Split the heel for the easiest approach to the calcaneus; this brings no disability. Osteitis of the skull presents with headache, combined D, osteomyelitis of the right calcaneus with a sinus. If infection is limited to the pin track, opening up and (3) Frontal sinusitis (29. You can approach the calcaneus from either side in order (6) Pyaemia causing metastatic lesions in the skull. For example, do not make a transverse incision in the temple which will divide the Osteomyelitis can affect either of the jaws, usually the temporal artery. Split skin grafts will not take on bare lower one, and can be secondary to: skull, but they will take on granulations. The offending teeth are usually loose, Define the extent of the frontal sinus with radiographs. Make a long incision (2) An open fracture, especially comminuted, of the lower above the hairline from ear to ear, and reflect the skin of jaw. If it is due to an open fracture or haematogenous, it is probably subacute and can be satisfactorily treated by antibiotics. No significant radiographic changes with multiple skin sinuses discharging sulphur granules suggest actinomycosis (31. There is no need to wait for an involucrum to form unless the sequestrum is very large. There is a dense white sequestrum in the skull, which has extended remove it under ketamine in toto or in pieces. Burns of the scalp are however the commonest cause of chip away a little living bone. Another cause is septic thrombophlebitis of the If the cavity bleeds, pack it for 5mins.

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Compress it suprapubically to make sure it is empty buy famvir 250 mg without prescription, and leave the catheter in for continuous drainage order famvir amex. Tip the table slightly head- down to let the bowel fall away from the pelvic cavity cheapest famvir. If you are inexperienced, make a midline A, put clamps on either side of the fundus. L, find the uterine arteries and cut the and that you have divided the rectus sheath and muscles as posterior leaf of the broad ligament almost as far as the artery. The illustrations here assume you are standing on the left, which most right-handed surgeons find easier. Push your finger through this thin part near Open the peritoneum with your finger in the middle of the the uterus, from behind forwards, to make a hole (23-22B). The incision is not curved and the cervix, near to its vesico-cervical reflexion (23-22C). With digital blunt dissection, gloved finger or a gauze while your force is exerted in the the wound is opened further, again after the horizontal direction of the uterus & cervix, not the bladder. If there was a previous Caesarean Section, you often need The rectus muscle (vertically) and peritoneum are sharp dissection: so cut even into the cervix superficially, separated/opened with the index finger. Feel the cervix from in front wall is made as large as that in the skin by manual traction and behind. Separate the bladder from the underlying after the peritoneum is opened (to prevent disrupting tissues somewhat laterally also. Trace them distally to beyond the tip of excellently with a Caesarean Section and minimises blood the cervix; recognize them by their feel: they are rather loss from the abdominal wall. Otherwise, put your left hand into the wound to are in no danger, and almost impossible to find when you feel the organs in the abdominal cavity quickly and need to find them! If you cannot find the ureters, these steps will protect Clear the operative field. Carefully pack the bowel out of the way with large damp (2);Lift the infundibulo-pelvic ligament and find the packs, attached to a cloth tape, to which a haemostat is ovarian vessels before you clamp them. Protect the wound edges with moist gauze, and (3);Very carefully dissect the bladder away from the insert a 3-blade self-retaining retractor. You must now decide if you The tubes and ovaries may be stuck down behind the broad want to retain them or not. If they have multiple large ligaments; get your fingers under them and free them from cysts, they are better removed, but try to retain at least below upwards. You may have to divide denser adhesions one ovary if the patient is pre-menopausal, or <5yrs with scissors, or if you think they are likely to contain post-menopausal. If there are any cysts it is better to blood vessels, clamp, divide, and tie them. You do not need a counter clamp if If you restore the proper anatomy first by removing you have already placed clamps on either side of the adhesions, you are far less likely later to damage ureters, fundus (see above): this makes it possible to ligate very bladder or bowel. Otherwise place the other clamp medial Put clamps on either side of the fundus of the uterus, to the ovary. Divide the ovarian pedicle medial to the (23-22A) and over the tubes and round ligaments lateral (not the counter) clamp, and tie it with a double (23-22B). Use them to exert traction, and control arterial transfixion suture using #1 absorbable. If you want to retain an ovary, apply a clamp across the If the bladder is well down and the posterior leaf of the Fallopian tube and its pedicle, 1cm lateral to the first broad ligament out of the way and the clamp (and suture) clamp that you applied to these structures near the uterus very near to the uterus, then the ureters should be out of (23-22H). Place the suture 1mm the other side, removing or retaining the ovary, medial and 1mm distal from the point of the clamp while as you decide. This will prevent Define, tie, and divide the lateral end of the round oozing later. Do this by pushing your finger under it and tying Complete the task of pushing the bladder down the cervix, it (23-22J,K). Cut the posterior leaf of the broad ligament with the loose areolar tissue inside it, Now decide if you want to proceed with a subtotal or total almost as far as the artery (23-22K,L). Dissect the peritoneum off the back of the cervix (23-22O), if it is not too adherent, otherwise leave it. Again, identify them by their feel: firm cords which you can roll between your finger and thumb. Doubly clamp the pedicle containing the uterine artery (23-22P), well away from the ureter, with the tip of the clamp biting the side of the cervix, and leaving little or no tissue on the uterine side. B,C, incise the anterior and because the uterus will start bleeding on one side when the posterior walls of the cervix. D,E, grasp the cervix stump and make a uterine artery on the other side is not clamped. In this way, you will be sure to have tied all the vessels lateral to the uterine part you are going to remove. When you are sure you have reflected the bladder adequately (23-23A), pull on the clamps attached to the uterus and incise the anterior wall of the cervix, above the reflexion of the bladder and the stump of the uterine vessel (23-23B). Then draw the uterus sharply forwards towards the symphysis, and incise the posterior wall of the cervix (23-23C).

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At first monopolar diathermy is introduced which can be used both for cutting tissues and coagulation famvir 250 mg online. Negative pole is directly in connection with patients skin order famvir on line, the hand port of the device must be grazed to the tissues or holding instrument buy discount famvir 250mg on line. Pressing blue button on hand port coagulation, pressing yellow button cutting can be performed. There is no need for negative electrode, because circuit is circulating between the two parts of forceps. It is suitable for quick cutting of soft tissues (muscles, fascia, and vessels) during amputation. Straight surgical raspatory: on side is flat, other side is rounded, half circular end is slightly sharp. Forcipes are varying in size; there are straight, curved and angular curved (dental forceps) types. Forceps has to be held as a pencil, while grabbing the shafts must be pressed by first and second finger (to ensure comfortable holding, finest movements, and widest size of movements). The teeth of the hooked forceps avoid loosening of tissues, thats why there is no need to expand big pressure for safe tissue holding. For that reason for holding skin and subcutaneous tissues surgical forceps is mostly used, but vessels, parenchymal and luminal organs (e. Anatomical forceps: end is fluted; ensuring atraumatic grabbing for vessels, luminal organs can be grabbed. Dressing forceps: Long instrument with ring at the end, with or without locking system. Hospital orderly is taking disinfective agent into a sterile container (mug), which contains also tupfers. Dressing forceps and tupfer are used during operation for removal of bleeding, only pressing tupfer on bleeding area a slice, not scrubbing it. The inner side of the shaft is fine, contains corrugations lengthways (it doesnt damage bowel wall while grabbing it). Gallbladder holder: mostly used during open cholecystectomy for grabbing and elevating the fundus of the gallbladder. Deschamps ligation needle (containing thread in its hole) must be guided into the riffle of the Payr probe. Thread must be grabbed by forceps on the other side, Deschamps needle drawn back. Particular closing of big vessels make possible, under the closing the circulation is continuous. Blalocks tourniquet: it can be closed using a twist; two ends are mostly covered with rubber (atraumatic closing). Wound hook: hanging into the wound corners and drawing the edges suturing can be performed easier. Advantage is the less tissue damage; disadvantage is the easy slide out from the operating area when it is not held correctly. After making sure there is no bowel or other organ between abdominal wall and self retractor, it can be opened. At first pressing needle is closed into the instrument, at second needle is held tight; at third pressing needle holder is opened. Inserting needle into needle holder: needle should held in left hand, needle holder in right hand. Needle have to be kept in needle holder in - ratio, needle have to be positioned perpendicular to needle holder. Sterile opening and taking of the atraumatic needle-thread combination: the outer bandage must be opened without touching inner bandage. Opening the inner bandage needle can be caught by needle holder, and needle-thread combination can be pulled out. Assistant is grabbing and elevating both wound edges using surgical forcipes (proper adaptation is very important to avoid irregular margins). Clip removal: clip remover must be positioned under the clip in the midline, than pressed. These sticks (Steri-Strip, Proxi-Strip ) are suitable for closing short superficial wound without need for suturing, and for securing intracutaneous suture. Tissue glues are mostly made from fibrin bases, causing consistent fibrin mesh (using last steps of the haemostatic cascade) (Beriplast P Combi-Set). Volkmans bone curette: this spoon-shaped instrument is sharp, it is used for removing tissue particles, and to refresh infected wounds base. Probe: end is dull, thats why extent of fistulas can be revealed without making tissue damage. Payrs stomach and bowel crushing forceps: inner side is finely fluted, atraumatic. It is suitable for crushing wall of the bowel, avoiding rupturing the serosa during ligation of the bowel.

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