A video showing the laser eye surgery

Laparoscopy in acute bowel obstruction following previous surgery is a difficult procedure and avoided by most of the surgeons due to the difficulty in obtaining pneumoperitoneum, port placement, lack of working space, adhesions and risk of bowel injury.
Here is a patient who had a previous laparotomy for trauma with a midline incision from xyphysternum to pubis; after unsuccessful conservative management he underwent a laparoscopy; a prior CT scan showed adhesions in the left side and a distal-mid small bowel obstruction. The pneumoperitoneum was obtained with the Visiport placed in the right lower quadrant; although the abdomen was grossly distended, under significant tension and distended loops of small bowel were occupying most the peritoneal cavity, with muscle relaxation there is usually enough space to perform a thorough inspection of the abdominal cavity. Port placement has to be done with special care as there is no room to push and usually a blunt trocar directed away from the bowel is employed in my practice. The collapsed loops of small bowel point quickly to the site of obstruction -- it is better to avoid manipulating the distended bowel as it is heavy, oedematous and prone to be lacerated with the instruments; once the pathology is identified, in this case the obstructive band, light packing is performed in order to expose the working space and protect the bowel from instruments like scissors or diathermy. In this case the band adhesion was slightly more difficult to separate from the bowel and required a combination of sharp and gentle blunt dissection.
Once the obstruction is release and the transit of contents is confirmed in the collapsed bowel the procedure is terminated. No abdominal drainage is usually necessary.

Fibroma Excision in the Cheek

51 yr old female with right flank pain and recurrent UTI. IVP showed a UPJ calculus on the right.

New treaments for psoriasis include Remicade, which blocks TNF- tumor necrosis factor, alpha.

For open hernia repair surgery, a single long incision is made in the groin. If the hernia is bulging out of the abdominal wall (a direct hernia), the bulge is pushed back into place. If the hernia is going down the inguinal canal (indirect), the hernia sac is either pushed back or tied off and removed.

Urogenital neoplasms spreading to the inguinal lymph nodes are penile carcinoma (the most frequent), urethral and scrotum cancers, tumors of the testis with scrotal violation. Penile carcinoma is an uncommon malignant disease and accounts for as many 0.4-0.6% of male cancers. Most patients are elder...ly. It rarely occurs in men under age 60 and its incidence increases progressively until it reaches a peak in the eighth decade 1. The risk of a lymph node invasion is greater with high grade and high stage tumors 2. Some investigators have reported the inaccuracy of the sentinel node biopsy 3, 4, described by Cabanas 5. Patients with metastatic lymph node penis cancer have a very poor prognosis if penectomy only is performed. Ilioinguinal lymphadenectomy is basically carried out as a treatment modality and not only as a staging act. Patients with lymph node invasion have a 30-40% cure rate. Ilioinguinal lymphadenectomy should be also performed in patients with disseminated neoplasms for the local control of the disease. The 5 years survival rate of patients with clinically negative lymph nodes treated with a modified inguinal lymphadenectomy is 88% versus 38% in patients not initially treated with lymphadenectomy 6. This video-tape clearly shows a therapeutic algorithm, the anatomy of the inguinal lymph nodes, according to Rouviere 7 and Daseler 8, the radical ilioinguinal node dissection with transposition of the sartorius muscle and the modified inguinal lymphadenectomy proposed by Catalona 9. References: 1. Lynch D.F. and Schellhammer P: Tumors of the penis. In Campbell’s Urology Seventh Edition, edited by Walsh P.C., Retik A.B., Darracott Vaughan E. and Wein A.J. W.B. Saunders Company, Vol. 3, chapt. 79, p. 2458, 1998. 2. Pizzocaro G., Piva L., Bandieramonte G., Tana S. Up-to-date management of carcinoma of the penis. Eur. Urol. 32: 5-15, 1997 3. Perinetti E., Crane D.B. and Catalona W.J. Unreliability of sentinel lymph node biopsy for staging penile carcinoma. J. Urol. 124: 734, 1980 4. Fowler J.E. Jr. Sentinel lymph node biopsy for staging penile cancer. Urology 23: 352, 1984 5. Cabanas R.M. An approach for the treatment of penile carcinoma. Cancer 39: 456, 1977 6. Russo P. and Gaudin P. Management strategies for carcinoma of the penis. Contemporary Urology;5:48-66, 2000 7. Rouviere H. Anatomy of the human lymphatic system. Edwards Brothers, p. 218, 1938 8. Daseler E.H., Anson B.J., Reimann A.F. Radical excision of the inguinal and iliac lymph glands: a study based on 450 anatomical dissections and upon supportive clinical observations. Surg. Gynecol. Obstet. 87: 679, 1948 9. Catalona W.J. Modified inguinal lymphadenectomy for carcinoma of the penis with preservation of saphenous veins: technique and preliminary results. J. Urol. 140: 306-310, 1988

Examination of the hip

surgical examination of intra abdominal lump or mass

Acoustic Neuroma

Extradural approach via Orbito-Zygomatic Craniotomy

Resection of a glioblastoma multiforme, a very malignant, aggressive brain tumor.

This 38 year old woman has increasingly intractable RUQ pain after cholecystectomy done one year prior. LFTs and pancreatic enzymes have been normal, and ducts are non-dilated, thus she is a Type III possible SOD patient. Initial goal is to define course of pancreatic duct for manometry. 5-4-3 Co...ntour catheter (Boston Scientific) is used to perform the pancreatogram which shows a small straight distal duct. The aspirating triple lumen manometry catheter (Wilson Cook) is used to cannulate the pancreatic duct, with continuous aspiration of fluid once the duct is entered. Careful stationed pullthrough manometry shows markedly abnormal basal pressures in both leads in the pancreatic sphincter. Plan is dual pancreatic and biliary sphincterotomy. Biliary manometry will not now change our plan therefore is omitted. Our first goal is to access the pancreatic duct so we can guarantee wire access for placement of a small caliber pancreatic stent which is critical for safety. Contrast is injected as the 0.018in Roadrunner wire (Wilson Cook) is advanced in order to outline the course of main duct. A separate biliary orifice is clearly seen, unusual in SOD patients. A soft 4Fr 3cm single inner flange pancreatic stent (Hobbs Medical) is placed. We did not want to use our typical 9cm long unflanged stent as even a 3 or 4 French stent might be traumatic to the tiny caliber of this duct out in the body of the gland. Next the bile duct is cannulated with a papillotome (Autotome 39, Boston Scientific), showing a small perhaps 6mm bile duct. Biliary sphincterotomy is performed in very careful stepwise fashion as landmarks are unclear and perforation is higher risk in small duct SOD patients. On the other hand, inadequate sphincterotomies offer limited chance of symptom relief. You can see here a patulous sphincterotomy. Next a pancreatic sphincterotomy is performed with the needle knife (Boston Scientific) over the pancreatic stent. Again this is performed cautiously due to the small size of the pancreatic duct. We are reaching along the stent and cutting the fibers deeply. This is a limited pancreatic sphincterotomy due to small pancreatic duct size, and concern for scarring of the pancreatic duct. It is important to document passage of the stent by xray or remove it endoscopically with two weeks or so. We and many other specialized centers perform dual sphincterotomies at the first ERCP in all SOD patients with abnormal pancreatic manometry and frequent or intractable symptoms based on the belief that response rates are better than for biliary sphincterotomy alone.

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Heart sounds S1, S2

Pulmonary adhesions

Fetal heart sound by sonique

Ophthalmoscopic exam

Infant Airway Obstruction and how to deal with

Motor examination of Upper Limb from the USMLE collection