Act as a Surgeon 🧠🔪

"Both are acceptable, but I prefer a stapled side-to-side functional end-to-end anastomosis if available, as studies show it provides a wider lumen, carries a lower rate of stricture, and significantly shortens operative time compared to hand-sewn closure."

"I will use the Purse-string skin closure technique. Since stoma sites are heavily contaminated, closing them linearly results in high wound infection rates. Purse-string closure leaves a small central aperture for drainage, which significantly lowers the risk of surgical site infections (SSI)."

"My primary concern is an Anastomotic Leak. Tachycardia is often the earliest clinical sign of an impending leak and localized peritonitis, even before a fever develops. I would immediately assess the patient for abdominal rigidity, check his vitals, and order urgent labs and a CT scan with oral contrast."

"This is most likely Post-operative Ileus (paralysis of the bowel). I would manage him conservatively using the 'Drip and Suck' method: make him NPO (nothing by mouth), insert a Nasogastric Tube (NGT) for decompression, provide IV fluids with electrolyte correction, and encourage early ambulation."

"This is a 45-year-old male patient, 3 months post-laparotomy for adhesive bowel obstruction. My provisional diagnosis is a functioning temporary RUQ stoma, mostly an ileostomy, with a radiologically proven patent distal bowel loop. My plan is to admit him electively for stoma closure and reversal surgery."

"There are two main reasons, sir. First, there might have been a compromised bowel loop—either ischemic or gangrenous—due to strangulation, requiring resection, where a primary anastomosis was deemed unsafe in an emergency, unstable patient with fecal contamination. Second, in cases of severe bowel edema and dilated loops, creating a temporary diverting stoma is safer to protect the patient from catastrophic anastomotic leaks."

"We must wait at least 6 to 12 weeks for two critical reasons: First, to allow peritoneal inflammation and dense adhesions to resolve, converting them into soft, mature adhesions that are safe to dissect without risking bowel perforation. Second, to optimize the patient’s nutritional and hydration status, as ileostomy patients lose significant fluids and proteins initially."

"Because a strangulated or obstructed inguinal or femoral hernia is one of the most common causes of intestinal obstruction. Skipping the groin exam means we could miss an underlying hernia, which must be repaired before or during the stoma reversal to prevent a recurrence of the obstruction."

"DRE is mandatory, sir, to assess anal sphincter tone and ensure rectal patency. If the patient has a weak sphincter or fecal incontinence, closing the stoma will cause severe fecal leakage and misery for the patient. We must ensure the distal mechanism functions perfectly before diverting stool back to it."

"A Water-soluble contrast enema (Gastrografin study) of the distal limb. It is crucial to confirm distal bowel patency and exclude any strictures or leaks. If we close the stoma against a distal obstruction, it will lead to an immediate anastomotic blowout."

"No, sir. This indicates severe hypoalbuminemia and malnutrition. Operating on a patient with an albumin level below 3.5 g/dL carries an extremely high risk of anastomotic leak and wound dehiscence because the tissues lack the protein needed to heal. I would postpone the surgery and optimize his nutrition via hyperalimentation first."

On general examination, the patient is a middle-aged male, looking well, cooperative, hemodynamically stable, and afebrile. He is well-hydrated with moist mucous membranes, no conjunctival pallor, no scleral icterus, no clubbing, and no palpable peripheral lymphadenopathy. His vital signs are all within normal limits. On abdominal examination ,the patient was placed in a supine position. Ideally, the exposure should be from the nipples to the mid-thighs to properly evaluate the groin areas; however, full exposure was deferred to maintain the patient's privacy, and he was exposed from the xiphoid process to the pubic symphysis with proper draping, Starting with inspection, the abdomen is flat, moving equally with respiration, with a well-healed midline laparotomy scar and a well-healed right iliac fossa scar from his previous appendectomy. There is a stoma located in the right upper quadrant; the stoma mucosa is pink, moist, and well-budded with no signs of prolapse, retraction, or ischemia, and the peristomal skin is completely intact with no erythema or excoriation. There are no visible pulsations, dilated veins, or visible peristalsis, and cough impulse is negative at all scar sites. On palpation, the abdomen is soft, completely lax, and non-tender globally. There is no superficial or deep tenderness, no guarding, and no rigidity. No organomegaly or abnormal masses are palpable. On percussion, there is normal resonant tympany over the gas-filled bowel loops, with normal liver dullness and an empty Traube's space, and there is no shifting dullness or fluid thrill. On auscultation, normal bowel sounds are heard all over the abdomen with no vascular bruits or friction rubs. To complete my examination,ideally, I should examine the external genitalia and groin status, but this was skipped out of respect for the patient's privacy. Finally, a Digital Rectal Examination (DRE) was performed, which revealed normal anal sphincter tone, a patent distal rectum, and an empty rectal vault with no palpable masses or strictures. Additionally, checking his recent outpatient Gastrografin contrast enema report is essential to confirm the patency of the distal limb prior to this reversal."

"Today I am presenting Mr. Ali, a 45-year-old married Yemeni construction worker, who lives in Sa'adah and is a chronic Qat chewer with no special habits of medical significance. He was admitted to our surgical ward electively 2 days ago, complaining of a temporary abdominal stoma for the past 3 months, and is currently seeking elective stoma closure and reversal. Regarding the history of the presenting illness, the patient’s condition started 3 months ago when he presented to the emergency department with an acute onset of severe, generalized, colicky abdominal pain associated with progressive abdominal distension, multiple episodes of bilious vomiting, and absolute constipation for 3 days. He underwent an emergency exploratory laparotomy, during which intraoperative findings revealed mechanical bowel obstruction secondary to extensive postoperative adhesions from an appendectomy done 10 years ago. Adhesiolysis was performed, and due to questionable viability of a segment of the distal ileum, a temporary diverting stoma was created in the right upper quadrant. Post-operatively, his recovery was smooth, and he was discharged home on day 7. Over the past 3 months, the stoma has been functioning well with 3 to 4 times daily evacuation of a semi-formed, pasty consistency output, with no history of high-output diarrhea, bleeding from the stoma, or painful peristomal skin irritation. Currently, the patient is completely asymptomatic; he tolerates a regular oral diet, has maintained a stable body weight, and denies any abdominal pain, distension, nausea, vomiting, or changes in his general health. A recent outpatient water-soluble contrast study was performed and confirmed complete patency and integrity of the distal bowel loop with no evidence of stricture or leak. Review of other systems, including the cardiovascular, respiratory, central nervous, and urinary systems, is completely unremarkable with no symptoms of clinical significance. Regarding his past medical and surgical history, he underwent an open appendectomy 10 years ago through a Gridiron incision, which was complicated by the recent adhesive bowel obstruction. He has no history of chronic illnesses such as hypertension or diabetes, no history of blood transfusions, and no known drug allergies. Family and social history reveal that he lives with his wife and four children in a house with adequate sanitation and clean water supply. There is no family history of gastrointestinal malignancies, inflammatory bowel disease, or similar conditions.

قد زين الأشعار اسم المصطفى وبــه علا بين الورى الإبـــداعُ..

يتسابقون بمدحهم لشفيعهم في شعرهم يشدو به الإجماعُ..

هيَّا معي حيّوا الفضيل تحيةً حتى تسرّ من اللقـــاء بقـــاعُ..

درب التوسط لا غلوٌ أو جفا إذ يقتدي في فعله الأتبــــاعُ..

فصلاتنا وسلامنا صوب الهدى في طيبة العظمى هناك مُذاعُ..ﷺ

🔶B. Chronic Pancreatitis

▪︎Continuous Inflammation Of The Pancreas Results in Progressive & Irreversible Destruction Of Pancreatic Tissue & Loss Of Function

🔹Causes Of Chronic Pancreatitis

🔹Clinical Features Of Chronic Pancreatitis

🔹Dx Of Chronic Pancreatitis

🔹Mx Of Chronic Pancreatitis

🔹Complications Of Acute Pancreatitis

🔶A. Systemic Complications (1st Week)

🔶B. Local Complications (2nd Week)

🔹Mx Of Acute Pancreatitis

*Don't Give Morphine (Biliary Spasm)

▪︎Gallstones Are The Cause Of Pancreatitis ▪︎Patient Develop Jaundice Or Cholangitis (Bile Ducts Inflammation) ▪︎Dilated Common Bile Duct

▪︎It's Inflammation Of The Pancreatic Tissue Due To Premature Activation Of Pancreatic Enzymes Within The Pancreas Leading To AutoDigestion Of The Pancreas & Systemic Inflammatory Response

🔰Types Of Pancreatitis

🔶A. Acute Pancreatitis

🔹Clinical Features Of Acute Pancreatitis

🔹Severity Of Acute Pancreatitis

▪︎20-50% Mortality Rate

🔰Upper GIT Bleeding

🔹Causes

📍A. From Esophagus

📍B. From The Stomach

📍C. From Doudenum

🔰Lower GIT Bleeding

🔹Causes 📍A. Severe Acute

📍B. SubAcute & Chronic

🔹Presentation Of GIT Bleeding 🔰Upper

🔹Ix & Mx Of GIT Bleeding

🔹Mx Of Cholecystitis

🔹Indications for Cholecystectomy

🔹Complications Of Cholecystitis

🔴Gallstones (Cholelithiasis) & Cholysystitis

🔹Risk Factors For Gallstones Formation (Fat/Fertile/Female/Forty)

🔹Clinical Features Of Gallstones

🔹Types Of Cholysystitis

🔹Dx Of Acute Cholecystitis

🔹DDX Of Acute Cholecystitis

هذه هي ثمرة التدريس الحقيقي، وهذا هو الدكتور الذي يستحق أن يُوصف بالمثالي ..🤍✨.