Imageing Antegrade Pylogra

Antegrade Pyelogram

Objectives

In cases of:

•   Poor or nonvisualised of urinary system on excretory urography.

•   Opacification of upper urinary tract for evaluating site and nature of obstruction.

•   To obtain urine specimen for cytology or culture.

Patient Preparation

•   Blood prothrombin time

•   Antibiotic cover if required

•   Fasting for 6 hours

•   Surgical cleaning and draping of the site of drainage.

Position

Prone with sandbag under abdomen.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 1% xylocaine, 10 ml

•   General anesthesia may be required for infants and uncooperative children.

Instruments

•   22 G, 20 cm long needle with stilet

•   20 ml syringe

•   50-100 ml of urografin 60%.

Procedure

   1.  Sonographic guidance.

   2.  Choose calyx to be punctured.

   3.  Puncture should be laterally as possible, through renal parenchyma.

   4.  Puncture chosen calyx under screening guidance with
22 G needle.

   5.  Check position of needle tip within the pelvicalceal system.

   6.  Remove stilette of needle.

   7.  Aspirate urine with a 20 ml syringe.

   8.  Measure volume of urine aspirated.

   9.  Urine may be sent for bacteriology, cytology, chemistry.

10.  Inject urografin through the needle, under US monitoring. Total volume of urografin injected should be less than the volume of aspirated urine.

11.  Withdraw the needle.

12.  Shift patient to the fluoroscopy site.

13.  Radiographs of the opacified renal collecting system various position, including delayed errect films.

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Imaging percutaneous intrabdominal pelvic abcess drainage

IMAGING PROCEDURE

Percutaneous Intraabdominal/
Pelvic Abscess Drainage

Objective

In cases of suspected intraabdominal abscess:

•   Diagnostic aspiration of intraabdominal fluid collections for microbiologic diagnosis

•   Drainage of postoperative/spontaneous abscesses

•   Drainage of liver/visceral abscesses

•   Prevent impending rupture of visceral abscesses.

Patient Preprocedure Preparation

•   Blood prothrombin time

•   Antibiotic cover if required

•   Fasting for 6 hours

•   Surgical cleaning and draping of the site of drainage.

Position

Supine and related to location of abscess.

Anesthesia

•   IV sedation with diazepam

•   Local infiltration analgesia with 1% xylocaine 10 ml

•   General anesthesia may be required for infants and uncooperative children.

Instruments

•   18 G, 20 cm long needle with stilet (Fig. 22.1)

•   0.035" or 0.038" diameter, 100 cm long J-shaped guidewire

•   Sterile surgical blades

•   Graded teflon dilators 7F-12F

•   Drainage catheter 8F-12F. Pigtail with multiple holes; or Malecot catheter/Sump drainage catheter with needle-introducer

•   Suture and needle for fixation of catheter

•   Adhesive tape

•   Connector (Fig. 22.2)

•   3-way stopcock (Fig. 22.3)

•   Negative suction bag (Romovac)

•   Biopsy needle (Fig. 22.4).

Procedure

   1.  Patient positioned according to location of abscess, such that puncture site is easily accessible.

   2.  Sonographic or CT guidance.

   3.  Puncture site chosen under sonographic/CT guidance with 18 G needle.

   4.  Follow needle till its tip is well inside the abscess cavity. Remove stilet of needle.

   5.  Aspirate 2-5 ml of fluid; store in sterile vial for microbiologic analysis.

   6.  Pass guidewire through needle. Check position of guidewire within abscess cavity.

   7.  Stab incision along needle tract.

   8.  Remove cannula of needle.

   9.  Dilate tract to one size above catheter size.

10.  Place catheter in abscess cavity over guidewire.

11.  Remove guidewire.

12.  Connect catheter to negative suction collection system.

13.  Suture catheter and skin wound.

14.  Secure catheter to skin with adhesive tape.

Postprocedure

1.  Flush abscess cavity with antibiotic saline periodically.

2.  Remove catheter when drainage stops completely.

Alternative Technique

1.  This technique is suitable for larger fluid collections, and requires an experienced operator.

2.  Local analgesia.

3.  Stab incision at site.

4.  Use needle/introducer/catheter assembly, e.g. pigtail catheter/Malecot catheter/Sump catheter.

5.  Insert assembly through stab incision, and direct toward abscess cavity.

6.  When needle tip is well inside the cavity, withdraw needle-introducer, leaving catheter in cavity.

7.  Aspirate some fluid for bacteriologic diagnosis.

8.  Connect catheter to negative suction system and follow remaining steps as above.

Complications

Hemorrhage.

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Imaging procedures Introduction

INTRODUCTION

Procedures to enhance imaging have been made possible by the:

•   Increase in number of modalities for imaging internal organs, i.e. radiology, ultrasound, CT scan

•   Enhanced accuracy in pinpointing internal organs

•   Improved devices available for assess to internal organs

•   Antibiotics to cover these procedures.

Procedure Room

It is located in the radiology department. The required imaging equipments are available in that room. The other essential requirements are:

•   Oxygen supply

•   Suction apparatus

•   Boyle’s apparatus

•   Emergency tray

     a.  Endotracheal tube

     b.  Laryngoscope

     c.  Ambu bag

     d.  Emergency drugs

     e.  IV set

     f.   Normal saline, dextrose saline

     g.  Syringes and needles

•   Procedure tray

     a.  Sterile gloves

     b.  Sterile coupling jelly

     c.  Savlon

     d.  Betadine

     e.  Spirit

     f.   Sterile gauze

     g.  Xylocaine

     h.  Heparin

     i.   Slides

     j.   Alcohol bottles

     k.  Formalin vials

     l.   Surgical blades

     m. Sutures and needles

     n.  Adhesive tape

•   Sterile set containing:

     a.  Drapes

     b.  Steel bowls

     c.  Artery forceps

     d.  Gauze

     e.  Side tray for spare instruments

     f.   Sponge forceps (Fig. 9.3)

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Pediatric Surgery Intussusception

Intussusception

Definition

In case of entry of the ileum with its mesentery into the colon intussusception resulting in a mechanical bowel obstruction.

Objectives

•   To open the abdomen to inspect the bowel

•   To reduce the intussusception and relieve obstruction

•   To resect and anastomose, if the bowel has become gangrenous.

Position

Supine.

Anesthesia

General with endotracheal intubation.

Procedure

   1.  Right transverse upper abdominal 7-8 cm long incision.

   2.  Avoid the subcutaneous tissues and muscles.

   3.  Open the peritoneal cavity.

   4.  Identify the intussusception mass.

   5.  Suck out the peritoneal fluid, if any.

   6.  Reduce the intussusception by “milking” from distal to proximal side, without injury to the bowel.

   7.  Resect and anastomoses the bowel, if it fails to reduce completely or found gangrenous.

   8.  Check for free flow of intestinal contents.

   9.  Check for any associated lesion, i.e. lymphoma Meckles diverticulum.

10.  Close the abdominal wound in layers.

Instruments

General pediatric set.

Sutures

•   Catgut       2/0, 3/0, 4/0

•   Silk             3/0, 4/0

•   Nylon         4/0

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