By G. Osmund. Pennsylvania College of Technology. 2019.
In certain cases of arterial spasm adventitial injection of papaverine may cure the condition generic prednisone 40 mg line. In these cases the affected portion is removed and if this segment is small buy generic prednisone, end-to-end suturing may become possible without any tension to the suture line discount prednisone 20mg with amex. If the affected segment is long purchase discount prednisone, a Dacron graft or a reversed long saphenous vein graft may be used to make good the loss of the segment. When the affected segment is small, a longitudinal incision is made over the diseased segment and is made deep till the atheromatous plaque is reached. The diseased intima, atheromatous plaque and the thrombus are removed through a plane of cleavage through the middle of the tunica media. The arteriotomy is then closed with continuous 5/0 polypropylene (prolene) suture with or without a vein patch graft. In case of longer diseased segment, arteriotomies are made only at the upper and lower ends of the diseased segment. An endarterectomy loop is inserted through the lower arteriotomy and is pushed upwards dissecting and separating the atheromatous plaque as far as the upper arteriotomy. Modern knitted prostheses leak even less as they are sealed with gelatin or collagen by the manufacturer. In fact there is probably little to choose between the types of Dacron graft to be used. In aorto-iliac occlusion mostly synthetic grafts are applied, whereas in femoro-popliteal occlusion, autogenous vein graft is mainly used. In case of aorto-iliac occlusion suture material used is monofilament polypropylene — 2/0 or 3/0. In femoropopliteal occlusion at the groin, 4/0 or 5/0 polypropylene is used; whereas in case of further down limb occlusion 7/0 suture material is used. The balloon is inflated with dilute contrast medium to a pressure of 5 to 10 atmospheres for a period of 15 to 30 seconds even upto 1 minute, after which it is deflacted. Expansion of the balloon produces fissures in atheromatous plaques and also ruptures muscle fibres of the tunica media thus widening the lumen and ensuring blood supply to the distal limb. This technique is mainly used in case of arterial occlusions of the iliac artery, superficial femoral or renal artery. Gradually the endothelial lining develops along the fissures in the atheromatous plaque within a few months. The balloon is positioned within the stenosis or occlusion which is confirmed by angiography. The problem is that often the vessel fails to stay adequately dilated after such treatment and in these cases metal stent may be used. In this technique the balloon catheter is introduced through the expanding stent and then the balloon is inflated. There is also a type of self-expanding stent, which is held compressed by a sheath of plastic before application. This procedure is not as good as reconstructive surgery, and is only used when latter type of surgery is not possible. However the advantage of this procedure is that it can be repeated if stenosis recurs. So that blood from the patent femoral artery is carried through the graft to the other femoral artery of the ischaemic side. A Dacron graft connects the common femoral artery to a thromboendarterectomised upper popliteal artery. A vein graft is again connected from this rebored upper popliteal artery to the arteries below the knee. In its upper part it is anastomosed with the axillary artery in an end-to-side fashion. In its lower end it is anastomosed to the femoral artery of the involved limb in the same fashion. By this blood flows sufficiently from the axillary artery to revascularise the lower limb. The thrombus often propagates upto the level of the renal arteries, occluding one renal artery and extending upto near the origin of the superior mesenteric artery. Concomitant coronary or cerebral atherosclerosis occurs in 30 to 50% of patients with symptomatic aorto-iliac disease. Claudication may be symmetric or asymmetric, depending upon the pattern of involvement of the iliac arteries. Rest pain and ulceration almost always indicate additional distal disease particularly in diabetics. Pulsation of the abdominal aorta may be palpable, but may be absent if the abdominal aorta is occluded upto the renal arteries. Systolic bruit is often audible over the aorta or iliac arteries confirming the presence of atherosclerosis. The syndrome probably arises from embolization of fragments of atherosclerotic plaques or thrombi dislodged from the surface of such plaque. For example, mild claudication in a 45 year old patient whose occupation necessitates frequent walking is a strong indication for operation. Whereas a retired patient of 70 with angina pectoris and claudication does not require operation. This may not only increase the walking tolerance, but also may enhance collateral circulation. It is almost proved that claudication improves when smoking is stopped and that the risk of gangrene becomes less than that of the patients who smoke. When the disease is more extensive than this, by-pass graft procedure should be the operation of choice. The peritoneum of the posterior abdominal wall is incised over the front of the aorta. The aorto-iliac bifurcation is clearly dissected out, great care being taken not to damage the wall of the iliac veins which are often firmly adherent to the adjacent arteries. When the diseased segment is short, a long arteriotomy is made over the diseased segment of the aorta and common iliac arteries. A plane of cleavage is found between the atheromatous core and the outer half of the tunica media. The core is removed and the distal intima is inspected to ensure that it is firmly attached to the media. The aorta proximally and the external and internal iliac artery distally are encircled with plastic tapes. Usually the external iliac clamps are applied before those of the abdominal aorta to protect from distal embolization. Incisions are made over the distal common iliac arteries and cleavage planes between the plaques and the media are developed. A longitudinal incision is made into the aorta above the level of the inferior mesenteric artery and an appropriate cleavage plane between the arterial intima and media is indentified. With an arterial stripper, the core of atherosclerotic material is freed proximally. By blunt dissection the aortic and the iliac core can be mobilized and removed in one piece. A diameter smaller than 16 F catheter indicates the necessity of extending endarterectomy to the common femoral arteries. The aortotomy incision is closed with a continuous 5/0 monofilament non-absorbable suture. The iliac arteriotomies are closed similarly with a patch graft of either autologous saphenous vein or prosthetic patch of knitted Dacron. Once blood flow is restored, heparin is neutralized with protamine, giving 1 mg for each mg of heparin. The superiority of the previous operative procedure over this has not been demonstrated conclusively as con comitant aneurysmal disease of the aorta is a definite contraindication to endarterectomy. Usually a Woven Dacron prosthesis is preferred because of firmer adherence of the neointima which forms subsequently in the wall of the graft. The proximal anastomosis is constructed in an end-to-side fashion with a continuous suture of 4/0 monofilament suture. Soft tissue tunnels are formed by blunt dissection anterior and parallel to the iliac vessels, through which the limbs of the prosthesis are brought parallel to the iliac arteries.
Many researches consider the clinical presentation of secretion of diferent metabolites discount 20mg prednisone with amex. Te reabsorption may nephronophthisis with ultrasound picture of medullary renal be across the tubular cells (transcellular) or passively cysts as being characteristic and sufcient to establish the diag- across the tight junctions in between tubular cells (para- nosis without the need for renal biopsy effective prednisone 10 mg. Interstitium: it refers to the “connective tissue” of both medullary renal cysts does not rule out the diagnosis cheap prednisone 40mg mastercard. Autosomal recessive polycystic kidney disease: outcomes from a single-center experience cheap 20 mg prednisone visa. Polycystic kidney disease: etiology, patho- mainly with hematuria and hypertension. When this parenchymal injury causes renal failure due to renal parenchymal fbrosis and impairment of renal functions, the term “renal failure” is atrophy. Examples of renal interstitial disorders include applied to the disease as a progression of parenchymal injury. Renal vascular disorders: typically present with parenchyma 15–25 mm; the pyramids are more hypertension (e. The normal renal volume after and heart disease (patent ductus arteriosus and coarctation adjustment to the body mass index is 231–281. Parenchymal echogenicity is a nonspecifc sign that parenchyma itself (glomerular, tubular, interstitial, or refects nephropathy, which is classifed as the vascular ). Three to fve tongue, gastrointestinal bleeding, lef heart failure, and reproducible waveforms from each kidney are maybe pericarditis. I n acute renal failure, morphological abnormalities in radiologist to characterize the renal status for the referring B-mode are only seen in 11 % of patients. Reduced renal volume is a fbrosis or nephrocalcinosis due to gout, medullary negative prognostic sign and correlates sponge kidney, primary hyperaldosteronism, histopathologically with the degree of atrophy, hyperparathyroidism, glycogenosis, and Wilson’s 4 necrosis, and fbrosis. For hyperechoic corticomedullary junction, this sign is nephropathy, widespread nephrosclerosis, and not specifc to a disease but can be seen in diabetes, end-stage chronic renal failure. Difusely hypoechoic kidney is an uncommon sign that than creatinine clearance and proteinuria, showing can be seen in acute pyelonephritis, lymphoma, and sensitivity (64 %) and specifcity (98 %). In later diagnosed diabetics, the kidney size is normal or stages of the disease, the kidney shrinks (size < 8 cm), enlarged (>13 cm in diameter) due to glomerular and the cortex starts to show increased echogenicity hyperfltration. I n nephrocalcinosis, the hypoechoic medulla appears Doppler sonography is almost always high (>0. A localized area of hyperechoic cortex is detected (arrowhead) with subsequent hyperemia on power Doppler mode (b ) References Fiorini F, et al. Glomerulocystic renal disease: ultra- correction by percutaneous transluminal angioplasty. Parapelvic kidney cysts: a distinguishing feature sound: is it better than renal length as an indicator of renal with high prevalence in Fabry disease. Noncardiac chest pain includes diseases of the great vessels, esophagitis, pneumonia, etc. Angina pectoris is a term used to describe transient myocardial ischemia in the absence of myocardial cell death. Each coronary branch is measured describe myocardial cell death and necrosis due to ischemia. Te score predicts the probability of rosternal chest pain, which radiates to the neck and the lef heart attacks in the next 5–10 years on the current status of shoulder, accompanied by a sensation of numbness in the the patient without treatment modifcations. Associated symptoms include tachycardia, dyspnea, Uncalcifed atherosclerotic plaques take up to 15 years and possibly arrhythmia. Te chest pain in angina pectoris before they are calcifed and visualized in a calcium scoring typically lasts <10 min in duration. Te chest because they are unstable and can be dislodged, initiating a pain typically may last up to 30 min in duration. Te technique depends upon the fact that Calcium scoring is a method that quantifes the athero- gadolinium difuses into the myocardial interstitial spaces sclerotic plaques within the coronary vessels. As long as the myocardial score is used to assess the risk of heart events, not to detect membrane (sarcolemma) is intact, the gadolinium is pumped coronary stenosis. This scenario occurs with normal and viable the coronary arteries, the examiner encircles the plaque by a myocardium. If the myocardium is diseased or infarcted, the cursor, and a special program will measure the plaque atten- gadolinium will difuse inside the extra- and intracellular uation and express it as a number in Hounsfeld units as a compartments, which makes its clearance take longer time 195 5 5. This situation is 5 Post-myocardial infarction calcification and typically seen in patients with long-standing, compromised ventricular dilatation may occur (. Although the perfusion is normally a established afer a long period of hypoperfusion, the muscles are not contracting due to a long period of cardiac muscle ischemia and hypofunction. Second 5 Stunned and hibernating myocardium is visualized as pattern is full-thickness myocardial wall enhancement wall motion abnormalities (akinesia or hypokinesia) (. T is occurs because the arterial pulsation assists in the 5 Pulmonary infarction can appear as a patchy deposition of the cholesterol molecules within the intima. Therefore, the within the arteries evokes the arterial wall to pulsate, result- radiographic signs have to be correlated with the ing in developing atherosclerosis within the pulmonary history and the clinical data. T e bronchial circulation only supplies nutrients and a does not participate in gas exchange in normal situations. A dislodged part of the initial thrombus, mostly from the lower limbs, travels through the venous cir- culation until it blocks an arterial pulmonary vessel in the chest as an embolus, causing pulmonary vascular conges- tion. In small percentage of patients, the unresolved thrombus afer treatment can be incorporated into the vessel wall and covered by a layer of epithelium. This thrombus organization causes intravascular stenosis of the afected lumen, resulting in the development of pulmonary hypertension and cor pul- monale. Hampton’s hump in (a ) ( arrowhead) and basal area of pulmonary parenchymal consolidation due to infarction in (b ) 198 Chapter 5 · Cardiology Signs on Doppler Sonography (most specifc and diagnostic sign), and there is loss of 5 Doppler sonography should be performed for color duplex signal within the vein. The thrombosed vessel may be enlarged, and the 5 Saddle thrombus is a term used to describe a big thrombus may appear hyperdense on non thrombus that abuts over the bifurcation of the main contrast-enhanced images. Aortic dissection is a condition characterized by separa- tion of the aortic intima with presence of blood in a false lumen between the intima and the medial layers of the aortic wall. Aortic wall intimal tear starts typically at sites of highest intramural pressure and wall tension. Afer intimal tear, the blood fow inside the tear dissects its way between the intima and the. Te structure between mosaic pulmonary parenchymal pattern (arrowheads ) and the true and the false lumen is called “intimal fap,” which is pruning of the pulmonary arteries (yellow circle ) the key diagnosis of aortic dissection on radiological exami- nations. This type is man- tion are systemic hypertension, bicuspid aortic valve, aortic aged medically; however, in the current era, even type B is coarctation, and Marfan’s syndrome. Patients typically pres- managed with endovascular stent across the origin of the ent with sudden acute chest pain that is described as “tear- dissection. Debakey Classifcation Aortic Dissection Is Classifed According Type I involves ascending aorta only. Stanford Classifcation Type A: this type involves the ascending aorta, and it is man- D i f erential Diagnoses and Related Diseases 5 aged surgically. This type carries the risk of spontaneous Vascular Ehlers–Danlos syndrome is a disease characterized rupture into the pericardium resulting in pericardial tam- by joint hypermobility, skin abnormalities (e. Patients cular fragility leading to dissection or rupture of medium to with this type can also develop aortic regurgitation (50 % large muscular arteries. Te dissection arises in vascular of dissection is typically just distal to the subclavian artery, Ehlers–Danlos syndrome that occurs typically without pre- near the insertion of the ligamentum arteriosum. Patients present with signs of acute aortic syndrome consist- ing of sudden chest pain that is radiating to the back or chest depending on which part of the aorta is afected. In contrast to aortic dissection, no inti- mal tear fap is identifed in this condition. However, the hematoma can progress into a true dissection if the aortic wall continues to enlarge in thickness by the hematoma >5 cm. There is no intimal focal area of aortic wall thickening due to intramural hematoma fap (. This topic discusses some of the common medical conditions where radi- ology plays an important role in their diagnosis and assessment. In contrast, pseudo-aortic aneurysm is a condition characterized by saccular dilatation of the outer most layers of the aortic wall (media and/or adventitia) with an intact inner wall layer (intima). In contrast, pseudo-aortic aneurysm usually arises at three basic levels: the aortic root, the aortic isthmus, and the aortic diaphragm.
Weak bulk laxative or cathartics is best in this condition discount 20mg prednisone free shipping, (c) Nitric oxide is a neurotransmitter which induces relaxation of the internal sphincter 20mg prednisone otc. Glyceryl trinitrate is a nitric acid donor and is applied as an ointment to the anal canal to produce the relaxation of the internal sphincter prednisone 10mg discount. Moreover glyceryl trinitrate improves blood flow to the area which further helps in healing of the fissure cheap prednisone 40mg overnight delivery. But glyceryl trinitrate has a few side effects of which severe headache is of main concern. This technique of using xylocaine lubricant and then dilating the anal canal with dilator should be practiced twice a day for a month. By this time the anal fissure may be healed, (f) Injection of long acting anaesthetic solutions promotes little relief and has significant complications. Under general anaesthesia and the patient in lithotomy position the index and the middle fingers of each hand are inserted simultaneously into the anus and pulled apart to give maximal anal dilatation. Any constricted bands should be well stretched and the fibrosis around the fissure should be ironed out. The patient can go home the same day, but should be warned that there may be some faecal incontinent for 10 days. When the chronic fissure is with excessive fibrosis and skin tag, there is every chance that anal dilatation will be a failure. The fibres of the internal sphincter will be seen running transversely in its floor. It must be remembered that only superficial fibres of the internal sphincters are divided and not the entire thickness of the internal sphincter. Postoperative treatment includes liquid diet for 2 days and the bowel is moved on 3rd day. After moving bowel a daily hip bath and passage of an anal dilator are required till the wound is absolutely healed. The only disadvantage of this operation is a prolonged convalescent period of 7 to 10 days and in occasional cases there may be persistent mucous discharge. Though it is said that the convalescent period is less in this operation, yet this operation is handicapped in the sense that excision of the ulcer or biopsy cannot be performed in one go. But in this operation the convalescent period is less, similarly hospital stay may be even 4 days. Even anal skin has been lifted up to cover the defect of the anal canal following excision of the ulcer. This technique has become popular recently as there is little risk of damage to the underlying internal sphincter, so there is no chance of incontinence. Only treatment of a few polyps which are more often seen in the rectum is described below. Usually it possesses a long pedicle and the tumour can be delivered through the anus. If the tumour is high up in the rectum or the pedicle is short, a snare may be used. Yet when an adenomatous polyp is detected, it should be removed, however little chance of malignant transformation there may be. When there is a long pedicle and the polyp can be delivered through the anus, the pedicle is transfixed and the tumour is excised. When the-growth has small pedicle or is higher up, the tumour is removed with a snare through sigmoidoscope. In case of sessile adenoma the tumour can be removed either by submucous dissection per annum or the tumour may be fulgurated with an insulated electrode passed through a sigmoidoscope. The malignant change can be assessed by palpation with the finger — any hard area should be assumed to be malignant and should be biopsied. This tumour discharges mucus and rarely it is so profuse, which is high in potassium, as to cause electrolyte imbalance and fluid loss. Small tumours may be excised by submucous dissection per annum or by sleeve resection from above. In this method a large operating sigmoidoscope is introduced, the rectum is distended with C0 (carbon dioxide) insufflation. The image of the operation field can be displayed on a monitor through2 a camera inserted via the sigmoidoscope. The lesion is excised with specially designed instrument observing the monitor screen. It is also a submucous tumour which appears as a constricting lesion at the rectosigmoid junction. Diagnosis is not difficult as dysmenorrhoea with rectal bleeding is the only peculiar symptom of this condition. On sigmoidoscopy the lesion is seen at the rectosigmoid junction as reddish projection into the lumen with the mucous membrane intact. Treatment is contraceptive pill which inhibits ovulation and amelioration of symptoms. Anterior resection or sphincter conserving operation is well suited for this purpose. Three varieties of adenocarcinoma can be seen according to their differentiation, (i) Well differentiated variety, (ii) averagely differentiated variety and (iii) anaplastic or undifferentiated variety. It may appear either from mucoid degeneration of adenocarcinoma or as a primary mucoid carcinoma. The mucus lies within the cell displacing the nucleus to the periphery like a signet ring appearance. Primary colloid carcinoma grows rapidly, metastasises early and possesses a poor prognosis. Longitudinal spread is restricted to a few centimetres except in anaplastic tumours. It takes about 6 months to involve1A th of the circumference and about 1 Vi to 2 years to involve the whole circumference of the rectum. Then the spread involves the full thickness of the rectum but is still limited by the fascia propria (perirectal fascia). Growth takes a long time to penetrate fascia propria and it is rare before 18 months from the commencement of the disease. Once the fascia propria is penetrated, the growth is liable to involve the adjoining structures which are as follows : Anteriorly — in males the prostate, seminal vesicles and the bladder; in females the vagina and the uterus. Laterally— the ureter may be involved in either sex causing secondary hydronephrosis. As soon as the muscles of the rectum are involved, there is chance of lymphatic spread. It must be remembered that enlargement of the draining lymph nodes does not mean that it is secondarily involved. Enlargement of lymph nodes may occur from secondary infection which is not infrequent. Next lymph nodes to be affected are the pararectal nodes of Gerota (same as paracolic nodes). The intermediate nodes are situated along the lower part of the superior rectal artery and the main nodes are at the origin of the inferior mesenteric artery. The peculiarity of the lymphatic spread of rectal carcinoma is that the spread is mainly upwards as the lymphatics move mainly in that direction. Carcinoma ofthe rectum above the peritoneal reflection spreads in an upward direction first involving the intermediate nodes and then the main nodes. Carcinoma below the peritoneal reflection to within 1 to 2 cm ofthe anal orifice spreads mainly in the upward direction but the first nodes involved are the pararectal nodes of Gerota, then the intermediate nodes and lastly the main nodes. Carcinoma between 4 to 8 cm from the anus spreads mainly in the lateral direction along the lymphatics that accompany the middle rectal vein, as this portion of the rectum is supplied by the middle rectal artery. Carcinoma involving 1 to 2 cm of the anal orifice usually spreads downwards to the inguinal group of lymph nodes as the area of anal canal below the dentate line is drained into the inguinal group of lymph nodes. Widespread and atypical lymphatic permeation may occur in case of anaplastic carcinoma.
Stones in the renal pelvis and calyces are in ideal location for this treatment as these are surrounded by fluid purchase prednisone australia. However discount prednisone 20 mg online, clinically significant haematuria or subcapsular/perirenal haematoma is rare purchase prednisone online. Lung tissue is sensitive to shock waves and needs to be out of the blast path or shielded prior to treatment cheap prednisone on line. A self retaining stent may be placed in the ureter so that the fragments of stone can pass without obstruction. The only excep tions are pregnant women, abdominal aortic aneurysms and uncorrectable coagulation disorders. There seems to be no long term effects on renal function or glomerular filtration rate. Third generation machines, with improvements in shock wave energy range and integration of the shock wave source and imaging are now available, but the main advantages seem to be economic and in ease of use. Following dilata tion the bladder is emptied and the ureteroscope is passed through the ureteric orifice guided by the presence of a previously placed guidewire. However flexible ureteroscopy allows better access to the proximal ureter and kidney where rigid instruments are unable to negotiate. Later stricture formation is also an uncommon complication (less than 5%) and can be managed by balloon dilatation. Obstruction may be required to be relieved with persistent symptoms and infections. The main complication is ureteric obstruction secondary to the passage of stone frag ments. If staghom calculi are asymptomatic and the general health of the patient is poor with a good second kidney, conservative treatment can be adopted unless there is sepsis, pain or loss of function. Removal of stone is indicated when it is presumed that it cannot be naturally eliminated and may cause obstruction and progressive renal damage. The different operations that may be performed in cases of renal calculus are — (a) Pyelolithotomy, i. This may be required when a stone in the calyx is so much impacted that it cannot be removed through the pyelotomy incision, so a second incision through the renal parenchyma may be necessary. Staghom calculus is often silent and better be left alone if the kidney function has already become zero. When the function of the kidney is still good, an attempt may be made to remove this calculus which is very difficult and may require Gigli saw to break the calculus and remove it through pyelo- and nephrolithotomy incisions. The kidney is well mobilised and drawn towards the wound margin, so that its posterior surface is well exposed. The kidney is grasped in the left hand, so that the tips of the index and middle fingers lie beneath the renal pelvis and the thumb above it which prevents the stone from slipping into one of the calyces. The area is surrounded widi gauze packs and an incision is made on the posterior wall of the pelvis directly over the stone in the long axis of the renal pelvis. The incision should not be extended to the pelvi-ureteric junction lest a stricture may cause subsequent obstruction. The stone is removed with suitable forceps or scoops without bruising the surrounding tissue. After this, a catheter may be introduced into the pelvis and a forceful stream of normal saline is injected to wash out any stone debris which might be present within the pelvis. If pyelography showed a stone in a calyx, the stone should be located by the little finger intro duced into the renal pelvis. If possible, it should be removed through this route by grasping with suitable forceps. If the stone cannot be removed through the incision in the renal pelvis, a small cortical incision is made over the stone which is steadied by the little finger within the pelvis. This stone is taken out with a suitable forceps again taking care not to damage the neck of calyx. Thus pyelolithotomy operation is added with nephrolithotomy to remove stones from the renal calyces. After this the cortical incision is closed with an interrupted fine catgut suture, not too tight to cut the renal cortex. A bougie is introduced through the renal pelvis into the pelvi-ureteric junction, to be sure that there is no obstruction hereabout. If the kidney is not infected, this incision in the renal pelvis is closed with interrupted sutures of fine catgut. If the kidney is grossly infected, a nephrostomy is performed before closing the incision in the renal pelvis. In these cases, the lower end of the incision on the renal pelvis may be extended along the medial border of the kidney for wider exposure. Still wider exposure has been advocated by Gilvernet who dissected the posterior wall of the renal pelvis into the renal sinus at a plane between the pelvis and calyces on one side and the branches of renal vessels on the other side. The incision is now possible to be continued into the neck of the calyces for a direct view into the calyx and to facilitate the removal of large stones. This technique can be performed with ease and taking time when local hypothermia of the kidney is brought forth either by ice-chips in polythene bag or liquid nitrogen circulating through coils placed on the kidney. This line actually demarcates between the areas supplied by the anterior and posterior branches of the renal artery — so this is a relatively avascular line. Even if the stone is not palpable, the incision is placed according to the position determined by radiography. Again care must be taken not to incise at the neck of the calyx to prevent excessive haemorrhage. The length of the incision should be such that it should not be too long or should not be too small to bruise the surrounding tissue during the removal of the stone. When all stones have been removed, the cavity of the kidney is washed with normal saline in order to remove any debris which may be left behind. The renal cortical inci sion is closed by interrupted catgut sutures which are tied not too tightly to cut out the cortex. If the surgeon anticipates chance of bleeding even after suturing the cortex, the sutures should be tied over a piece of muscle graft or oxycel. If there is gross infection present within the kidney, a nephrostomy should be carried out by pushing a self-retaining catheter through this incision into the renal pelvis. This is particularly the case in case of stone in the lower most calyx (lower pole). But these calculi are notorious for recurring, so nephrectomy is often the best treatment. It must be remembered that ihe contralateral kidney must be proved healthy before considering this operation. These cases are — (a) During pyelolithotomy if the renal artery is injured and the torrential bleeding cannot be controlled, nephrectomy may be considered. Similarly after nephrolithotomy if haemorrhage cannot be controlled or if secondary haemorrhage starts after a few days of operation, nephrectomy may be considered. The indications of such operation are — (i) Stone with pyonephrosis when the patient is too ill to stand any other operation. This operation has been described in detail in ‘A Practical Guide to Operative Surgery’. Usually the kidney with the better function is operated on first and the operation on the contralateral side is postponed for no less than 2 months to allow adequate time for the first kidney to recover. If the kidneys are without infection or without any symp tom and particularly, if the patient is elderly it is probably better to avoid any operation. The main disadvantage is that the access is limited being bounded above by the last rib and below by the iliac crest. Position of the patient — The patient lies on his sound side with its back brought well over towards the edge of the table. The loin overlies the bridge of the table, which can be screwed up to increase the space between the costal margin and the iliac crest. To maintain the stability of this position, the lower hip and the knee are kept flexed and the upper leg is extended over them. Sand-bags are kept in position with a wide strapping to prevent the patient from rolling over. The upper arm is supported on an arm rest to prevent the shoulder from sagging forwards and to relieve the chest of compression by the weight of the arm. In case of obese patients or when a large kidney has to be operated on, the incision can be extended forwards as far as the lateral border of the rectus muscle. The lower fibres of the latissimus dorsi are cut along the line of the incision and while this incision is extended forwards, it cuts the most superficial i.