Renal transplant

Kidney transplantation or renal transplantation is the organ transplant of a kidney into a patient with end-stage renal disease. Kidney transplantation is typically classified as deceased-donor (formerly known as cadaveric) or living-donor transplantation depending on the source of the donor organ. Living-donor renal transplants are further characterized as genetically related (living-related) or non-related (living-unrelated) transplants, depending on whether a biological relationship exists between the donor and recipient. Exchanges and chains are a novel approach to expand the living donor pool.

Indications

The indication for kidney transplantation is end-stage renal disease (ESRD), regardless of the primary cause. This is defined as a glomerular filtration rate <15ml/min/1.73 sq.m. Common diseases leading to ESRD include malignant hypertension, infections, diabetes mellitus, and focal segmental glomerulosclerosis; genetic causes include polycystic kidney disease, a number of inborn errors of metabolism, and autoimmune conditions such as lupus. Diabetes is the most common cause of kidney transplantation, accounting for approximately 25% of those in the US. The majority of renal transplant recipients are on dialysis (peritoneal dialysis or hemofiltration) at the time of transplantation. However, individuals with chronic renal failure who have a living donor available may undergo pre-emptive transplantation before dialysis is needed.

bone marrow transplantation

Hematopoietic stem cell transplantation (HSCT) is the transplantation of multipotent hematopoietic stem cells, usually derived from bone marrow, peripheral blood, or umbilical cord blood. It is a medical procedure in the fields of hematology, most often performed for patients with certain cancers of the blood or bone marrow, such as multiple myeloma or leukemia. In these cases, the recipient's immune system is usually destroyed with radiation or chemotherapy before the transplantation. Infection and graft-versus-host disease is a major complication of allogenic HSCT.

Hematopoietic stem cell transplantation remains a dangerous procedure with many possible complications; it is reserved for patients with life-threatening diseases. As the survival of the procedure increases, its use has expanded beyond cancer, such as autoimmune diseases.

Donor registration and recruitment

At the end of 2012, 20.2 million people had registered their willingness to be a bone marrow donor with one of the 67 registries from 49 countries participating in Bone Marrow Donors Worldwide. 17.9 million of these registered donors had been ABDR typed, allowing easy matching. A further 561,000 cord blood units had been received by one of 46 cord blood units from 30 countries participating. The highest total number of bone marrow donors registered were those from the USA (8.0 million), and the highest number per capita were those from Cyprus (15.4% of the population).

Within the United States, racial minority groups are the least likely to be registered and therefore the least likely to find a potentially life-saving match. In 1990, only six African-Americans were able to find a bone marrow match, and all six had common European genetic signatures.

Africans are more genetically diverse than people of European descent, which means that more registrations are needed to find a match. Bone marrow and cord blood banks exist in South Africa, and a new program is beginning in Nigeria.

Liver transplant

Liver transplantation or hepatic transplantation is the replacement of a diseased liver with some or all of a healthy liver from another person (allograft). The most commonly used technique is orthotopic transplantation, in which the native liver is removed and replaced by the donor organ in the same anatomic location as the original liver. Liver transplantation is a viable treatment option for end-stage liver disease and acute liver failure. Typically three surgeons and two anesthesiologists are involved, with up to four supporting nurses. The surgical procedure is very demanding and ranges from 4 to 18 hours depending on outcome. Numerous anastomoses and sutures, and many disconnections and reconnections of abdominal and hepatic tissue, must be made for the transplant to succeed, requiring an eligible recipient and a well-calibrated live or cadaveric donor match..

Indications

Liver transplantation is potentially applicable to any acute or chronic condition resulting in irreversible liver dysfunction, provided that the recipient does not have other conditions that will preclude a successful transplant. Uncontrolled metastatic cancer outside liver, active drug or alcohol abuse and active septic infections are absolute contraindications. While infection with HIV was once considered an absolute contraindication, this has been changing recently. Advanced age and serious heart, pulmonary or other disease may also prevent transplantation (relative contraindications). Most liver transplants are performed for chronic liver diseases that lead to irreversible scarring of the liver, or cirrhosis of the liver. Some centers use the Milan criteria to select patients with liver cancers for liver transplantation

Nephrectomy (laparoscopic)

Nephrectomy is the surgical removal of a kidney. See below for partial nephrectomy.

Procedure

The surgery is performed with the patient under general anesthesia. A kidney can be removed through an open incision or laparoscopically. For the open procedure, the surgeon makes an incision in the side of the abdomen to reach the kidney. Depending on circumstances, the incision can also be made midline. The ureter and blood vessels are disconnected, and the kidney is then removed. The laparoscopic approach utilizes three or four small (5–10 mm) cuts in the abdominal and flank area. The kidney is completely detached inside the body and then placed in a bag. One of the incisions is then expanded to remove the kidney for cancer operations. If the kidney is being removed for other causes, it can be morcellated and removed through the small incisions. Recently, this procedure is performed through a single incision in the patient's belly-button. This advanced technique is called single port laparoscopy.

In January 2009, a woman who had previously had a hysterectomy was able to donate a kidney and have it removed through her vagina. The operation took place at Johns Hopkins Medical Center. This is the first time a healthy kidney has been removed via this method, though it has been done in the past for nephrectomies carried out due to pathology. Removing organs through orifices prevents some of the pain of an incision and the need for a cosmetically unappealing larger scar. Any advance which leads to a decrease in pain and scarring has the potential to boost donor numbers.This operation also has taken place at the Cleveland Clinic. The first transvaginal Nephrectomy actually took place at the Cleveland Clinic in Cleveland Ohio.

For some illnesses, there are alternatives today that do not require the extraction of a kidney. Such alternatives include renal embolization for those who are poor candidates for surgery, or partial nephrectomy if possible.

Occasionally renal cell cancers can involve adjacent organs, including the IVC, the colon, the pancreas or the liver. If the cancer has not spread to distant sites, it may be safely and completely removed surgically via open or laparoscopic techniques.

Indications

There are various indications for this procedure, such as renal cell carcinoma, a non-functioning kidney (which may cause high blood pressure) and a congenitally small kidney (in which the kidney is swelling, causing it to press on nerves which can cause pain in unrelated areas such as the back). Nephrectomy for renal cell carcinoma is rapidly being modified to allow partial removal of the kidney. Nephrectomy is also performed for the purpose of living donor kidney transplantation. A nephroureterectomy is the removal of a kidney and the entire ureter and a small cuff of the bladder for urothelial cancer of the kidney or ureter.

After care

Pain medication is often given to the patient after the surgery because of pain at the site of the incision. An IV with fluids is administered. Electrolyte balance and fluids are carefully monitored, because these are the functions of the kidneys. It is possible that the remaining kidney does not take over all functionality. A patient has to stay in the hospital between 2 and 7 days depending on the procedure and complications.

Gastrectomy

A gastrectomy is a partial or full surgical removal of the stomach.

Indications

Gastrectomies are performed to treat cancer and perforations of the stomach wall.

In severe duodenal ulcers it may be necessary to remove the lower portion of the stomach called the pylorus and the upper portion of the small intestine called the duodenum. If there is a sufficient portion of the upper duodenum remaining a Billroth I procedure is performed, where the remaining portion of the stomach is reattached to the duodenum before the bile duct and the duct of the pancreas. If the stomach cannot be reattached to the duodenum a Billroth II is performed, where the remaining portion of the duodenum is sealed off, a hole is cut into the next section of the small intestine called the jejunum and the stomach is reattached at this hole. As the pylorus is used to grind food and slowly release the food into the small intestine, removal of the pylorus can cause food to move into the small intestine faster than normal, leading to gastric dumping syndrome.

Adenoidectomy

Adenoidectomy surgical removal of the adenoids for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches. The surgery is less commonly performed in adults in whom adenoids are considered vestigial and purposeless. It is most often done on an outpatient basis under general anesthesia. Post-operative pain is generally minimal and reduced by icy or cold foods. The procedure can be combined with tonsillectomy if indicated and recovery time can range from several hours to two or three days (though as age increases so does recovery time).

Adenoidectomy is not often performed under one year of age as adenoid function is part of the body's immune system but its contribution to this decreases progressively beyond this age.

Indications

The indications for adenoidectomy are controversial. Widest agreement surrounds their removal for obstructive sleep apnea, usually combined with tonsillectomy.

Even then, it has been observed that a significant percentage of the study population (18%) did not respond. There is also support for adenoidectomy in recurrent otitis media in children previously treated with tympanostomy tubes.Finally, the effectiveness of adenoidectomy in children with recurrent upper respiratory tract infections has been questioned with the outcome, in some studies, being no better than watchful waiting.

contraindication

Cause open rhinolalia sometimes, so it's in the list of contraindications.

Colonoscopy

Colonoscopy or coloscopy is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (e.g. ulceration, polyps) and grants the opportunity for biopsy or removal of suspected colorectal cancer lesions.

Colonoscopy can remove polyps as small as one millimetre or less. Once polyps are removed, they can be studied with the aid of a microscope to determine if they are precancerous or not. It takes 15 years or fewer for a polyp to turn cancerous.

Colonoscopy is similar to sigmoidoscopy—the difference being related to which parts of the colon each can examine. A colonoscopy allows an examination of the entire colon (1200–1500 mm in length). A sigmoidoscopy allows an examination of the distal portion (about 600 mm) of the colon, which may be sufficient because benefits to cancer survival of colonoscopy have been limited to the detection of lesions in the distal portion of the colon.

The American Cancer Society "Guidelines for the Early Detection of Cancer" recommend, beginning at age 50, both men and women follow one of these testing schedules for screening to find colon polyps and cancer:

Flexible sigmoidoscopy every 5 years

Colonoscopy every 10 years

Double-contrast barium enema every 5 years

CT colonography (virtual colonoscopy) every 5 years

A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a fecal occult blood test (FOBT). About 5% of these screened patients are referred to colonoscopy.

Virtual colonoscopy, which uses 2D and 3D imagery reconstructed from computed tomography (CT) scans or from nuclear magnetic resonance (MR) scans, is also possible, as a totally non-invasive medical test, although it is not standard and still under investigation regarding its diagnostic abilities. Furthermore, virtual colonoscopy does not allow for therapeutic maneuvers such as polyp/tumour removal or biopsy nor visualization of lesions smaller than 5 millimetres. If a growth or polyp is detected using CT colonography, a standard colonoscopy would still need to be performed.

Additionally, surgeons have lately been using the term pouchoscopy to refer to a colonoscopy of the ileo-anal pouch.

Colposcopy

Colposcopy is a medical diagnostic procedure to examine an illuminated, magnified view of the cervix and the tissues of the vagina and vulva.Many premalignant lesions and malignant lesions in these areas have discernible characteristics which can be detected through the examination. It is done using a colposcope, which provides an enlarged view of the areas, allowing the colposcopist to visually distinguish normal from abnormal appearing tissue and take directed biopsies for further pathological examination. The main goal of colposcopy is to prevent cervical cancer by detecting precancerous lesions early and treating them. The procedure was developed in 1925 by the German physician Hans Hinselmann, with help from Helmut Wirths.

A specialized colposcope equipped with a camera is used in examining and collecting evidence for victims of rape and sexual assault.

Aparoscopic cholecystectomy

Cholecystectomy is the surgical removal of the gallbladder. It is a common treatment of symptomatic gallstones and other gallbladder conditions. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy.

Laparoscopic surgery

Laparoscopic cholecystectomy has now replaced open cholecystectomy as the first-choice of treatment for gallstones and inflammation of the gallbladder unless there are contraindications to the laparoscopic approach. This is because open surgery leaves the patient more prone to infection.Sometimes, a laparoscopic cholecystectomy will be converted to an open cholecystectomy for technical reasons or safety.

A US Navy general surgeon and an operating room nurse discuss proper procedures while performing a laparoscopic cholecystectomy surgery.

Laparoscopic cholecystectomy requires several small incisions in the abdomen to allow the insertion of operating ports, small cylindrical tubes approximately 5 to 10 mm in diameter, through which surgical instruments and a video camera are placed into the abdominal cavity. The camera illuminates the surgical field and sends a magnified image from inside the body to a video monitor, giving the surgeon a close-up view of the organs and tissues. The surgeon watches the monitor and performs the operation by manipulating the surgical instruments through the operating ports.

To begin the operation, the patient is placed in the supine position on the operating table and anesthetized. A scalpel is used to make a small incision at the umbilicus. Using either a Veress needle or Hasson technique, the abdominal cavity is entered. The surgeon inflates the abdominal cavity with carbon dioxide to create a working space. The camera is placed through the umbilical port and the abdominal cavity is inspected. Additional ports are opened inferior to the ribs at the epigastric, midclavicular, and anterior axillary positions. The gallbladder fundus is identified, grasped, and retracted superiorly. With a second grasper, the gallbladder infundibulum is retracted laterally to expose and open Calot's Triangle (cystic artery, cystic duct, and common hepatic duct). The triangle is gently dissected to clear the peritoneal covering and obtain a view of the underlying structures. The cystic duct and the cystic artery are identified, clipped with tiny titanium clips and cut. Then the gallbladder is dissected away from the liver bed and removed through one of the ports. This type of surgery requires meticulous surgical skill, but in straightforward cases, it can be done in about an hour.

Recently, this procedure is performed through a single incision in the patient's umbilicus. This advanced technique is called Laparoendoscopic Single Site Surgery or "LESS" or Single Incision Laparoscopic Surgery or "SILS". In this procedure, instead of making 3-4 four small different cuts (incisions), a single cut (incision) is made through the navel (umbilicus). Through this cut, specialized rotaculating instruments (straight instruments which can be bent once inside the abdomen) are inserted to do the operation. The advantage of LESS / SILS operation is that the number of cuts are further reduced to one and this cut is also not visible after the operation is done as it is hidden inside the navel. A meta-analysis published by Pankaj Garg et al. comparing conventional laparoscopic cholecystecomy to SILS Cholecystectomy demonstrated that SILS does have a cosmetic benefit over convention four-hole laparoscopic cholecystectomy while having no advantage in postoperative pain and hospital stay

Hemorrhoids resection

Hemorrhoids or haemorrhoids, are vascular structures in the anal canal which help with stool control.They become pathological or piles when swollen or inflamed. In their normal state, they act as a cushion composed of arterio-venous channels and connective tissue.

The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids may produce few symptoms or if thrombosed significant pain and swelling in the area of the anus. Many people incorrectly refer to any symptom occurring around the anal-rectal area as "hemorrhoids" and serious causes of the symptoms should be ruled out.While the exact cause of hemorrhoids remains unknown, a number of factors which increase intra-abdominal pressure, in particular constipation, are believed to play a role in their development.

Initial treatment for mild to moderate disease consists of increasing fiber intake, oral fluids to maintain hydration, NSAIDs to help with the pain, and rest. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Surgery is reserved for those who fail to improve following these measures. Up to half of people may experience problems with hemorrhoids at some point in their life. Outcomes are usually good.

Surgery

A number of surgical techniques may be used if conservative management and simple procedures fail.All surgical treatments are associated with some degree of complications including bleeding, infection, anal strictures and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder. There may also be a small risk of fecal incontinence, particularly of liquid, with rates reported between 0% and 28%. Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse.

Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases. It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery. However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation.It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours.Glyceryl trinitrate ointment post procedure, helps both with pain and healing.

Doppler-guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate, but fewer complications compared to a hemorrhoidectomy.

Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, is a procedure that involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomy and thus it is typically only recommended for grade 2 or 3 disease.

Hiatal hernia repair surgery

A hiatus hernia or hiatal hernia is the protrusion (or herniation) of the upper part of the stomach into the thorax through a tear or weakness in the diaphragm.

Treatment

In most cases, sufferers experience no discomfort and no treatment is required. If there is pain or discomfort, 3 or 4 sips of room temperature water will usually relieve the pain. However, when the hiatal hernia is large, or is of the paraesophageal type, it is likely to cause esophageal stricture and discomfort. Symptomatic patients should elevate the head of their beds and avoid lying down directly after meals until treatment is rendered. If the condition has been brought on by stress, stress reduction techniques may be prescribed, or if overweight, weight loss may be indicated. Medications that reduce the lower esophageal sphincter (or LES) pressure should be avoided. Antisecretory drugs like proton pump inhibitors and H2 receptor blockers can be used to reduce acid secretion.

Where hernia symptoms are severe and chronic acid reflux is involved, surgery is sometimes recommended, as chronic reflux can severely injure the esophagus and even lead to esophageal cancer.

The surgical procedure used is called Nissen fundoplication. In fundoplication, the gastric fundus (upper part) of the stomach is wrapped, or plicated, around the inferior part of the esophagus, preventing herniation of the stomach through the hiatus in the diaphragm and the reflux of gastric acid. The procedure is now commonly performed laparoscopically. With proper patient selection, laparoscopic fundoplication has low complication rates and a quick recovery.

Complications include gas bloat syndrome, dysphagia (trouble swallowing), dumping syndrome, excessive scarring, and rarely, achalasia. The procedure sometimes fails over time, requiring a second surgery to make repairs.

Inguinal hernia repair surgery

Inguinal hernia surgery refers to a surgical operation for the correction of an inguinal hernia. Surgery is not advised in most cases, watchful waiting being the recommended option.In particular, elective surgery is no longer recommended for the treatment of minimally symptomatic hernias due to the significant risk (>10%) of chronic pain (Post herniorraphy pain syndrome) and the low risk of incarceration (<0.2% per year).As general advice in surgery, the choice of the surgeon and hospital are more important than the choice of a particular surgical technique or material.

Tension repairs

Bassini technique, first suture. 1. Aponeurosis musculi obliq. ext.; 2. Musculus obliquus internus; 3. Musculus transversalis; 4. Fascia transversalis; 5. Peritoneum; 6. Ligamentum inguinale.

The first efficient inguinal hernia repair was described by Edoardo Bassini in the 1880s.The Bassini technique is a "tension" repair, in which the edges of the defect are sewn back together, without any mesh. In the Bassini technique, the conjoint tendon (formed by the distal ends of the transversus abdominis and internal oblique muscles) is approximated to the inguinal ligament and closed.Today, Bassini's main interest is historical. It remains performed in some developing countries, if surgeons do not have knowledge of the mosquito-net alternative to commercial meshes in Lichtenstein repair, or if they ignore more efficient suture-based repairs.[citation needed]

McVay/Cooper's ligament

The floor of the canal is reinforced by approximating the transversus abdominal aponeurosis and transverse fascia to pectineal (Cooper's) ligament medially from the pubic tubercle to the femoral vein. Lateral to this the floor is restored by approximating the femoral sheath to the inguinal ligament. It is also used in femoral hernia repairs.

Shouldice

The Shouldice technique is the mainstream suture-based repair. It is a relatively difficult four layer reconstruction of fascia transversalis; however, it has relatively low reported recurrence rates in the hand of a surgeon experienced with this method.

Shouldice repairs are less commonly used today than in previous years, especially in developed countries. This is mostly due to the fact that mesh-based Lichtenstein method is easier to perform. The Shouldice repair has a higher rate of hernia recurrence in the hands of surgeons inexperienced with them (<200 operations/year). Another drawback is the post-operative pain due to the tension on muscles, which generally lasts some weeks. However, this pain is well-managed with analgesics, and this short-term pain must be balanced with the much lower risk of long-term pain of the Shouldice technique, which is half Lichtenstein (but similar to laparoscopic). This is why few tension repairs are still in use today; these include the Shouldice and the Cooper's ligament/McVay repair.

The main advantage of the Shouldice technique remains the relatively low report of chronic pain (10% incidence), as compared with mesh-based open repair (Lichtenstein) (20% incidence). However, the risk of chronic pain with this method is comparable to a laparoscopic repair performed by a surgeon experienced with inguinal hernia repair (i.e. >200 hernias/year) (8% incidence) (and not simply a surgeon experienced with laparoscopy. This difference is important).

Moreover, if the surgeon is not experienced enough with the Shouldice technique, as is the case for most surgeons nowadays, mesh-based repair can be advised. For example, in developing countries, where commercial meshes are expensive, but where surgeons might also be less qualified, a mosquito-net mesh open repair can be better than Shouldice. Indeed, both have a similar cost (a mosquito-net mesh costs less than $0.01. Its sterilization costs less than $1), and mesh repair is easier to perform than Shouldice. Desarda repair is also another option, but it is less widely known.

Another advantage of suture-based repairs over permanent mesh repairs is that they do not introduce significant permanent foreign-body material, at worst, only polypropylene non-absorbable sutures. Permanent meshes can cause additional long-term complications due to this fact.[citation needed]

Tension-free repairs

Desarda

The Desarda technique is an emerging suture-based technique.It can be performed with absorbable sutures. It is simpler and faster to perform than Shouldice and Lichtenstein.It also gives similar results to Lichtenstein in terms of recurrence, with the significant benefit of not introducing permanent foreign-body material. Moreover, this technique is tension-free,mesh-free, and it pays attention to the physiology.Other techniques using a flap from the external oblique aponeurosis were proposed independently by other surgeons.

Guarnieri

Guarnieri technique appeared in 1988. It can be used with or without mesh.Like Desarda technique, the Guarnieri method pays attention to the physiology, and it is also tension-free.

Gastro-esophageal reflux disease

Gastroesophageal reflux disease (GERD), gastro-oesophageal reflux disease (GORD), gastric reflux disease, or acid reflux disease is a chronic symptom of mucosal damage caused by stomach acid coming up from the stomach into the esophagus.

GERD is usually caused by changes in the barrier between the stomach and the esophagus, including abnormal relaxation of the lower esophageal sphincter, which normally holds the top of the stomach closed, impaired expulsion of gastric reflux from the esophagus, or a hiatal hernia. These changes may be permanent or temporary.

Treatment is typically via lifestyle changes and medications such as proton pump inhibitors, H2 receptor blockers or antacids with or without alginic acid.Surgery may be an option in those who do not improve. In the Western world between 10 and 20% of the population is affected.

Ureterolithotomy

A combination of traditional Chinese and western medicine treatment.(such as clothing line stone soup, acupuncture, cystoscope, ultrasonic lithotripsy intubation or set of basket,extracorporeal shock wave lithotripsy if possible).Only when the above treatment is invalid,to protect the renal function and prevent infection and relieve the recurrent colic,we suggest to use open nephrolithotomy.

Notes:

Avoid calculi slip away in the operation, once it slips off, we should take the plain film of the kidney, ureter and bladder flat piece, to determine the hidden parts of the stone.

Treatment after operation：

Pay attention to the wound bleeding and hematuria

Drink more water

Continue to give the anti infection treatment

Transurethral Laser Prostatectomy

With laser prostate surgery a fiber optic cable pushed through the urethra is used to transmit lasers such as holmium-Nd:YAG high powered "red" or potassium titanyl phosphate (KTP) "green" to vaporize the adenoma. More recently the KTP laser has been supplanted by a higher power laser source based on a lithium triborate crystal, though it is still commonly referred to as a "Greenlight" or KTP procedure. The specific advantages of utilizing laser energy rather than a traditional electrosurgical TURP is a decrease in the relative blood loss, elimination of the risk of post-TURP hyponatremia (TUR syndrome), the ability to treat larger glands, as well as treating patients who are actively being treated with anti-coagulation therapy for unrelated diagnoses.

Tonsillectomy

Tonsillectomy is a 3,000-year-old surgical procedure in which, traditionally, each tonsil is removed from a recess in the side of the pharynx called the tonsillar fossa. The procedure is performed in response to repeated occurrence of acute tonsillitis, sleep surgery for obstructive sleep apnea, nasal airway obstruction, diphtheria carrier state, snoring, or peritonsillar abscess. For children, the adenoids (also known as a pharyngeal tonsil or nasopharyngeal tonsil), are usually removed at the same time, a procedure called adenoidectomy, or tonsilloadenoidectomy, when combined. Adenoidectomy is uncommon in adults in whom the adenoids are usually vestigial. Although tonsillectomy is performed less frequently than in the 1950s, it remains one of the most common surgical procedures in children in the United States.

Appendicectomy

An appendectomy is the surgical removal of the vermiform appendix. This procedure is normally performed as an emergency procedure, when the patient is suffering from acute appendicitis. In the absence of surgical facilities, intravenous antibiotics are used to delay or prevent the onset of sepsis; it is now recognized that many cases will resolve when treated perioperatively. In some cases the appendicitis resolves completely; more often, an inflammatory mass forms around the appendix, causing transruptural flotation. This is a relative contraindication to surgery.

Appendectomy may be performed laparoscopically (this is called minimally invasive surgery) or as an open operation. Laparoscopy is often used if the diagnosis is in doubt, or if it is desirable to hide the scars in the umbilicus or in the pubic hair line. Recovery may be a little quicker with laparoscopic surgery; the procedure is more expensive and resource-intensive than open surgery and generally takes a little longer, with the (low in most patients) additional risks associated with pneumoperitoneum (inflating the abdomen with gas). Advanced pelvic sepsis occasionally requires a lower midline laparotomy.

Circumcision

Male circumcision (from Latin circumcidere, meaning "to cut around")is the surgical removal of the foreskin (prepuce) from the human penis.In a typical procedure, the foreskin is opened and then separated from the glans after inspection. The circumcision device (if used) is placed, and then the foreskin is removed. Topical or locally injected anesthesia may be used to reduce pain and physiologic stress.For adults, general anesthesia is an option, and the procedure is often performed without a specialized circumcision device. The procedure is most often elected for religious reasons or personal preferences,but may be indicated for both therapeutic and prophylactic reasons. It is a treatment option for pathological phimosis, refractory balanoposthitis and chronic urinary tract infections (UTIs);it is contraindicated in cases of certain genital structure abnormalities or poor general health.

The foreskin extends out from the base of the glans and covers the glans when the penis is flaccid. Proposed theories for the purpose of the foreskin are that it serves to protect the penis as the fetus develops in the mother's womb, that it helps to preserve moisture in the glans, or that it improves sexual pleasure. The foreskin may also be a pathway of infection for certain diseases. Circumcision removes the foreskin at its attachment to the base of the glans.

Removal of the foreskin

For infant circumcision, devices such as the Gomco clamp, Plastibell and Mogen clamp are commonly used in the USA.These follow the same basic procedure. First, the amount of foreskin to be removed is estimated. The practitioner opens the foreskin via the preputial orifice to reveal the glans underneath and ensures it is normal before bluntly separating the inner lining of the foreskin (preputial epithelium) from its attachment to the glans. The practitioner then places the circumcision device (this sometimes requires a dorsal slit), which remains until blood flow has stopped. Finally, the foreskin is amputated.For adults, circumcision is often performed without clamps,and non-surgical alternatives such as the elastic ring controlled radial compression device are available.

Pain management

The circumcision procedure causes pain, and for neonates this pain may interfere with mother-infant interaction or cause other behavioral changes,so the use of analgesia is advocated.Ordinary procedural pain may be managed in pharmacological and non-pharmacological ways. Pharmacological methods, such as localized or regional pain-blocking injections and topical analgesic creams, are safe and effective.The ring block and dorsal penile nerve block (DPNB) are the most effective at reducing pain, and the ring block may be more effective than the DPNB. They are more effective than EMLA (eutectic mixture of local anesthetics) cream, which is more effective than a placebo.Topical creams have been found to irritate the skin of low birth weight infants, so penile nerve block techniques are recommended in this group.

For infants, non-pharmacological methods such as the use of a comfortable, padded chair and a sucrose or non-sucrose pacifier are more effective at reducing pain than a placebo,but the American Academy of Pediatrics (AAP) states that such methods are insufficient alone and should be used to supplement more effective techniques.A quicker procedure reduces duration of pain; use of the Mogen clamp was found to result in a shorter procedure time and less pain-induced stress than the use of the Gomco clamp or the Plastibell.The available evidence does not indicate that post-procedure pain management is needed.For adults, general anesthesia is an option,and the procedure requires four to six weeks of abstinence from masturbation or intercourse to allow the wound to heal.