THYROIDECTOMY

What is thyroidectomy?

Thyroidectomy is an operation in which one or both lobes of the thyroid gland are removed.

What is a thyroid gland and what are its functions?
The thyroid is a gland located in the neck. It is a part of the endocrine (hormone) system, and plays a major role in regulating the body's metabolism. Thyroid disorders are more common in older children and adolescents (especially in girls) than in infants. Most thyroid conditions can be treated medically, but occasionally surgery is required.

Child Thyroid Anatomy	Thyroid Anatomy in Adult
Normal Anatomy

Indications for the removal of thyroid gland

Thyroidectomy may be recommended for the following:

• - Increased thyroid function (hyperthyroidism or thyrotoxicosis)
  - Decreased thyroid function (hypothyroidism) with enlargement (hypertrophy) of the gland
  - Primary cancer of the thyroid
  - Enlargement of the thyroid (nontoxic goiter)
  - Patients unwilling to be treated with radioactive iodine whose hyperthyroidism cannot be treated with antithyroid drugs.
  - Hashimoto's disease (a type of hypothyroidism)

Commom tests to determine whether thyroidectomy is necessary
The most common tests to determine whether a thyroidectomy is necessary include a fine needle aspiration biopsy, thyroid scan, ultrasound, x-rays and/or CT scan, and assessment of thyroid hormone levels

The various types of thyroidectomy include:

1. 1. Partial thyroid lobectomy (a rare procedure) - Only part of one thyroid lobe is removed.
   2. Thyroid lobectomy - All of one thyroid lobe is removed.
   3. Thyroid lobectomy with isthmusectomy - All of one thyroid lobe is removed, together with the thyroid isthmus.
   4. Subtotal thyroidectomy - One thyroid lobe, the isthmus, and part of the second lobe are removed.
   5. Total thyroidectomy - The entire thyroid gland is removed.

A thyroidectomy may be performed by using a conventional surgical approach or a newer endoscopic method done through very small incisions.

What It's Used For -
Conventional thyroidectomy is done for the following reasons:

• > To remove malignant (cancerous) or benign (noncancerous) thyroid tumors
  > To treat thyrotoxicosis, a condition in which an overactive thyroid gland produces extremely high levels of thyroid hormone
  > To remove all or part of a goiter (an enlarged thyroid gland) that is pressing on neighboring structures in the neck, especially if this pressure interferes with swallowing or breathing
  > To remove and evaluate an undiagnosed thyroid mass

In some people, as an alternative to a conventional thyroidectomy, an endoscopic thyroidectomy can be performed to remove small thyroid cysts or small benign thyroid nodules (less than 4 centimeters, or about 1½ inches). Endoscopic thyroidectomy is not used to treat multiple thyroid nodules, thyroid cancer or thyrotoxicosis.

How It's Done
Both types of thyroidectomy are done under general anesthesia. However, if general anesthesia is too risky for a patient, local or regional anesthesia may be used to permit the patient to remain awake during the procedure. An intravenous (IV) line will be inserted into one of your veins to deliver fluids and medications.

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Conventional thyroidectomy -

In a conventional thyroidectomy, a 3- to 4-inch incision will be made through the skin in the low collar area of your neck (the lower front portion of your neck, above the collarbones and breast bone). Next, a vertical cut will be made through the straplike muscles located just below the skin, and these muscles will be spread aside to reveal the thyroid gland and other deeper structures. Then, all or part of your thyroid gland will be removed, after first being cut free from surrounding tissues. During the entire procedure, the surgeon will be very careful to preserve your parathyroid glands (two pairs of small glands located near the thyroid) and to avoid damaging important nerves and blood vessels in your neck. After your thyroid gland is removed, one or two stitches will be used to bring your neck muscles together again. Then the deeper layer of your incision will be closed with stitches, and your skin will be closed with sterile paper tapes. A small suction catheter (tube) will be inserted near the area of your incision to drain any blood accumulated inside your neck. Following surgery, you will be taken to a recovery room, where you will be monitored for several hours until you are stable enough to return to your hospital room. After about 24 hours, the suction catheter will be removed from your neck. Most patients go home one or two days after the surgery.

Complications of thyroidectomy
Two complications specific to thyroid surgery are hypocalcemia and vocal cord weakness or paralysis. Hypocalcemia, or low blood levels of calcium, may occur after complete removal of both thyroid lobes. This condition is caused by interference with four tiny glands called parathyroid glands, which are located within or very close to the thyroid gland. Hypocalcemia is usually temporary, but sometimes may require calcium supplements if sufficiently pronounced. Permanent hypocalcemia is fortunately rare. Vocal cord weakness or paralysis may be caused by swelling, stretching, or injury to the recurrent laryngeal nerve which passes very close to the thyroid gland. Temporary hoarseness may result. Again, this is an uncommon, ususally temporary complication. Permanent vocal cord paralysis is rare.

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Endoscopic Thyroidectomy

Endoscopic thyroidectomy - A viewing instrument called an endoscope and small surgical instruments will be inserted into your neck through three or four small incisions

Endoscopic thyroidectomy is a minimally invasive approach to thyroid excision in which the surgeon makes three or four small incisions in the neck (2mm to 5mm in length) instead of a single large incision several inches in length. A miniature fiberoptic video camera and special instruments are inserted through the small openings, enabling the surgeon to perform the operation by remotely manipulating the instruments from outside the body, guiding their movements by watching them on a television monitor. Proper patient selection is the key to the success of this procedure.

Patient eligibility for endoscopic thyroidectomy include:

• Solitary thyroid nodule < 3 cm in diameter
  Small toxic thyroid nodule
  Thyroid cysts
  Absence of malignant features (i.e. benign biopsy)

Contraindications for endoscopic thyroidectomy include:

• Thyroid nodule > 4 cm
  Large multinodular gland
  Graves disease
  Carcinoma
  Prior neck surgery

What are the advantages of endoscopic thyroidectomy

• Smaller scar
  Less pain
  Quicker return to normal activity
  Magnification provided by the endoscope

What are the disadvantages of endoscopic thyroidectomy?

• Longer operating time
  Requires special equipment

Tonsils and Tonsillectomy

What are tonsils and adenoids?

The tonsils are two clumps of tissue, on either side of the throat, embedded in a pocket at the side of the palate (roof of the mouth). The lower edge of each tonsil is beside the tongue...way in the back of the throat. The adenoids are a single clump of tissue in the back of the nose (nasopharynx). They are located (in the adult) on the back wall of the throat (pharynx)...about one inch above the uvula (the little teardrop shaped piece of tissue that hangs down in the middle of the soft palate).

What function do they serve? Aren't they important?

The tonsils and the adenoids are mostly composed of lymphoid tissue, which is found thoughout the gastointestinal tract and on the base of the tongue. Lymphoid tissue is composed of lymphocytes...which are mostly involved in antibody production. Since we generally consider antibody production to be a good thing, many studies have been performed to try to clarify the importance of the tonsils. There seems to be no adverse effect on the immune status or health of patients who have had them removed.

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Q&A

Q. What is tonsillitis?
A. Tonsillitis is an infectious condition of the tonsils.

Q. What are the symptoms of tonsillitis?
A. Symptoms of tonsillitis include frequent throat and ear infections or obstructed breathing.

Q. Who gets tonsillitis?
A. Though tonsillitis can occur at any age, seventy percent of the patients who have tonsillectomies are under 18.

Q. Can tonsillitis be treated with antibiotics?
A. Antibiotics are frequently effective in treating tonsillitis; however, your physician may suggest a tonsillectomy if antibiotics are no longer combating the illness.

Q. Is tonsillitis contagious?
A. Yes. All forms, bacterial or viral, are contagious. It usually spreads from person to person by contact with the throat or nasal fluids of someone who is already infected.

Q. How can I avoid getting tonsillitis?
A. Wash your hands frequently and keep the infected person's eating utensils and drinking glasses away from yours.

Q. How many times do you have to get tonsillitis before considering a tonsillectomy?
A. It is not possible to give an exact number of infections needed before a tonsillectomy should be considered because each person is different. However, general guidelines suggest that individuals who have five or more throat infections in one year would probably benefit from a tonsillectomy.

Q. What is a tonsillectomy?
A. A tonsillectomy is the surgical removal of tonsils, most often due to chronic infection.

Q. Is the surgery painful?
A. The patient is under a general anesthetic during the surgical procedure.

Q. How long does the patient have to stay in the hospital following a tonsillectomy?
A. Tonsillectomies are usually performed on an outpatient basis (does not require an overnight hospital stay).

Q. Will a tonsillectomy eliminate sore throats?
A. Surgery will not eliminate throat infections, but will likely decrease the frequency of occurrence.

Q. Are tonsillectomies rare?
A.surgical removal of the tonsils is one of the most frequently performed procedures of the throat.

Q. When will my child be able to return to school?
A. Patients usually return to school after about one week, and vigorous physical activity may be resumed at that time also. However, you and your doctor should determine when your child is ready for normal activity.

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Indications for tonsillectomy

• Absolute indications
• # Enlarged tonsils that cause upper airway obstruction, severe dysphagia, sleep disorders, or cardiopulmonary complications
  # Peritonsillar abscess that is unresponsive to medical management and drainage documented by surgeon, unless surgery is performed during acute stage
  # Tonsillitis resulting in febrile convulsions
  # Tonsils requiring biopsy to define tissue pathology
• 
  Relative indications
  # Three or more tonsil infections per year despite adequate medical therapy
  # Persistent foul taste or breath due to chronic tonsillitis that is not responsive to medical therapy
  # Chronic or recurrent tonsillitis in a streptococcal carrier not responding to beta-lactamase-resistant antibiotics.

Contraindications: Contraindications for tonsillectomy include the following:

• # Bleeding diathesis
  # Poor anesthetic risk or uncontrolled medical illness
  # Anemia
  # Acute infection

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How is tonsillectomy done?

While the patient is under general anesthesia, the ear-nose-throat (ENT) surgeon holds the mouth open to expose the tonsils. The tonsils are then cut away with an instrument or a cautery (burning instrument). Bleeding is controlled, and the cut heals naturally without stitches.

Tonsillectomy: Expectations after Surgery
In most cases, the surgery clears problems immediately. After surgery, the number of throat infections is reduced, but not completely eliminated.

Tonsillectomy: Convalescence & Recovery
Tonsillectomy is usually done on an outpatient basis, with the patient returning home the same day as the surgery. Rarely, patients are observed overnight in the hospital and return home the day after the surgery. Complete recovery can take 2 weeks.

Expect some throat and ear pain in the first days following surgery. The use of ice packs to relieve pain may be helpful, and sucking on an ice cube or eating ice cream may provide adequate comfort. In addition, pain-relief medication may be prescribed. During recovery, it is recommended to eat soft, easy-to-swallow food and to drink a lot of cold fluids.

The use of humidifier at home can also bring some comfort. Your child may experience alternating "good and bad" days for 2 weeks after surgery. It is a good idea to keep your child away from crowds or ill people for 7 days, since the throat is highly susceptible to infections during this period

Tonsillectomy: Risks

• Risks for any anesthesia include the following:
• - Reactions to medications
  - Breathing problems
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• Risks for any surgery include the following:
  - Bleeding
  - Infection

In rare instances, post-surgical bleeding can go unnoticed and can cause serious consequences. Frequent swallowing may be a sign of bleeding from tonsils.

New techniques
Various newer techniques for tonsillectomy have been described and are in use, including ultrasonic dissection, cold ablation, laser tonsillectomy, and diathermy tonsillectomy. These are currently being assessed, and possible benefits and harms have not yet been fully evaluated.

SINUSITIS

What is a sinus?

The sinuses are air-filled bony cavities located in the face and skull adjacent to the nose. There are four pairs of sinuses. The right and left frontal sinuses are found in the forehead region, the maxillary sinuses are in the cheek area, the ethmoid sinuses are between the eyes, and the sphenoid sinuses lie deep in the center of the skull. Each sinus is connected to the nose by a small opening called an ostium. All except the frontal sinuses begin growing before birth as small pockets approximately the size of a pea. They increase in size through childhood until they are about as large as a walnut.

What is sinusitis?

Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It usually is preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician's diagnosis and treatment with an antibiotic to cure the infection and prevent future complications.

When Acute Becomes Chronic Sinusitis

When you have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.

Tests to confirm the diagnosis

If the diagnosis is not entirely clear, if an acute infection recurs, or if your symptoms have been ongoing (chronic), then additional tests that your doctor may consider include an xray, CT scan, or magnetic resonance imaging (MRI). Sometimes, a referral to a specialist (known as an Ear Nose and Throat (ENT) doctor [also called an otolaryngologist]) is necessary. This specialist may perform a rhinoscopy (also called nasal endoscopy) using a fiber optic scope to look at your sinuses or a sinus puncture to test for different organisms that may be causing your sinusitis

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Treating Sinusitis

Bacterial sinusitis:
Therapy for bacterial sinusitis should include an appropriate antibiotic. If you have three or more symptoms of sinusitis (see chart), be sure to see your doctor for diagnosis. In addition to an antibiotic, an oral or nasal spray or drop decongestant may be recommended to relieve congestion, although you should avoid prolonged use of nonprescription nasal sprays or drops. Inhaling steam or using saline nasal sprays or drops can help relieve sinus discomfort.

Antibiotic Resistance
Antibiotic resistance means that some infection-causing bacteria are immune to the effects of certain antibiotics prescribed by your doctor. Antibiotic resistance is making even common infections, such as sinusitis, challenging to treat. You can help prevent antibiotic resistance. If the doctor prescribes an antibiotic, it is important that you take all of the medication just as your doctor instructs, even if your symptoms are gone before the medicine runs out.

Chronic Sinusitis
If your doctor thinks you have chronic sinusitis, intensive antibiotic therapy may be prescribed. Surgery is sometimes necessary to remove physical obstructions that may contribute to sinusitis.

Sinus Surgery
Surgery should be considered only if medical treatment fails or if there is a nasal obstruction that cannot be corrected with medications. The type of surgery is chosen to best suit the patient and the disease. Surgery can be performed under the upper lip, behind the eyebrow, next to the nose or scalp, or inside the nose itself.
Functional endoscopic sinus surgery (FESS) is recommended for certain types of sinus disease. With the endoscope, the surgeon can look directly into the nose, while at the same time, removing diseased tissue and polyps and clearing the narrow channels between the sinuses. The decision whether to use local or general anesthesia will be made between you and your doctor, depending on your individual circumstances.

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Endoscopic sinus surgery

Why It Is Done
Endoscopic surgery may be needed when medication treatment has failed to improve or cure chronic sinusitis. It is the preferred method of surgery for most cases of chronic sinusitis that require surgery.

How Well It Works
Endoscopic surgery improves symptoms in about 85% of people.
However, surgery does not always completely eliminate sinusitis. Up to 20% may need a second operation.1
Surgery is most successful when used along with medication and home treatment to prevent future sinus infections. A second surgery and future sinus infections may be avoided if antibiotics are taken to prevent reinfection.

Risks
As with any surgery, there are always some risks involved. However, endoscopic sinus surgery is very safe when performed by an experienced surgeon who has special training with endoscopic surgical techniques.
Minor complications (such as scar tissue attaching to nearby tissue, or bruising and swelling around the eyes) occur in a small number of people who have the surgery. Major complications (such as heavy bleeding) occur in fewer than 1% of cases.2 Most complications of endoscopic sinus surgery can be managed or prevented.

What To Think About
Sinus surgery may involve the use of scalpels, lasers, or small rotating burrs that scrape away tissue. No one method is necessarily any better or safer than another; techniques vary depending on the surgeon's experience and preferences. The rotating burr is becoming the preferred device for sinus surgery.

Endoscopic sinus surgery is less invasive than traditional sinus surgery. It does not require a visible incision, so there is no visible scarring. It is also less expensive than traditional surgery because it involves a shorter hospital stay, if any, and a shorter recovery.

Surgery Overview
In endoscopic sinus surgery, an endoscope is inserted into the nose, providing the doctor with an inside view of the sinuses.

Surgical instruments are inserted alongside the endoscope. This allows the doctor to remove small amounts of bone or other material blocking the sinus openings and remove growths (polyps) of the mucous membrane. In some cases a laser is used to burn away tissue blocking the sinus opening. A small rotating burr that scrapes away tissue may also be used.

The surgery may be done in a hospital (inpatient) or in a doctor's office or clinic (outpatient). Either local or general anesthesia may be used. The procedure takes 30 to 90 minutes.

What To Expect After Surgery

Minor discomfort and bleeding are common during the first 2 weeks after surgery. Weekly visits to the surgeon may be necessary for about 3 weeks after the surgery to have dried blood and mucus removed.
Recovery also may involve:

• > Packing the nose with gauze to absorb bloody drainage.
  > Taking antibiotics.
  > Using a nasal spray containing a steroid for 6 months or longer to reduce inflammation.
  > Using saltwater washes (saline nasal lavage or irrigation) to keep the nasal passages moist.
  > Avoiding activities such as blowing the nose, exercising strenuously, and bending forward for a few days.
  > Using a humidifier to keep room air moist, especially in the bedroom.

KIDNEY FAILURE

What is Kidney Failure?

Inability of kidneys to function properly

Symptoms of Kidney Failure
The signs and symptoms of kidney failure vary, depending on whether the failure is acute or chronic.

Acute kidney failure - Acute kidney failure occurs when your kidneys suddenly stop filtering waste products from your blood. The signs and symptoms may include:

- Fluid retention
- Bleeding, often in your stomach or intestines
- Confusion
- Seizures
- Coma

Chronic kidney failure - They include:

- High blood pressure
- Unexplained weight loss
- Anemia
- Nausea or vomiting
- Malaise or fatigue
- Headaches that seem unrelated to any other cause
- Decreased urine output
- Decreased mental sharpness
- Muscle twitches and cramps
- Bleeding in the intestinal tract
- Yellowish-brown cast to the skin
- Persistent itching
- Sleep disorders
- End-stage renal disease

For some people, end-stage renal disease is the final result of chronic kidney failure Anemia

- High blood pressure
- Congestive heart failure
- Bone disease
- Digestive tract problems
- Loss of mental functioning (dementia)

Quick summary of the common causes of kidney failure:

- Diabetes
- High blood pressure
- Glomerulonephritis
- Polycystic kidney disease
- Scarring from kidney infection in childhood
- Obstruction

Screening and diagnosis - To help confirm a diagnosis of kidney failure, you may have the following tests:

> Ultrasound imaging. This test that uses high-frequency sound waves and computer technology to generate images of your kidneys. Ultrasound scans are noninvasive and usually take less than 30 minutes.
> Computerized tomography (CT) scan. This test uses computers to create more detailed images of your internal organs - including your kidneys - than conventional X-rays do.
> Magnetic resonance imaging (MRI). Instead of X-rays, this test uses magnetic fields and radio waves to generate cross-sectional pictures of your body.
> Renal biopsy. Sometimes your doctor may remove a small sample of kidney tissue and send it to a laboratory for analysis.

A diagnosis of end-stage renal disease is confirmed when blood tests consistently show very high levels of urea and creatinine - a sign that kidney function has been severely and permanently damaged

Kidney failure is treated by a combination of methods which include diet, medication, and possibly dialysis. Another option which may be possible for you is to be considered for a kidney transplant

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Patients guide to Kidney Transplant Surgery

About The Kidney - HOW THE KIDNEYS WORK The kidneys are two bean-shaped organs located toward the back of the body on either side of the spine near the waistline. They are about the size of a fist and are protected by other organs and two of the lower ribs. Normal functioning kidneys serve the body in several very important ways. They: - Clean your blood and remove waste products - Balance water and salt to control fluid in the body - Control blood pressure - Help make red blood cells and strong bones - Control the amount of potassium, calcium, magnesium and phosphorus in the blood SYMPTOMS OF KIDNEY DISEASE Symptoms may include:

> Fluid retention
> Shortness of breath
> Change in mental status
> Abnormal urine or blood test results
> Headache
> High blood pressure
> Fatigue

WHY A TRANSPLANT IS NECESSARY ?

A number of diseases can directly damage the kidney. Damage to the kidney can seriously affect the removal of water and waste products, production of red blood cells, regulation of blood pressure and balance of electrolytes such as potassium, calcium and phosphorus.

If the damage is severe enough, transplantation may be necessary. A transplant provides a patient with a kidney that can keep up with the demands of a full, active life.

THE KIDNEY TRANSPLANT SURGERY PROCEDURE
The patient will be under general anesthesia throughout the surgery. Once asleep, the transplant surgeon will make an incision on the right or left side of the lower abdomen just above the groin. [Also see: Kidney Donation Process]

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After Surgery

MEDICAL MANAGEMENT IN THE ACUTE CARE UNIT
After the patient's medical condition has stabilized, he will be transferred from the ICU to the acute care unit. During the patient's stay on this unit, his laboratory studies, medications, nutritional status and exercise tolerance will be monitored. As soon as the patient is able, discharge instructions will begin to prepare him for going home.

CLINIC VISITS

Upon leaving the hospital, the patient will receive a schedule of follow-up clinic visits for lab tests and checkups. The purpose is to track your progress and detect potential complications as early as possible.

RESUMING NORMAL ACTIVITIES
Although the patient is encouraged to resume normal activities after recovery, it is important to understand that having a new kidney brings new responsibilities.

- Skin and Hair Care
- Sexual Activity
- Smoking
- Vacations and Travel
- Dental Care
- Pregnancy
- Exercise
- Diet and Nutrition
- Alcoholic Beverages

Signs to Watch Out For
While primary concerns involve infection and rejection, many other problems, such as colds or flu, adjus

KIDNEY STONES IN ADULTS

Introduction to the Urinary Tract

The urinary tract, or system, consists of the kidneys, ureters, bladder, and urethra. The kidneys are two bean-shaped organs located below the ribs toward the middle of the back. The kidneys remove extra water and wastes from the blood, converting it to urine. They also keep a stable balance of salts and other substances in the blood. The kidneys produce hormones that help build strong bones and help form red blood cells. Narrow tubes called ureters carry urine from the kidneys to the bladder, an oval-shaped chamber in the lower abdomen. Like a balloon, the bladder's elastic walls stretch and expand to store urine. They flatten together when urine is emptied through the urethra to outside the body.

What is a kidney stone? A kidney stone is a hard mass developed from crystals that separate from the urine and build up on the inner surfaces of the kidney. Normally, urine contains chemicals that prevent or inhibit the crystals from forming. These inhibitors do not seem to work for everyone, however, so some people form stones. If the crystals remain tiny enough, they will travel through the urinary tract and pass out of the body in the urine without being noticed. Who gets Kidney Stones? Stones occur more frequently in men. The prevalence of kidney stones rises dramatically as men enter their 40s and continues to rise into their 70s. For women, the prevalence of kidney stones peaks in their 50s

What Causes Kidney Stones?
Kidney stones are hardened crystal clumps that can develop in the urinary system. They usually form because there is a breakdown in the balance of liquids and dissolved solids in the urine. The kidneys must keep the right amount of water in the body while they remove materials that the body cannot use. If this balance is disturbed, the urine can become overloaded with substances (usually small crystals) that won't dissolve in water. Crystals begin to stick together and slowly add layer upon layer to form a stone. A kidney stone may grow for months or even years before it causes a problem.

What are the symptoms?
Kidney stones often do not cause any symptoms. Usually, the first symptom of a kidney stone is extreme pain, which occurs when a stone acutely blocks the flow of urine. The pain often begins suddenly when a stone moves in the urinary tract, causing irritation or blockage. Typically, a person feels a sharp, cramping pain in the back and side in the area of the kidney or in the lower abdomen. Sometimes nausea and vomiting occur. Later, pain may spread to the groin.

If the stone is too large to pass easily, pain continues as the muscles in the wall of the tiny ureter try to squeeze the stone along into the bladder. As a stone grows or moves, blood may appear in the urine. As the stone moves down the ureter closer to the bladder, you may feel the need to urinate more often or feel a burning sensation during urination.
If fever and chills accompany any of these symptoms, an infection may be present. In this case, you should contact a doctor immediately.

How are Kidney Stones diagnosed?
Sometimes "silent" stones-those that do not cause symptoms-are found on x rays taken during a general health exam. If they are small, these stones would likely pass out of the body unnoticed.
More often, kidney stones are found on an x ray or sonogram taken on someone who complains of blood in the urine or sudden pain. These diagnostic images give the doctor valuable information about the stone's size and location. Blood and urine tests help detect any abnormal substance that might promote stone formation.
The doctor may decide to scan the urinary system using a special test called a CT (computed tomography) scan or an IVP (intravenous pyelogram). The results of all these tests help determine the proper treatment.

How are Kidney Stones treated?
Fortunately, surgery is not usually necessary. Most kidney stones can pass through the urinary system with plenty of water (2 to 3 quarts a day) to help move the stone along. Often, you can stay home during this process, drinking fluids and taking pain medication as needed. The doctor usually asks you to save the passed stone(s) for testing. (You can catch it in a cup or tea strainer used only for this purpose.)

The First Step: Prevention
If you've had more than one kidney stone, you are likely to form another; so prevention is very important. To prevent stones from forming, your doctor must determine their cause. He or she will order laboratory tests, including urine and blood tests. Your doctor will also ask about your medical history, occupation, and eating habits. If a stone has been removed, or if you've passed a stone and saved it, the laboratory should analyze it because its composition helps in planning treatment.

Lifestyle Changes
A simple and most important lifestyle change to prevent stones is to drink more liquids-water is best. If you tend to form stones, you should try to drink enough liquids throughout the day to produce at least 2 quarts of urine in every 24-hour period.

Medical Therapy
The doctor may prescribe certain medications to prevent calcium and uric acid stones. These drugs control the amount of acid or alkali in the urine, key factors in crystal formation

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Surgical Treatment
Surgery should be reserved as an option for cases where other approaches have failed. Surgery may be needed to remove a kidney stone if it

• - does not pass after a reasonable period of time and causes constant pain
  - is too large to pass on its own or is caught in a difficult place
  - blocks the flow of urine
  - causes ongoing urinary tract infection
  - damages kidney tissue or causes constant bleeding
  - has grown larger (as seen on followup x ray studies).

Extracorporeal Shockwave Lithotripsy

Extracorporeal shockwave lithotripsy (ESWL) is the most frequently used procedure for the treatment of kidney stones. In ESWL, shock waves that are created outside the body travel through the skin and body tissues until they hit the denser stones. The stones break down into sand-like particles and are easily passed through the urinary tract in the urine. Extracorporeal shockwave lithotripsy There are several types of ESWL devices. In one device, the patient reclines in a water bath while the shock waves are transmitted. Other devices have a soft cushion on which the patient lies. Most devices use either x rays or ultrasound to help the surgeon pinpoint the stone during treatment. For most types of ESWL procedures, anesthesia is needed. In most cases, ESWL may be done on an outpatient basis. Recovery time is short, and most people can resume normal activities in a few days. Complications may occur with ESWL. Most patients have blood in their urine for a few days after treatment. Bruising and minor discomfort in the back or abdomen from the shock waves are also common. To reduce the risk of complications, doctors usually tell patients to avoid taking aspirin and other drugs that affect blood clotting for several weeks before treatment.

Another complication may occur if the shattered stone particles cause discomfort as they pass through the urinary tract. In some cases, the doctor will insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Sometimes the stone is not completely shattered with one treatment, and additional treatments may be needed. ESWL is not ideal for very large stones.

HYDROCELE

Definition of Hydrocele

The term hydrocele literally means a sack of water.

A hydrocele is a collection of serous fluid between the two layers of the tunica vaginalis which normally surrounds the testis. This is the most common benign cause of scrotal swelling and has been estimated to occur in as many as 1 percent of the adult male population.

MALE REPRODUCTIVE ANATOMY

The normal scrotum and testes
The scrotum is normally loose, soft, and fleshy. It holds the two testes. Usually you can easily feel the testes in the scrotum. A tube (the vas) takes sperm from each testis to the the penis. It is normal for one testis to hang lower than the other.

What do hydroceles look and feel like?

A hydrocele feels like a small fluid filled balloon inside the scrotum. It feels smooth, and is mainly in front of one of the testes. They vary greatly in size. Very large hydroceles are sometimes seen in elderly men who have never shown their swelling to a doctor. It might have been getting larger over a number of years. Hydroceles are normally painless. Large hydroceles may cause discomfort because of their size. Walking or sexual activity may become uncomfortable if you have a very large hydrocele.

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Congenital Hydrocele

What is a congenital hydrocele?

A congenital hydrocele is a collection of fluid in the scrotal sac of male infants that drains downward from the abdominal cavity. The baby's scrotum will appear swollen or large, but he will not have other symptoms.

There are two types of congenital hydroceles:

Communicating hydrocele -- This is a hydrocele that has contact (or communication) with the fluids of the abdominal cavity.

Non-communicating hydrocele -- This may be present at birth or may develop years later for no obvious reason. A non-communicating hydrocele usually remains the same size or has a very slow growth.

How can a hydrocele be repaired?
A non-communicating hydrocele usually does not need to be surgically repaired, since it usually goes away spontaneously within
6 to 12 months. A communicating hydrocele needs to be surgically repaired to prevent further complications. The surgery takes about an hour and is usually an outpatient procedure (which means the patient can go home the same day of the procedure).

During the surgery
- An anesthesiologist (a physician who specializes in pain relief) gives your child general anesthesia, which induces sleep.
- A small incision, or cut, (2 cm.) is made in the skin fold of the groin.
- The hydrocele "sac" containing the fluid is identified.
- The surgeon empties the fluid from the sac. The sac is removed.
- The muscle wall is reinforced with stitches to prevent a recurrent hernia or hydrocele.

After the surgery
Most children will be able to go home a few hours after surgeryCaring for your child after surgery
Usually, your child will feel fine again the evening after surgery or by the next morning. As soon as your child is able, he can resume normal eating habits and activities. You may give your child a sponge bath the day after surgery. Tub baths are permitted two days after surgery.

Treatment in adults
Hydroceles are usually not dangerous, and they are usually only treated when they cause discomfort or embarrassment, or they get so large that they threaten the testicule's blood supply.One option is to remove the fluid in the scrotum with a needle (a process called aspiration). However, aspiration can cause infection, and it is common for the fluid to re-accumulate. Therefore, aspiration is not routine and surgery is generally preferred. On the other hand, aspiration may be the best alternative for people who have certain surgical risks.Injection of sclerosing (thickening or hardening) medications may be performed after needle aspiration to close off the opening through the scrotal sac. This helps prevent re-accumulation of fluid. The medications include tetracycline, sodium tetradecyl sulfate, or urea. Possible complications after aspiration and sclerosing include infection, fibrosis, mild to moderate pain in the scrotal area, and recurrence of the hydrocele.

SURGERY
Hydrocelectomy is often performed to correct a hydrocele. This is a minor surgical procedure performed on an outpatient basis using general or spinal anesthesia. An incision may be made in the scrotum or the lower abdomen.

The procedure may require a scrotal drainage tube or a large bulky dressing to the scrotal area. You will be advised to wear a scrotal support for some time after surgery. Ice packs should be kept to the area for the first 24 hours after surgery to reduce the swelling in the area.

Complications
Possible complications of this procedure include hematoma (blood clot formation), infection, or injury to the scrotal tissue or structures.

Hydroceles associated with an inguinal hernia should be repaired surgically as quickly as possible. Hydroceles that do not resolve spontaneously over a period of months should be evaluated for possible surgery.

HERNIA

WHAT IS A HERNIA ?

A hernia (rupture) is usually noticed as a lump, commonly in the groin or the umbilical region. It appears when a portion of the tissue which lines the abdominal cavity (peritoneum) breaks through a weakened area of the abdominal wall. This can give rise to discomfort as the hernia enlarges and can sometimes be dangerous if a piece of intestine becomes trapped ('strangulated') inside.

HERNIA TYPES

Causes, incidence, and risk factors

Usually, there is no obvious cause of a hernia, although they are sometimes associated with heavy lifting.
Hernias can be seen in infants and children. This can happen when the lining around the abdominal organs does not close properly before birth. About 5 out of 100 children have inguinal hernias (more boys than girls). Some may not have symptoms until adulthood.

If you have any of the following, you are more likely to develop a hernia:

• - Family history of hernias
  - Cystic fibrosis
  - Undescended testicles
  - Extra weight
  - Chronic cough
  - Chronic constipation from straining to have bowel movements
  - Enlarged prostate from straining to urinate

Symptoms

1. > Groin discomfort or groin pain aggravated by bending or lifting
   > A tender groin lump or scrotum lump
   > A non-tender bulge or lump in children

Signs and tests

A doctor can confirm the presence of a hernia during a physical exam. The mass may increase in size when coughing, bending, lifting, or straining. The hernia (bulge) may not be obvious in infants and children, except when the child is crying or coughing.

WHAT ARE THE TREATMENT OPTIONS?

Surgical procedures are now done in one of two fashions. I. The first, or traditional approach, is done from the outside through an incision in the groin or the area of the hernia. The incision will extend through the skin, subcutaneous fat, and allow the surgeon to get to the level of the defect. The surgeon may choose to use a small piece of surgical mesh to repair the defect or hole. This technique is usually done with a local anesthetic and sedation but may be performed using a spinal or general anesthetic. II. The second approach is a laparoscopic hernia repair. In this approach, a laparoscope (a tiny telescope) connected to a special camera is inserted through a canula, a small hollow tube, allowing the surgeon to view the hernia and surrounding tissue on a video screen.

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LAPAROSCOPIC HERNIA REPAIR

THE PRINCIPLE OF LAPAROSCOPIC HERNIA REPAIR

Imagine a bathtub. When you put the rubber stopper at the outlet and fill it with water, the water pressure pushes the stopper in place and keeps it fixed there. The more the water, the firmer is the stopper. Now, if we were to put the stopper from the outside. Then the water pressure in the tub is going to push the stopper out as the pressure increases. This is Pascal's law.

The same scenario can be imagined with placing a mesh on the hole where the hernia is. Is it going to be better fixed from outside or inside? Open surgery places it from outside and laparoscopic surgery places it from inside.

During laparoscopic surgery, we make a small ½ inch cut in the skin at the belly button. Then a cannula (thin tube) is introduced in between the muscle fibres without cutting any of the muscle. Through the cannula, the laparoscope is inserted into the patient's body. It is equipped with a tiny camera and light source that allows it to send images through a fibre-optic cord to a television monitor. The television monitor shows a high resolution magnified image. Watching the monitor, the surgeon can perform the procedure. While looking inside the patient, further two ½" diameter cannulas are put in. This way, the already weak muscles are not disturbed and the net is placed through the half inch holes that are away from the hernia. Thus there is minimal disturbance to the normal body physiology and as a result the pain is minimal and very little rest is required. Also the hernia that is going out from the tummy is pulled back in rather than pushed in from outside as is done in an 'open' operation. There are more and more reports now from the USA and Europe showing the success of this technique in reducing post operative pain, rest and recurrence rates.

The greatest advantage of laparoscopic surgery for hernias is in patients of recurrent hernias where the anatomy has already been disturbed and also in patients of hernias on both sides, as they can be repaired through the same three holes avoiding any further pain or trauma.

The two real problems of the laparoscopic hernia repair are the cost of the operation, which is almost twice the cost of an ordinary operation due to the expensive imported instruments that are needed ; and the necessity for general anaesthesia. The increased cost should be compared with the gain associated by a quicker and more productive return to work by the majority of the patients. Laparoscopic hernia is an efficient technique that compares favourably to current open surgical techniques.

Patients are relatively pain free following this procedure and can return to work and normal activities much quicker than following conventional hernia repairs. Recent reports from the USA show that these patients took an average of 9 days off work compared to 48 days after an open operation.

WHAT ARE THE COMPLICATIONS OF LAPAROSCOPIC HERNIA REPAIR?

1. Any operation may be associated with complications. The primary complications of any operation are bleeding and infection, which are uncommon with laparoscopic hernia repair. 2. There is a slight risk of injury to the urinary bladder, the intestines, blood vessels, nerves or the sperm tube going to the testicle. 3. Difficulty urinating after surgery is not unusual and may require a temporary tube into the urinary bladder. 4. Any time a hernia is repaired it can come back. This long-term recurrence rate is not yet known. Your surgeon will help you decide if the risks of laparoscopic hernia repair are less than the risks of leaving the condition untreated.

WHAT HAPPENS IF THE OPERATION CANNOT BE PERFORMED BY THE LAPAROSCOPIC METHOD?

In a small number of patients the laparoscopic method is not feasible because of the inability to visualize or handle the organs effectively. Factors that may increase the possibility of converting to the "open" procedure may include obesity, a history of prior abdominal surgery causing dense scar tissue, or bleeding problems during the operation. The decision to perform the open procedure is a judgment decision made by your surgeon either before or during the actual operation. The decision to convert to an open procedure is strictly based on patient safety