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Sometimes liver has been metastasized even after many years of removal of the eye due to malignant melanoma order zebeta master card. Sometimes malignant melanoma does not show pigment and such lesion is called amelanotic melanoma order zebeta online now. Gradually the malignant cells permeate through the intradermal lymphatics and cause satellite nodules at a little distance away from the primary tumour order zebeta 10 mg overnight delivery. Sometimes the patient may complain of lymph node enlargement buy zebeta 5 mg on line, that means swelling Fig. Melanoma of the left cheek, in the groin, axilla or neck according to the region of the primary tumour. Only in late cases one may complain of weight loss, dyspnoea or jaundice (due to hepatic involvement). More blackish is the colour, more chance is there of malignancy, as malignant melanocytes produce more pigments. But the students are cautioned that melanomas may be seen without pigmentation and such growth is known as amelanotic melanoma and this causes tremendous confusion, so far as the diagnosis is concerned. Bleeding is quite common on the surface and the surface of a big melanoma looks wet, soft and boggy. Black nodules may be seen in the skin anywhere between the primary tumour and the regional lymph nodes. It carries a bad prognosis even worse than nodular melanoma with quick regional lymph node metastasis. These sites include— (i) Mucous membranes (specially the oral cavity and nasal sinuses, the genitalia, rectum and anal canal). These uveal melanomas do not metastasise to regional nodes as uveal tract does not have lymphatic drainage. If a lesion is present with both satellites and enlarged regional lymph nodes, the lesion is staged as Ilab. There is no method to detect presence of micrometastasis, which would have otherwise helped in the proper treatment. Depending on the suspicion of metastasis various investigations can be performed e. Lymphangiography to detect lymph node metastasis is of no definite value as this often produces false positive or negative result. Histopathology plays a key role in determining prognostic indicators and the natural history of a particular melanoma. The type of melanoma, whether it is nodular, superficial spreading, lentigo maligna or acral, does not have much significance in survival. The lentigo maligna melanoma, which was previously thought to have a good prognosis has shown no difference in 5-year mortality compared to other histogenic types of melanoma of equal thickness. In melanoma, the extent of malignancy at the time of diagnosis is also an important prognostic factor. Patients with localized diseases of the skin have better prognosis than patients with disease involving first-order lymph nodes and in­ transit lesions. When nodal metastasis had occurred, the prognosis is based on the number of lymph nodes involved. Pigmentations are seen on the lips, in the buccal mucous membrane and around the mouth. Its compressibility and blanching on pressure help in differentiating this lesion from melanoma. Excisional biopsy with a margin of 2 to 5 mm of surrounding healthy skin is indicated for most pigmented lesions. These tumours are very unlikely to metastasize and rarely recur if a margin of 2 cm clearance is achieved. To determine the excision margin, it is better to remember that for the lesion which is impalpable, palpable or frankly nodular, the clearance margin should be 1 cm, 2 cm or 3 cm respectively. It has been found out by randomized trials that excision with more clearance margin does not offer a better local recurrence rate. Skin grafting from the ipsilateral limb is avoided as there is every possibility of recurrence. A split skin graft is preferred as local recurrence will be clearly seen through the graft. If the lesion is located in the proximal half of the digit, disarticulation is performed at the level of the corresponding tarsometatarsal or carpometacarpal joint. At present the trend is towards conservatism but the margins should be excised to give a local recurrence to zero. But computer tomography and magnetic resonance imaging, which are being used in majority institutions, are also quite effective in staging the disease of malignant melanoma. The problem is whether the surgeon should perform an immediate elective node dissection as soon as the diagnosis of malignant melanoma is made or to wait for the clinical evidence of node involvement. Immediate elective node dissection does not improve the survival rate and it should be restricted to those patients for whom follow-up is a problem. Only for thick lesions (more than 2 mm in tumour thickness) consideration should be given to prophylactic node dissection for increased survival rate. In these cases it may be more sensible to perform only node sampling and full regional node dissection is only restricted to those with histological metastasis in the lymph node. But this is not always advocated if the primary tumour is well away from the regional lymph nodes. Locally recurrent disease is defined as cutaneous or subcutaneous disease arising within 5 cm of the primary site after complete excision of the primary lesion. The risk of local recurrence obviously increases with the thickness of the lesion. If lymph node metastasis is present in the absence of distant metastatic disease, radical resection of the involved lymph nodes is advised. In-transit recurrence between the primary lesion and the first order lymph nodes is also a regional recurrence. Another option for patients with this regionally recurrent melanoma is hyperthermic limb perfusion (isolated limb perfusion). In this process the arterial supply and the venous drainage of the extremity are surgically isolated. High dose of chemotherapy is perfused into the involved limb under hyperthermic conditions (at 40°-41°C). This treatment is usually well tolerated, though at times toxicity can be so severe that amputation may be necessary. The major role of this hyperthermic perfusion is to avoid amputation in patients with advanced regional disease in the absence of visceral metastasis. This is a definitive treatment of in-transit metastasis, non-resectable recurrence or non-resectable tumours. It can be used as adjunct to surgical excision for regionally confined poor prognosis melanoma. Isolated limb perfusion is currently the treatment of choice for recurrent melanoma which is confined to an extremity and it has been proved useful in dealing with local and in-transit metastases. Different combinations of drugs have been used and multiple drug regimens are even better. This regimen is observed over a 40 days interval and if additional metastatic lesions are not evident, removal of the remnants with continuation of postoperative chemotherapy should be the treatment of choice. External fixation followed by radiation and chemotherapy is the most accepted method of treatment. High dose alpha-interferon reduces mortality when given for patients who have had surgical clearance of nodal metastasis. Most recent reports suggest a response rate of 35% including some complete responses. This is the single most effective immunotherapeutic regimen evaluated in humans to date. It is however used in cases with nodal metastasis where complete surgical excision has been in doubt, particularly in the head and neck region, but its effect on improving survival is as yet unproven.

The combination of obstruction and infection of the urinary tract is the other condition that is a urologic emergency cheap zebeta 5mg free shipping. Any situation in which these two conditions coexist can lead to destruction of the kidney in a few hours purchase zebeta 5mg with mastercard, and potentially to death from sepsis buy zebeta 10 mg low price. A typical scenario is a patient who is being allowed to pass a ureteral stone spontaneously purchase zebeta amex, and who suddenly develops chills, fever spike 40–40. This should be accomplished by the quickest and simplest means (in this example, ureteral stent or percutaneous nephrostomy), deferring more elaborate instrumentations for a later, safer date. Patients have frequency, painful urination, with small volumes of cloudy and malodorous urine. Pyelonephritis, an infection involving the kidney, produces chills, high fever, nausea and vomiting, and flank pain. Acute bacterial prostatitis is seen in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender prostate on rectal exam. Gentle catheterization can be done to empty the bladder (the valves will not present an obstacle to the catheter). Voiding cystourethrogram is the diagnostic test, and endoscopic fulguration or resection will get rid of them. The urethral opening is on the ventral side of the penis, somewhere between the tip and the base of the shaft. Circumcision should never be done on such a child, inasmuch as the skin of the prepuce will be needed for the plastic reconstruction that will eventually be done. Vesicoureteral reflux and infection produce burning on urination, frequency, low abdominal and perineal pain, flank pain, and fever and chills in a child. The patient feels normally the need to void, and voids normally at appropriate intervals (urine deposited into the bladder by the normal ureter); but is also wet with urine all the time (urine that drips into the vagina from the low implanted ureter). Thus the classic presentation is an adolescent who goes on a beer- drinking binge for the first time in his life and develops colicky flank pain. Most cases of hematuria are caused by benign disease, but any patient presenting with this condition should get a work-up to rule out cancer (the one exception is the adult who has a trace of urine after significant trauma who needs a work-up but not to identify cancer). Renal cell carcinoma in its full-blown picture produces hematuria, flank pain, and a flank mass. That full-blown picture is rarely seen today, since most patients are worked up as soon as they have hematuria. Surgery is the only effective therapy and may include partial nephrectomy, radical nephrectomy, or even inferior vena cava resection. Cancer of the bladder (transitional cell cancer in most cases) has a very close correlation with smoking (even more so than cancer of the lung), and usually presents with hematuria. Surveillance frequently stops at age 75, beyond which survival is not affected by treatment. Widespread bone metastases respond for a few years to androgen ablation, surgical (orchiectomy) or medical (luteinizing hormone-releasing hormone agonists or antiandrogens like flutamide). Testicular cancer affects young men, in whom it presents as a painless testicular mass. Because benign testicular tumors are virtually nonexistent, biopsy is not done, and a radical orchiectomy is performed by the inguinal route. Most testicular cancers are exquisitely radiosensitive and chemosensitive (platinum-based chemotherapy), offering many options for successful treatment even in cases of clinically advanced, metastatic disease. It is often precipitated during a cold, by the use of antihistamines and nasal drops, and abundant fluid intake. The patient wants to void but cannot, and the markedly distended bladder is palpable. An indwelling bladder catheter needs to be placed and left in for at least 3 days. Postoperative urinary retention is also very common, and sometimes it masquerades as incontinence. The patient may not feel the need to void because of post-op pain, medications, etc. A huge distended bladder will be palpable, confirming that the problem is overflow incontinence from retention. Stress incontinence is also very common in middle-aged women who have had many pregnancies and vaginal deliveries. They leak small amounts of urine whenever intra-abdominal pressure suddenly increases. This includes sneezing, laughing, getting out of a chair, or lifting a heavy object. Examination will show a weak pelvic floor, with the prolapsed bladder neck outside of the “high-pressure” abdominal area. For advanced cases with large cystoceles, surgical repair of the pelvic floor is indicated. Although there are a variety of endoscopic and other modalities to address retained urinary stones, intervention is not always needed. Small stones (≤3 mm) at the ureterovesical junction have a 70% chance of passing spontaneously. Such cases can be handled with analgesics, plenty of fluids, and watchful waiting. Other options include basket extraction, sonic probes, laser beams, and open surgery. Although there is specific therapy for the prevention of recurrences in defined types of stones, abundant water intake is universally applicable. Psychogenic impotence has sudden onset, is partner- or situation-specific, and usually does not interfere with nocturnal erections (which can be tested with a roll of postage stamps). Psycho- or behavioral therapy may be beneficial, or the condition may be self-limited. Organic impotence, if caused by trauma, will also have sudden onset, specifically related to the traumatic event (after pelvic surgery, because of nerve damage, or after trauma to the perineum, which involves arterial disruption). Because of chronic disease (arteriosclerosis, diabetes), organic impotence has very gradual onset, going from erections not lasting long enough, to being of poor quality, to not happening at all (including absence of nocturnal erections). Sildenafil, tadalafil, and vardenafil have become first choice therapy in many cases but there are many other options, including vascular surgery (well-suited for those with arterial injury), suction devices (can be used on almost everybody), and prosthetic implants. Even donors with metastatic cancer can donate corneas, because the cornea does not have a blood supply. After an organ has been transplanted, rejection can develop despite immunosuppressive medications. Tissue typing and a close tissue match may minimize that risk, but it is an ever-present concern for most patients. Transplant rejection can happen in 3 ways: hyperacute, acute, and chronic rejection. Hyperacute rejection is a vascular thrombosis that occurs within minutes of reestablishing blood supply to the organ. Acute rejection (most common) occurs after the first 5 days, and usually within the first 3 months. In the case of the liver, technical problems are more commonly encountered than immunologic rejection. In the case of the heart, signs of functional deterioration occur too late to allow effective therapy, thus routine ventricular biopsies (by way of the jugular, superior vena cava, and right atrium) are done at set intervals. Chronic rejection is seen years after the transplant, with gradual, insidious loss of organ function. Although we have no treatment for it, patients suspected of having it have the transplant biopsied in the hope that it may be a delayed (and treatable) case of acute rejection. Orotracheal intubation with rapid-sequence anesthetic induction and pulse oximetry (or topical anesthesia) is preferred in the setting of a trauma center. The patient with subcutaneous emphysema requires fiberoptic bronchoscopy (more details follow). A patient involved in a severe car accident has multiple injuries and is unconscious. Altered mental status is the most common indication for intubation in the trauma patient. Unconscious patients with Glasgow coma scale ≤8 may not be able to maintain or protect their airway. An unconscious patient is brought in by the paramedics with spontaneous but noisy and labored breathing. They relate that at the accident site the patient was conscious, but was complaining of neck pain and was unable to move his lower extremities.

Now apply Allis clamps to the remaining defect in the anastomosis and close it by a final application of the 55/3 trusted zebeta 10mg. Take care to include a portion of each of the previously applied staples lines in the final application of the stapler buy cheap zebeta line. During closure of the mesentery cheap 10mg zebeta overnight delivery, cover the anastomosis between the antimesenteric borders of ileum everted staple lines with adjoining mesentery or omentum if and colon generic 10 mg zebeta fast delivery, as seen in Fig. The end result is step is to insert the cutting linear stapling device, one illustrated in Fig. Wound Closure Postoperative Care The surgical team now changes gloves and discards all Discontinue gastric suction in the operating room or as soon instruments used up to this point. Cover the anastomosis with omentum if Initiate early oral intake of liquids and food as tolerated. Laparoscopic-assisted resection of right-sided colonic carcinoma: a case–control study. Preoperative Indications marking of polyps by endoscopic tattooing using India ink is necessary to ensure intraoperative identification of the lesion Ileocolic Crohn’s disease and to avoid the need for intraoperative colonoscopy. In Endoscopically irretrievable adenomatous polyps patients with recurrent Crohn’s disease or history of multiple Arteriovenous malformations laparotomies, imaging studies are particularly important in Cecal volvulus providing “roadmaps” to define the extent of previous resec- Ischemia tions, length of remaining bowel, and degree of previous Carcinoma mobilization of flexures. Preoperative mechanical and antibi- Right-sided diverticulitis otic bowel preparation consists of 45 cc sodium phosphate solution (Fleets phosphosoda; C. In addition, 2 g of cefotetan are ligament administered intravenously and 5,000 units of heparin Hemorrhage from epigastric, mesenteric, iliac, or gonadal injected subcutaneously at the start of the operation. The bowel Preoperatively, patients undergo an appropriate medical eval- is then exteriorized through a small midline port incision uation. Extracorporeal division of and colonoscopy are undertaken for preoperative planning to the mesentery is followed by resection of bowel and creation assess the location of disease, review any associated compli- of a side-to-side functional end-to-end ileocolic anastomo- sis. Department of Colorectal Surgery, Cleveland Clinic Florida, The resection may be performed in a lateral-to-medial fash- 2950 Cleveland Clinic Blvd. Alternatively, medial-to-lateral dissection is feasible Department of Surgery, Florida Atlantic University College of (see references at the end). Both arms are tucked at the small bowel from the ileocecal valve to the jejunoduodenal patient’s sides, and extra care is taken to secure the patient to junction using a two-instrument technique is essential to the bed because of the rotation and tilt required during sur- assess synchronous locations of disease which are addressed gery. A minimum of two monitors is needed and are placed after maximal mobilization is accomplished laparoscopi- one on each side of the patient at the head of the bed cally. Bilateral ureteral stents may be placed by a urol- stricturoplasties are most easily performed extracorporeally ogist, if desired, followed by insertion of a urinary catheter through a limited incision, preferably midline to preserve and an orogastric tube. For port placement, the assistant stands to the right of the patient while the surgeon stays to the left. Three to Operative Technique four 10 mm trocars are employed for most procedures (Fig. Initially, a 10 mm trocar is placed by the open Room Setup and Trocar Placement Hasson technique in the supraumbilical position through which the camera is inserted. In the reoperative abdomen, After the induction of general anesthesia, the patient is the initial trocar can be placed in the left upper quadrant placed in the modified lithotomy position with the lower in a site remote from scars. The abdomen is insufflated to extremities in padded stirrups placed low for unimpeded an intra-abdominal pressure of 15 mmHg. This configuration allows adequate triangulation essential to assess anatomy and identify pathology. All port place- chronous “skip areas” of disease, such as inflammation or ments should take into consideration the potential for future strictures, can be marked with sutures for subsequent resec- ostomy or drain sites. In obese patients or patients with tion or strictureplasty after the index resection has been extensive intra-abdominal adhesions, an optional port can be accomplished through the midline incision. Once all ports are placed, the assistant moves to the patient’s left to direct the camera. Mobilization of the Cecum The operating table is tilted toward the patient’s left side, and Exploration Trendelenburg position is used to facilitate medial retraction of the right colon and prevent the small bowel from entering Exploration is undertaken to assess for adhesions and unex- the field of dissection. The mesentery of the cecum is gently pected pathology and to define the extent of disease. In the grasped and retracted medially using Babcock clamps placed cases of neoplasia, peritoneal surfaces and the liver are through the left upper port. Extensive adhesions may require placed through the left lower port, the peritoneum along the early conversion while large phlegmons or masses may base of the terminal ileum mesentery and around the cecum is require long incisions for removal obviating the need for a opened exposing the retroperitoneum (Fig. Unexpected complications of inflam- is begun in an area free of inflammation and adhesions and matory bowel disease mandates advanced laparoscopic skills proceeds in the avascular plane medially under the cecum to and may necessitate conversion to laparotomy. The lateral peritoneal attachments of the dissection of the lateral attachments is continued around the cecum are incised (Fig. The ureter is identified in the hepatic flexure dividing the hepatocolic ligament (Fig. Great care should be taken to iden- omentum retracted cephalad, the omentum is separated from tify the correct plane of dissection anterior to Gerota’s fascia the midtransverse colon to the hepatic flexure with the ultra- as more lateral dissection results in medial mobilization of sonic scalpel or scissors through the avascular omental-colic the kidney with difficulty in subsequent mobilization of the junction (Fig. Hemostasis of small vessels is important for port may be placed to provide upward traction on the omen- visualization of the tissue planes during this portion of the tum and is particularly in the presence of significant obesity, procedure. For to mobilize the proximal transverse colon to the level of the patients expected to have extensive intra-abdominal adhe- middle colic vessels to ensure optimal length for mobilization sions and/or intra-abdominal, pelvic, or retroperitoneal into the midline. Upon completion of the mobilization, the inflammation, ureteric catheters can be a valuable adjunct. Mobilization of the Hepatic Flexure Extracorporeal Resection and Anastomosis The surgeon often moves to a position between the patient’s legs while working on the hepatic flexure and transverse colon. Once appropriate mobilization has been achieved, the supra- With the patient in steep reverse Trendelenburg position, umbilical port site is extended to an approximately 4 cm 50 Laparoscopic Right Hemicolectomy 463 Fig. In patients with inflammatory bowel disease, it may be placed, the cecum is gently grasped, and the right colon is useful to inspect the entire length of the small bowel through easily delivered through the wound (Fig. The mesentery between these points is clamped, ligated, and divided prior to bowel resection to prevent twisting of the Re-insufflation and Inspection bowel and mesentery. Once the mesentery is divided, closure of the mesenteric defect with absorbable suture is begun but The fascia of the midline incision is closed with running left untied. Linear cutting staplers are used to divide the absorbable sutures begun at each end but left open in the ileum and transverse colon and, subsequently, to perform the midportion. Inspection of the intra-abdominal con- be tension-free, airtight, and well vascularized. Closure of tents is undertaken to ensure no twisting of the mesentery the mesenteric defect is then completed. The diet advanced with onset of bowel are reapproximated with absorbable sutures and covered function and the patient discharged shortly thereafter. Complications Postoperative Care Anastomotic leak Postoperatively, the patient is begun on clear liquids and a Small bowel obstruction self-administered analgesic pump. On the first postoperative Wound infection day, the bladder catheter is removed and pain is controlled Port-site hernia 50 Laparoscopic Right Hemicolectomy 465 Fig. Laparoscopic colectomy in diverticular and Crohn’s disease: minimal access surgery, part 1. Chassin† Indications Except for treating lesions situated in the distal sigmoid, the lower point of division of the colon is through the upper Whereas malignancies of the proximal three-fourths of the rectum, 2–3 cm above the promontory of the sacrum transverse colon require excision of the right and transverse (Figs. Presacral elevation of the rectal stump colon, cancers of the distal transverse colon, splenic flexure, need not be carried out, and the anastomosis should be intra- descending colon, and sigmoid are treated by left hemicolec- peritoneal (please see Chap. The blood supply of a rectal stump of this length, arising from the infe- rior and middle hemorrhoidal arteries, is almost invariably of Preoperative Preparation excellent quality. The blood supply of the proximal colonic segment, arising from the middle colic artery, generally is See Chap. Pitfalls and Danger Points Liberation of Splenic Flexure Injury to spleen Injury to ureter The splenic flexure of the colon may be completely liberated Failure of anastomosis without dividing a single blood vessel if the surgeon can recog- nize anatomic planes accurately. Bleeding dur- Operative Strategy ing the course of this dissection arises from three sources. Frequently, downward traction on the colon and its Extent of Dissection attached omentum avulses a patch of splenic capsule to which the omentum adheres. It is worthwhile to inspect Lymph draining from malignancies of the left colon flows the lower pole of the spleen at the onset of this dissection along the left colic or sigmoidal veins to the inferior mesen- and to divide such areas of adhesion with Metzenbaum teric vessels.

Irritable bowel syndrome buy line zebeta, pylorospasm buy generic zebeta online, peptic ulcer disease zebeta 5 mg discount, gallstone and pancreatitis may stimulate diffuse oesophageal spasm purchase zebeta american express. Oesophageal manometry has been considered the ultimate test in the diagnosis of this condition. This is due to fibrous replacement of oesophageal smooth muscle and then the distal oesophagus loses its tone and normal response to swallowing and gastro-oesophageal reflux occurs. In distal 2/3rds or 3/4ths of the oesophagus normal peristalsis gives way to weak nonpropulsive contractions. At its most upper part at the pharyngo- oesophageal junction and is known as pharyngo- oesophageal diverticulum or pharyngeal pouch which has been discussed above. This occurs in association with tuberculosis or histoplasmosis of the subcarina and parabronchial lymph nodes to which this diverticulum becomes adherent. This condition rarely causes symptom and is discovered accidentally on barium oesophagogram. This is due to oesophageal motor dysfunction of the distal oesophagus leading to mechanical distal obstruction. There is virtually no the mucosa and submucosa of the oesophagus dilatation of the oesophagus above the growth. Many patients may remain constricted part is very much irregular — ‘rat-tail’ deformity of the lower end of the oesophagus. This condition is diagnosed by barium oesophagogram, though oesophageal manometry should be performed to identify the exact motor disturbance. It is generally located at the oesophagogastric junction and has squamous epithelium on one side, gastric mucosa on the other side and fibrous tissues in the centre. Due to sloughing of a portion of the growth dysphagia may be eased out temporarily. Regurgitated material is usually alkaline mixed with saliva and streaked with blood from malignant growth. Anorexia is another symptom but more often seen in growths at the lower end of the oesophagus. Exfoliative cytology from oesophageal lavage may clinch the diagnosis very early even when radiology has not been positive. In late stages pressure on recurrent laryngeal nerve may cause hoarseness of voice or erosion of bronchus may lead to broncho-oesophageal fistula. If symptoms occur these are usually fullness after meals, early satiety and post­ prandial vomiting. Gastro-oesophageal reflux, which is a very common occurrence in sliding or axial or type I hiatus hernia, does not take place in this condition. The filling defect is then it courses behind the oesophagus (or in rare instances usually more irregular than is shown in front of the oesophagus between the oesophagus and the in this case. It is only when reflux occurs with increased frequency and at times when the stomach is not distended that pathologic gastro-oesophageal reflux is considered. The symptoms of this reflux are heart-burn and regurgitation aggravated by postural change. These are associated with dysphagia, substernal chest pain, sensation of something sticking in the throat and bleeding. Reflux of gastric contents irritates the oesophagus causing secondary muscle spasm alongwith inflammation of the mucosa leading to fibrosis and stricture. Closed injuries are due to waves of shock or direct compression of a viscus against a bony prominence. If a large segment of the abdomen or abdominothoracic wall is compressed it may burst or split organs like liver and spleen. It should be remembered that a similar force, particularly if the breath is held and the diaphragm is tense, may split the diaphragm. In case of penetrating wounds, the length of the weapon and the velocity with which it was struck are important. High velocity injuries produced by gunshot or fragments from exploding mines and shells penetrate deeply and may damage extensively anything in or around their paths. Seat-belt injuries, though not common in India, yet often seen in other countries where wearing a seat-belt is a must at the time of driving a car. The harness may impinge heavily on the points of contact with the trunk and the viscera may continue to move when the abdominal wall has suddenly been decelerated. The combination of these two factors may result in contusion of the abdominal contents, detachment of the gut from its mesentery and less commonly rupture of solid viscera. In suspected injury to the kidney and pelvic bones enquire whether the patient has passed urine or not. If the patient has passed blood mixed with urine, chance of injury to the kidney should be kept in mind. If the patient shows intense desire to pass water but no urine comes out, instead a few drops of blood comes out, extraperitoneal rupture of the bladder or rupture of the membraneous urethra is the most probable diagnosis. If the patient has not passed water and has no intention to do so, possibility of intra-peritoneal rupture of bladder should be kept in mind. Signs of hypovolaemia out of proportion of external injury, if blood in the chest can be excluded, is an almost cardinal indication for opening the abdomen. Bruise, laceration or perforating wound is the external sign of injury which one may locate on careful inspection and injury to internal organ may be at the depth of this external wound. There will be absence of abdominal movements in respiration due to peritonitis from perforation or due to internal haemorrhage. Generalized distension of the abdomen occurs in internal haemorrhage or in late case of peritonitis. Umbilicus may be bulged due to distension of the abdomen caused by internal haemorrhage, late cases of peritonitis, intraperitoneal rupture of the urinary bladder and paralytic ileus. When adhesion of the surrounding viscera and greater omentum succeed in keeping the peritonitis localized, there will be localized tenderness. When the internal bleeding is localized there will be localized tenderness and when the internal bleeding is generalized, there will be generalized tenderness. Rebound tenderness can only be elicited when the parietal peritoneum is inflamed or irritated due to internal haemorrhage. The abdominal muscles in the vicinity of the irritant parietal peritoneum go into involuntary spasm, leading to muscle guard. Generalized muscle guard occurs when there is generalized peritonitis or when internal bleeding has spread all over the peritoneal cavity. Voluntary muscular rigidity means rigidity of the abdominal musculature brought about by the patient himself due to fear of being hurt during examination and also indicates abdominal injury underneath but no parietal peritonitis. Such swelling may be present due to subcapsular haematoma of the spleen or liver, or distended bladder in rupture of posterior urethra. There may be bruise with haematoma affecting lumbar region which should arouse suspicion of renal injury. Similarly bruising with haematoma affecting lower ribs should arouse suspicion of liver or splenic injury according to the side of injury. In case of rupture of anterior urethra there will be perineal swelling or swelling due to extravasation of urine. Shifting dullness test becomes positive when there is free fluid inside the peritoneal cavity. This may occur from internal haemorrhage without localization, in late case of generalized peritonitis, ascites etc. But this examination should be repeated as it takes sometimes for disappearance of bowel sound after injury to the viscera. Auscultation of the chest may indicate presence of bowel sound in case of rupture of the diaphragm. The spine and pelvis (compression test) must be examined properly to exclude any injury here. Patients often complain of abdominal pain in case of injury to the intercostal nerves (T7 to T12). Fluid in the rectouterine or rectovesical pouch indicates free fluid in the peritoneal cavity, intraperitoneal rupture of urinary bladder and intraperitoneal haemorrhage. In many cases you will find that no definite clue can be received in the first examination, but characteristic signs appear later to clinch the diagnosis. X-ray chest to exclude thoracic injury and presence of abdominal viscus in case of rupture of diaphragm. Straight X-ray of the abdomen particularly in sitting position may reveal gas under the diaphragm — a definite sign of rupture of a hollow viscus. Loss of psoas shadow may be helpful in the diagnosis of retroperitoneal effusion of blood.