In bone sarcoma there is always the soft tissue shadows in the skiagram due to increased vascularity of the tumour discount levitra super active 20 mg with visa gluten causes erectile dysfunction. Chondrosarcoma in skiagram shows frank destruction of the trabecular bone and cortex with an expanding lesion which contains irregular flecking and the mottling of calcified tissue order levitra super active us erectile dysfunction treatment over the counter. At least 50% of medulla must be destroyed before a lesion will be seen radiologically generic levitra super active 40mg visa erectile dysfunction commercials. Osteolysis without formation of new bone is the feature except in carcinoma of the prostate where Fig, 11. In Paget’s disease the bone as a whole is thick and bent; its density in the vascular stage is decreased and in the sclerotic stage increased. In Osteitis fibrosa (Hyperparathyroidism; Von Recklinghausen’s disease) skiagram shows a mixture of osteoporosis, cystic changes and coarsening of the trabecular pattern. Cysts may extend beyond the confines of the long bones and there may be subperiosteal erosions of the cortex. There may be even disappearance of the terminal outline with only longitudinal trabeculae remaining. In Multiple myeloma circumscribed areas of rarefaction affect the different bones, which may mimic secondary metastasis. All these features may not be present simultaneously in all primary malignant tumours, but one or the other change will be obvious. It can indicate the presence of local infection in the same fashion as a primary or metastatic bone tumour. Only very anaplastic tumours and quiescent, long-standing lesions fail to show positive results. Scanning is performed 1-4 hours after the intravenous injection of 5-10 mci of 99 Tcm- phosphates complex. The patient must empty his bladder before the pelvis is scanned as about 40% of the injected dose is excreted in the urine within first 4 hrs. The gamma camera detects, records and displays the activity within its total field of view (about 25 cm diameter). Using a gamma camera and taking multiple overlapping views, it can detect a far greater number of counts leading to much better statistical quality than the whole body scanner in a similar time. The great potential value of bone scanning lies in its ability to detect early active lesions in bone before they are visible on X-ray. It might possibly be of value in clinical practice in the early detection of primary osteosarcoma, although usually they are already clearly visible on X-ray when the patient is first seen. But it is probably more valuable in detecting bone secondaries to know the spread of the disease, suitability of radical operation, differentiation between simple and pathological fracture, to find out the site suitable for biopsy and for staging reticulosis. It has been claimed that some 20% bone secondaries which are not visible on X-ray could be detected by radio-isotope scanning. It is essential in all cases, for one cannot with certainty make the diagnosis on clinical or radiological ground alone. The risk of dissemination which was supposed to be great, is now found to be absolutely theoretical. To give clear decision on frozen section biopsy is difficult and only a few institutions in the world can have the privilege to get pathologists of that grade. There is hardly any place of prophylactic small dose irradiation before taking biopsy. Aspiration biopsy though unrivalled in surgically difficult regions such as spine (where open biopsy is not possible), biopsy of limb tumours by means of wide-bore needle has never become popular in this country. This is partly due to reluctance on the part of pathologists to give opinion on small cores of tissues. Marrow biopsy is helpful in diagnosing multiple myeloma in which numerous plasma cells will be present. Bacteriological examination of the pus obtained by aspiration in cases of acute osteomyelitis is of immense value to determine the causative organism and the most effective antibiotic by sensitivity test. Histopathological examination of the tumour, either from humerus which leads to patho biopsy or from curettage as done in osteoclastoma and bone cyst, logical fracture. Marrow biopsy should be performed in case of multiple myeloma which reveals presence of numerous plasma cells. Secondary Carcinoma of bone by (i) primary carcinomas metastasis from thyroid, bronchus, breast prostate, kidney, uterus, gastrointestinal tract, testis etc. Generally the children of the first decade are involved by this disease and the incidence considerably comes down after the age of twelve. High pyrexia, intense toxaemia with high pulse rate and leucocytosis are the general signs found in acute fulminating type of osteomyelitis. In chronic type, which is commoner in the adult, there will be malaise, fever, headache and backache. Locally there will be swelling, extreme tenderness, local erythema, limitation of joint movement and effusion of the nearest joint (10% of cases). Later on, subperiosteal pus may find its way superficially and then fluctuation test will be positive. In more chronic cases the pus will find its way out through a sinus and may lead to chronic osteomyelitis. It must be emphasised that radiography, which plays an important role in the diagnosis of bone diseases, is practically valueless in the detection of early stage of this condition. Superficial oedema, localized swelling, temperature, extreme tenderness with general signs of toxaemia will tell the diagnosis by themselves. A piece of bone becomes dead (Sequestrum) and remains within the cavity which is formed by destruction of the bone due to the infection. The cavity contains serous fluid and pus, which may be discharged through the sinus. The mouth of the sinus shows sprouting granulation tissue, which indicates presence of the sequestrum in the depth. X-ray shows areas of bony rarefaction surrounded by dense sclerosis and sometimes sequestrum within the cavity of the bone. The commonest sites are the upper end of the tibia, the lower end of the femur, the lower end of the tibia and the upper end of the humerus according to the frequency. This condition may remain silent for years or present with recurrent attacks of pain. Typically the pain becomes worse at night, but in some instances it is worse on walking and relieved by rest. Skiagram shows translucent area with a well defined margin and surrounding sclerosis, beyond which the bone looks normal. It may occur during the later period of prolonged suffering from this disease or may even occur months or years after one has suffered from this disease. The disease runs a mild course with poor bone formation which is observed in X-ray. Diagnosis is mainly confirmed by clinical observations, but discovery of causative organisms in the pus collected by aspiration wipes away any suspicion about the diagnosis.
This ligation to control the hemorrhage that results often is impos- maneuver helps deﬁne the lateral ligaments 20mg levitra super active for sale erectile dysfunction treatment without medication. They can usually be readily identi- ties during total proctectomy are caused by this type of pre- ﬁed and occluded by ligature purchase levitra super active 20mg visa disease that causes erectile dysfunction. As most serious bleeding during pelvic dissec- trolling massive hemorrhage from a torn presacral branch of tions is of venous origin purchase 20 mg levitra super active otc erectile dysfunction in diabetes mellitus pdf, ligation of the hypogastric arteries the basivertebral vein. To accomplish this step effectively, ﬁrst demonstrate of Hypogastric Nerves that the blood is emerging from a single foramen. If the bleeding is controlled by applying the ﬁngertip to one fora- As the rectum is elevated from the presacral space and the men, applying the thumbtack will be effective. In some cases anterior surface of the aorta cleared of areolar and lympho- stufﬁng some cottonoid Oxycel (oxidized cellulose) into the vascular tissue, a varying number of preaortic sympathetic foramen before inserting the thumbtack may be helpful. If the surgeon cannot quickly control lacerated presacral They are the contribution of the sympathetic nervous system veins with a stitch, a thumbtack, or bone wax, the bleeding to the bilateral inferior hypogastric (pelvic) plexuses. In area should be covered with a sheet of Surgicel over which a male patients their preservation is necessary for normal ejac- large gauze pack is placed, ﬁlling the sacral hollow. After they cross the region of the aortic bifurcation practice almost always controls the hemorrhage. Each nerve, which bulky tumor of the mid-rectum, massive presacral venous may have one to three strands, runs toward the posterolateral hemorrhage is entirely preventable. Blunt hand dissection wall of the pelvis in the vicinity of the hypogastric artery (see of the presacral space is not a desirable technique. With most malignancies of the distal geon’s hand does not belong in this area until scissors or rectum, these nerves can be preserved without compromis- electrocautery dissection under direct vision has freed all ing the patient’s chances of cure. This should be done with long Metzenbaum scis- and the lymphovascular tissues are elevated from the bifur- sors combined with gentle upward traction on the rectum. At the prom- tion with the rectal mesentery and associated lymphatics ontory of the sacrum, if the rectum is dissected as described intact but without removing the periosteum and thin areolar above, the right and left hypogastric nerves can be seen pos- tissue covers the presacral veins. When the presacral dis- terior to the plane of dissection and can be preserved pro- section stays in the proper plane, the presacral veins are vided there is sufﬁcient distance separating them from the hidden from view by this layer of fascia (see Fig. There also seems to be diminution in the incidence of Occasionally, branches of the middle sacral vessels enter bladder dysfunction after nerve preservation. This dissection is easily continued down to the area of the Ureteral Dissection coccyx, where the fascia of Waldeyer becomes somewhat dense as it goes from the anterior surfaces of the coccyx and To prevent damage to the ureters, these delicate structures sacrum to attach to the lower rectum (see Fig. The Attempts to penetrate this fascia by blunt ﬁnger dissection normal ureter crosses the common iliac artery, at which point may rupture the rectum rather than the fascia, which is this structure bifurcates into its external and internal strong. Because the ureter and a leaf of incised peritoneum scalpel, after which one can see the levator diaphragm. When are often displaced during the course of dissection, if the ure- the posterior dissection has for the most part been completed, ter is not located in its usual position, the undersurfaces of only then should the surgeon’s hand enter the presacral space both the lateral and medial leaves of peritoneum should be 506 C. The identity of the ureter can be conﬁrmed if Mobilization of Sigmoid pinching or touching the structure with forceps results in typical peristaltic waves. Occlude the lumen may be instructed to inject indigo carmine dye intravenously, of the colon by ligating the distal sigmoid with umbilical which strains the ureter blue unless the patient is oliguric at tape. The ureter should be traced into the several congenital attachments between the mesocolon and pelvis beyond the point at which the lateral ligaments of the the posterolateral parietal peritoneum with scissors rectum are divided. Identify the left ureter and tag it with a Silastic loop for Operative Technique later identiﬁcation. Use scissors to continue the peritoneal incision along the left side of the rectum down to the recto- Incision and Position vesical pouch. Now retract the sigmoid to the patient’s left, Patients who have lesions within 14 cm of the anal verge and make an incision on the right side of the sigmoid meso- should be placed in the same modiﬁed lithotomy position colon. The incision should begin at a point overlying the utilizing Lloyd-Davies or Allen leg rests, as described in bifurcation of the aorta and should continue in a caudal Chap. After thighs for the pelvic portion of the operation, and the sur- the right ureter has been identiﬁed, carry the incision down geon works from the patient’s left. These techniques are best done with the patient in this step until the presacral dissection has elevated the rec- this position. A midline incision, extending from a point tum sufﬁciently to bring the rectovesical pouch easily to the about 6 cm below the xiphoid process down to the pubis, is ﬁeld of vision. Lymphovascular Dissection Exploration and Evisceration of Small Bowel Apply skyward traction to the colon and gently separate the Palpate and inspect the liver. A moderate amount of metasta- gonadal vein from the lateral leaf of the mesocolon, allow- sis is not a contraindication to a conservative version of the ing it to fall posteriorly. Explore the remainder of the abdomen deep margin of the mesosigmoid and the bifurcation of the and then eviscerate the small bowel into a plastic intestinal aorta to feel the pulsation of the inferior mesenteric artery bag or moist gauze pads. In most point where the inferior mesenteric vessels were divided patients, however, it is simple to incise the peritoneum over- and continue to the descending colon or upper sigmoid. In routine cases divide patients it is feasible to incise the peritoneum up to the point the inferior mesenteric vessels between 2 and 0 ligatures where a vessel is visualized and then apply hemostats just distal to this junction. Chassin technique, the surgeon encounters only one or two vessels on the way to the marginal artery of the colon. Sweep the mesosigmoid and the lymphovascular bundle distal to the ligated inferior mesenteric vessels off the ante- rior surfaces of the aorta and common iliac vessels by blunt dissection. To minimize the time during which the patient’s abdomen is exposed to possible fecal contamination, do not divide the descending colon at this stage. Presacral Dissection With the lower sigmoid on steady upward retraction, it becomes evident that there is a band of tissue extending from the midsacral region to the posterior rectum and mesorectum. Instead, use long, closed Metzenbaum scissors for sharp and judicious blunt dissection (Fig. Repeat this maneuver identically on the left side of tinue laterally to the right and left walls of the pelvis (see the midsacral line. Gently dissect these nerves from the band of tissue, which contains branches of the middle sacral posterior wall of the specimen unless the nerves have been artery, and divide it with the electrocautery (Fig. At this time the surgeon sees a thin layer of ﬁbroareolar Now insert a hand into the presacral space, with the tissue covering the sacrum. If a shiny layer of sacral perios- objective not of penetrating more deeply toward the coccyx teum, ligaments, or the naked presacral veins can be seen but, rather, of extending the presacral dissection laterally to (Fig. Elevate the distal men is elevated from the sacrum as far as the lateral liga- rectum from the lower sacrum with gauze in a sponge ments on each side. If the dissection has been completed properly, as on stretch by applying traction to the rectum toward the right. Place a right-angle Mixter tion to further separate the rectum from the posterior wall of clamp underneath the lateral ligament, and divide the tissue the prostate. Carry out a similar maneuver to divide the right lateral In female patients the anterior dissection is somewhat ligament. With a Harrington retractor elevating the uterus, position of the respective ureter and hypogastric nerve to be use scalpel dissection to initiate the plane of dissection certain they lie away from the point of division. Then divide separating the peritoneum and fascia of Denonvilliers from the fascia of Waldeyer, which extends from the coccyx to the the posterior lip of the cervix until the proximal vagina posterior rectal wall (Fig.
A Incontinence of solid stool is rare with normal preoperative 17-year follow-up of a prospective purchase levitra super active with a visa impotence means, randomized trial buy discount levitra super active on line impotence depression. Closed vs open hemorrhoidec- review on the diagnosis and treatment of hemorrhoids buy levitra super active 40mg cheap impotence 60 years old. Hemorrhoids, anal ﬁssure, and carcinoma of the retroperitoneal sepsis after hemorrhoid injection sclerotherapy: colon, rectum, and anus during pregnancy. Randomized clinical trial of micronized open vs closed day-case haemorrhoidectomy. Survey of hemorrhoidectomy prac- the treatment of chronically bleeding internal hemorrhoids. Chassin† Indications Pitfalls and Danger Points Drainage of any anorectal abscess is indicated as soon as the Failure to diagnose anorectal sepsis and to perform early diagnosis is made. There is no role for conservative man- incision and drainage agement because severe sepsis can develop and spread Failure to diagnose or control Crohn’s disease before ﬂuctuance and typical physical ﬁndings appear. Failure to rule out anorectal tuberculosis or acute leukemia This is especially true in diabetic patients. Induction of fecal incontinence by excessive or incorrect Recurrent or persistent drainage from a perianal ﬁstula calls division of the anal sphincter muscles for repair. Weak anal sphincter muscles are a relative contraindica- tion to ﬁstulotomy, especially in the unusual cases in which Operative Strategy the ﬁstulotomy must be performed through the anterior aspect of the anal canal. Absence of the puborectalis muscle Choice of Anesthesia in the anterior area of the canal causes inherent sphincter weakness in this location. This category of case is probably Because palpation of the sphincter mechanism is a key com- better suited for treatment by inserting a seton or by an ponent of the surgical procedure, a light general anesthetic is advancement ﬂap, especially in women. Preoperative Preparation Localizing Fistulous Tracts Cathartic the night before operation and saline enema on the Goodsall’s Rule morning of operation When a ﬁstulous oriﬁce is identiﬁed in the perianal skin pos- Preoperative anoscopy and sigmoidoscopy terior to a line drawn between 3 o’clock and 9 o’clock, the Colonoscopy, small bowel radiography series, or both when internal opening of the ﬁstula is almost always found in the Crohn’s enteritis or colitis is suspected posterior commissure in a crypt approximately at the dentate Antibiotic coverage with mechanical bowel preparation if an line. Goodsall’s rule also states that if a ﬁstulous tract is iden- advancement ﬂap is contemplated tiﬁed anterior to the 3 o’clock/9 o’clock line, its internal ori- ﬁce is likely to be located along the course of a line connecting the oriﬁce of the ﬁstula to an imaginary point exactly in the middle of the anal canal. In other words, a ﬁstula draining in the perianal area at 4 o’clock in a patient lying prone is likely C. Chassin If the external ﬁstula opening is more than 3 cm from the polyester ligature through the remaining portion of the tract. Look for Tie the ligature loosely with ﬁve or six knots without com- Crohn’s disease, tuberculosis, or other disease processes pleting the ﬁstulotomy. When the patient is examined in the such as hidradenitis suppurativa or pilonidal disease. If no more than half of gloved index ﬁnger into the anal canal and gently “pinch” the the external sphincter muscles in the anal canal have been tissue between the dentate line and perianal skin with index divided, fecal continence should be preserved in patients ﬁnger and thumb. A tract may be palpable as a region of with formed stools and a normally compliant rectum. Second, carefully palpate the region of the dentate exception would be those patients who had a weak sphincter line. Next, insert a bivalve speculum into the anus and try to iden- tify the internal opening by gentle probing at the point indi- cated by Goodsall’s rule. If the internal opening is not readily Fistulotomy Versus Fistulectomy apparent, do not make any false passages. The most accurate method for identifying the direction of the tract is gently to When performing surgery to cure an anal ﬁstula, most insert a blunt malleable probe, such as a lacrimal duct probe, authorities are satisﬁed that incising the ﬁstula along its into the ﬁstula with the index ﬁnger in the rectum. Others have advo- fashion it may be possible to identify the internal oriﬁce by cated excision of the ﬁbrous cylinder that constitutes the ﬁs- palpating the probe with the index ﬁnger in the anal canal. The latter technique leaves a large open wound, however, which takes much longer to heal. Moreover, much more Injection of Dye or Hydrogen Peroxide bleeding is encountered during a ﬁstulectomy than a ﬁstu- lotomy. Hence there is no evidence to indicate that excising On rare occasions injection of a blue dye may help identify the wall of the ﬁstula has any advantages. These agents allow one to perform multiple injec- Combining Fistulotomy with Drainage tions without the extensive tissue staining that follows the of Anorectal Abscess use of blue dye. After the pus has been evacuated, a search is made for the internal opening of Preserving Fecal Continence the ﬁstulous tract and then the tract is opened. As mentioned in the discussion above, the puborectalis mus- First, many of our patients who undergo simple drainage of cle (anorectal ring) must function normally to preserve fecal an abscess never develop a ﬁstula. Identify this muscle accu- nal oriﬁce of the anal duct has become occluded before the rately before dividing the anal sphincter muscles during the abscess is treated. Second, acute inﬂammation and edema surrounding general anesthesia for the ﬁstulotomy. If the ﬁstulous tract the abscess make accurate detection and evaluation of the can be identiﬁed with a probe preoperatively, the surgeon’s ﬁstulous tract extremely difﬁcult. There is great likelihood index ﬁnger in the anal canal can identify the anorectal ring that the surgeon will create false passages that may prove so without difﬁculty, especially if the patient is asked to tighten disabling to the patient that any time saved by combining the the voluntary sphincter muscles. We If there is any doubt about the identiﬁcation of the anorec- presently drain many anorectal abscesses in the ofﬁce under tal ring (the proximal portion of the anal canal), do not com- local anesthesia, in part because this method removes the plete the ﬁstulotomy; rather, insert a heavy silk or braided temptation to add a ﬁstulotomy to the drainage procedure. Examination under anesthesia may be necessary to conﬁrm Coding for anorectal procedures is complex. Occasionally an internal opening • Relationship to sphincters draining a few drops of pus is identiﬁed near the dentate • Fistulotomy or not? Then insert a bivalve speculum and inspect the Operative Technique circumference of the anus to identify a possible ﬁssure or an internal opening of the intersphincteric abscess. After iden- Anorectal and Pelvirectal Abscesses tifying the point on the circumference of the anal canal that is the site of the abscess, perform an internal sphincterot- Perianal Abscess omy by the same technique as described in Chap. Place the internal sphincterotomy directly over a patch of overlying skin so the pus drains freely. Explore the cavity, perianal abscess is located fairly close to the anus, and often which is generally small, with the index ﬁnger. Packing is abscess has been properly unroofed, simply reexamine the rarely necessary and may impede drainage. Uneventful healing can be anticipated unless in place in patients with recurrent abscesses or Crohn’s dis- the abscess has already penetrated the external sphincter ease in whom continued problems may be anticipated. After muscle and created an undetected extension in the ischio- 10 days, ingrowth of tissue keeps the Malecot in place with- rectal space. This serves as a temporizing procedure prior to ﬁstulotomy in patients without Crohn’s disease. It may be Pelvirectal Supralevator Abscess used as a permanent solution for the difﬁcult Crohn’s patient An abscess above the levator diaphragm is manifested by with perianal ﬁstula disease. Pus can Ischiorectal Abscess appear in the supralevator space by extension upward from The ischiorectal abscess is generally larger than the perianal an intersphincteric ﬁstula, penetration through the levator abscess, develops at a greater distance from the anus, and diaphragm of a transsphincteric ﬁstula, or direct extension may be deep seated. Early drainage under general anesthesia obvious infection in the ischiorectal fossa secondary to a is indicated. Make a cruciate incision over the apex of the transsphincteric ﬁ stula, manifested by local induration and inﬂamed area close to the anal verge so any resulting ﬁstula tenderness, make an incision at the dependent point of the is short.
This pulsation should be differentiated from transmitted pulsation caused by a swelling order levitra super active with american express impotence 24-year-old, just in front of the aorta purchase levitra super active 20mg with amex erectile dysfunction quick natural remedies. The swelling in front of the aorta will hang loose forward leaving contact with the aorta cheap 20mg levitra super active free shipping erectile dysfunction pumps cost, hence losing its pulsatile property. In addition to the usual causes of enlargement of lymph nodes, the followings are more important in this region : (i) tabes mesenterica, (ii) lymphosarcoma and (iii) secondary malignant growth from the neighbouring organs and also from the testis. Retroperitoneal sarcoma and teratoma are the two conditions commonly seen in the posterior abdominal wall arising from the retroperitoneal tissue. Malaria and kala-azar are common in this country but are of little surgical importance. As sodium leaks into the cell its osmotic pressure rises, the cell swells, becomes spherical and more fragile. In the spleen there is deficiency of both glucose and oxygen in the pulp and therefore a large number of red cells are destroyed. Though it does not cure the congenital red cell membrane defect yet it makes the red cell survival time normal and thus lessens anaemia. The circulating excess bilirubin remains unconjugated with glycuronic acid and is attached to albumin. Though it is a congenital condition yet it may not be manifested before puberty or even adult life. Such attacks are characterized by abdominal pain, nausea, vomiting and pyrexia besides usual extreme pallor and jaundice. These crises may be precipitated by acute infection and may be as dangerous as to cost lives. The liver may be palpable and chronic ulcers of the legs are often seen in adult sufferers. Faecal urobilinogen is increased as most of the urobilinogen is excreted by this route. Measurement of faecal urobilinogen, if made possible, is the best guide to the extent of haemolysis in this condition. The liver may also be palpable and there is sometimes generalized enlargement of the lymph nodes. Acute episode consists of cutaneous purpura, bleeding from the oral mucous membrane and epistaxis. Ecchymoses or purpuric patches in the skin and the mucous membrane are the main manifestations of this disease. These lesions are mainly seen in the dependent areas due to increased intravascular pressure. Sustained bleeding from the wounds which may even be trifle is also a noticeable feature. Bleeding from the mucous membrane either from the gums or in the form of epistaxis or in the form of menorrhagia is not uncommon. On examination there is hardly any abnormality detected except that the tourniquet test becomes positive. Enlargement of spleen is hardly noticed if so the spleen becomes just palpable and never hugely enlarged. In the tourniquet test, the cuff of a sphygmomanometer is applied to the upper arm and inflated to just below the systolic blood pressure for 10 minutes. The main surgical importance is the association of abdominal crisis with this condition. Enlargement of the spleen with hypochromic anaemia, eosinophilia, leukopenia and lymphocytosis are the usual features. In late cases there will be enormous enlargement of the spleen and ascites due to liver atrophy. Associated pyogenic infections, infected ulcers around the ankles, anorexia, loss of weight and enlargement of lymph nodes help in the diagnosis. The spleen is grossly enlarged in case of the former and not so in case of the latter. The blood count will reveal large number of white cells in both the types with more percentage of myelocytes in myeloid leukaemia and very high percentage of lymphoblasts in lymphatic leukaemia. Swellings in connection with other organs are discussed under the right hypochondrium. The hernia is reducible and tympanitic, whereas the abscess is partially reducible and dull on percussion. The features of caries spine — deformity, tenderness, and rigidity will clinch the diagnosis. Sometimes a granulomatous mass resulting from deep seated infection, may look an adenoma. The hernia is usually seen just above the umbilicus where the two recti divaricate and this allows the hernia to come out. Irreducibility and incarceration (obstruction) are the two frequent complications. The clinician is warned against the diagnosis of incarceration, as the real event may be strangulation and valuable time may be lost by giving enema, waiting for the result and doing this or that. Incidence of strangulation is less in this hernia than in inguinal or femoral hernia. The wall of this hernia consists of fibrous tissue and the contents may be adherent. These are readily diagnosed by the presence of scar with a history of previous operation, expansile impulse on coughing and reducibility. Tearing of the inferior epigastric artery will cause haematoma in the lower abdomen below the arcuate line. Following a severe bout of coughing or a sudden blow to the abdomen may cause an exquisitely tender lump in relation to the rectus abdominis. There will be bruising of the skin with discolouration suggesting a haematoma underneath. Some form of trauma either stretching of the muscle fibres during pregnancy or operational wound will cause haematoma within the muscle fibres which may initiate the tumour formation. Matted coils of intestine with tuberculous mesenteric lymphadenitis is generally presented with a lump. A pale looking child with loss of appetite, loss of weight and evening pyrexia is probably suffering from this condition. Sometimes the pain becomes the main symptom and on deep palpation infected mesenteric lymph nodes may be palpable. So absence of calcified lymph node radiologically does not exclude this condition. Adenoma, submucous lipoma and leiomyoma are the benign tumours but they do not produce any palpable swelling. The tumours which may produce palpable lumps are lymphosarcoma and spindle-cell sarcoma. Cysts of the mesentery may be of various types of which chylolymphatic, enterogenous (derived from a diverticulum on the mesenteric border of the intestine) and dermoid (teratoma) cysts deserve mentioning. Besides these, tubercular abscess of the mesentery and hydatid cyst of the mesentery are rarely seen.