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Hello. Good evening. Welcome to today's session. Today is teaching session. Um, today will be having, um 333 teaching sessions. The first to be basic, um, skin, um, and transplantation, Uh, the principles of Sorry. The principals basic principles of skin grafting and transplantation will also be having the teaching on ulcerative colitis. And, uh, finally, one on, um, basic abdominal, uh, emergencies. Thank you very much for thank you very much for, um, joining, Uh, we would give a few minutes. We'll give a few minutes for other people to join. Um, Then we would start. Um, So I would aim to start the teaching session today by 6. 30. So I'm going to invite on stage or genetic. Uh, she will be given the first presentation. Um, organization. If you can hear me, could you please join? Um, the stage. Um, can you hear me getting a checkup? Uh huh. Hello? Okay. Can you hear me? Okay. Okay. So, um, so today is the, I think, the third day of teaching session. Um, we've gone through a few topics. I think on the first day we had, uh, teaching on, uh, ulcerative colitis. Unfortunately, um, that teaching was interacted with Paul Network. Hopefully, we'll have the rest of that teaching today. And also, we would, uh, we had a teaching on basic, um, surgical emergencies done by moving anymore yesterday. And a brief, um, teaching as well on, um, basic principles of management of acute traumatic chest injuries. Um, so today we have the plan is to have three teaching sessions. We will be having one on the, um, basic principles for skin grafting and transplantation to be done by the anesthesia. She's on stage, and we'll be introducing herself shortly. Um, and also will be having, uh, teaching an authoritative calamities as well to be given by, um, uh, Juanita, uh, lastly, the teaching of Yeah. Okay. Okay. Okay. Um, so, uh, okay, let's take a How are things on your end? Um, are you able to present now? Can you see? Um, I want to upload the document. Okay. Good. Um, so while we do that, we'll try and wait for, um, other people to join. So, uh, I can see Mohammed amongst a few hours. Um, Mohammed, could you please um, introduce yourself in the chat box of just a few words? Um what you do and things like that. Yeah, that would be much much. I appreciate it. However, if you choose to remain anonymous, that will be also respected. Yeah. Can remain an animal. Too late. You're presenting too late. So it's It's uploading, I think about 11 slides now. 11 slides. Good. So we still have some some few minutes to go. Mm. Yeah. Uh huh. Yeah. Um, take a How are things on your end? Um, are the slides fully uploaded now? It's on the last one. Last one. Okay. Yeah. Okay. Okay, good. So if you could give me just a few minutes for other people who would want to join? Okay. Let me just be sure it's going to scroll through. Okay? Okay. I think it is. Is it legible enough? Hope it's not. It is legible. Yes. Uh huh. Yes. Where is he able to figure out the feedback stuff for the presenters? Yeah, yeah, yeah. I've been able to do that. Everything is ready at the end of today's session. Um, I would send out the feedbacks as well. I would also place it on the chats of function for those who want to do that as well. But everyone should get an email. Email on feedback. Yes. Okay, so I'll ignore my last. Then I did one. You know, you can You can gather your own feedbacks. You're allowed to have your own feedbacks. Yeah, I think it's something that would would help you as well. So I'm not against it, So yeah, I think the last, uh, no, I think opening from yesterday had his own feedback. Um, yeah. Section as well. So I'm happy for you to have a feedback. Okay, so we have two more minutes. Uh oh, boy. Mhm. You try. So we'll be starting in the next minute. Um, so yeah, So that I wouldn't want to keep those already active online. I'm waiting. So by 6. 30 you're allowed to start. Okay. All right. 6. 30. Hello, everyone. My name is take a, um, currently working as a trust doctor in in the field hospital Plastic department. At the moment, I'm giving a presentation on principles of skin grafting. Um, is my voice okay? Or is it to do No, it is actually okay. Very. Okay. Okay. Because I've been through that. I don't speak loud enough anyways, back to okay, so I'll be giving a presentation on skin grafting and basically, what to look out for and how to go about the things to have in mind when you're preparing a patient for skin grafting and how the process is done. Basically, um, we'll go through these outlines quickly, and I have some pictures just to portrays the point. So by way of introduction, skin grafting is something that has been on for ages. Um, it's been said it started out in India, and over time it's progressed. Different people have done different works, and they have been different improvements on the techniques from burrowing. You're doing a full thickness grafting on a lamp in 18 04, up to when, um, full thickness graft was also used on an amputated thumb, um, from a stump and up to when skin graft was used to cover a large one. So basically it's been evolving over time, and it's still evolving. Um, skin grafts, uh, to define them. They are basically it basically means taking a skin from one donor site to a recipient side without its blood supply. So the graft depends on the recipient site. for its blood supply, so that also would have a lot of effect on what could affect the graft. Surviving. Um, there are different types of skin graft, but we'll be talking basically on the autograph. That's from the same person, because you could have skin grafts from, um, xenograft from for animals. You could have also using category skin graft. But most of those ones are usually temporary because of, um, the chances of the body reacting to these grafts. Okay, so I have a diagram here that just basically shows the basic anatomy of the skin is made up of the epidermis, the damage and, um, the subcutaneous layer. So grafting, as we said, involves taking a layer of the skin so it could be It depends on how quick it is. It can involve taking just the epidermis from this picture you can see here, which is just the top, most layer or part of the top, most layer, and then it or it could evolve, taking part of the epidermis and part of the damage. It all depends on how how you set where the to you used to have s the graft or basically, uh, the graphs could be involving. If it's just a split, it made a graph. It was taking just the superficially of the skin, which is the epidermis and part of the damage. And then, if it's a full thickness graft, you're taking both the epidermis and all of the dermis. And then, um, the demise we know contains most of the glands. Sweat glands, it contains nerves, contains hair follicles and order. So this also gives each option. It's advantage, and disadvantage is we'll get to that as we go on this. Um, sure, so next to be talking about the types of skin grafts. So we have brought worldly two types. We have the split thickness, skin graft, and we have the full thickness skin graft. So, as I said earlier, the split one involves taking just part of the epidermis epidemic. Very superficial part of them is, and he could have, um, issues with this. It's its own advantages and disadvantages, basically. But the split thickness skin, skin grafts, um, you could take them from any side. Basically, you just need a site that has that is large enough. And also, um, would be a site that can be well hidden. Depends on if it's not for something. So, um, say, for example, you don't need so much, um, skin from the donor site is preferably. Take this from areas of the body that could be hidden by clothes. Um, some of the advantages of the split, um, skin graft is you can use it to cover a larger area because you get two. Mesh it like it comes out like you could mix it with a machine, and it comes out like a net. Another thing is, when you do have a test, this split thickness skin graft, it doesn't contract initially as compared to the full thickness graft. So the contraction you have, what they call primary and secondary contraction. So for the split thickness, grafting it's primary contraction is less. And meaning when you have is the skin graft. The total size of the graft, the way it shrinks, let me use the world is less compared to that that happened. The shrinkage, basically, that happens in the full thickness, grafting some of the disadvantages of the split thickness graft is it's secondary contracture. That's the contraction that happens when the wound is healing or later on is more that's one, Um, it's because it's so thin it's less resistant to trauma. So these wounds are all these areas of the body that grafted are prone to breaking down. If I put on their own, do stress because of how it looks most times when it's messed or because of the areas that you need to feel. Sometimes you could have some cosmetic deformities in the area. So if there was a contour in the area by loss of Mosul and rest, the graft is not going to produce. Those is just going to perform the function of covering the area. So the contour defect to still be there at the recipient site. Most times you might find a change in color. So the graph they either be darker or, um, less pigmented than the surrounding skin. So you may have colored issues. So which makes it not so suitable for places of aesthetic values like the face. And then, um, on the long term, some areas you get to still see the mesh in that was done on the graph. So you see those patterns still on the areas that were grafted and then um from the picture we saw earlier. When you're taking a skin graft and we split thickness skin graft, you're not taking the area of the skin that produces the hair. So basically, the area you're grafting will not have hair growth. And since it doesn't contain nerves and all that, you still the sensation at the donor site. So sorry, the sensation at the recipient site will also be be quite minimal. Um, the the the donor site for the split thickness skin graft usually heals by epithelialization. So you really because the demise is still intact. So you really don't have to worry so much about it's healing. Um, this is a picture, Um, that shows what it looks like. So on the first picture that shows what the donor site will look like after I have a skin, the skin, and it should it's actually bleed easily. Two. And then the recipient said this is how it looks like when you've actually put the mesh on and secured it to the side. Okay, so for full thickness skin graft, so as compared with the skin, um, split STs gi rather, instead of pronouncing it every time, so as compared with the split one. Um, in this one, you have the epidemics, and the entire them is being taken out. Um, harvesting here, you don't have to use the machine. You just use your basic scalpel and for a food in it for a full thickness graft, you need a good vascular bed for survivor because it's thicker than the split one. So the nutritional requirements will be more, um, the donor sites for the full technique. A graph most times is closed directly, and this also would limit areas that skin can be taken from because you need to consider how to close the donor site when you're harvesting it, so it will allow you to take a large area of skin. So most times you get to use like super clavicular for some areas where you have redundant skin or you can easily get away with the music was stealing a bit of skin from that area, just opposing the skin together just to cover the defect. So mostly you end up using supraclavicular area pre auricular post auricular, then around the growing sometimes. But when harvesting full thickness grafts, you have to also consider where the recipe insight. So it's going to take skin from an area that would end up looking like what the recipe inside or march with the recipient said just so that you don't have those aesthetic problems. Because most times you end up doing these grafts on face, let's say you're taking out a long um uh, a suspicious alone from someone's face and you're trying to cover the defect so you would. It's the face is what everybody sees. People don't really put dressings on the face, so you would want to put something that over. After a while, it will heal, and it will barely be noticeable. Um, for the full thickness graft. It has its own advantages and disadvantages just compared with the previous one. Um, so it's like the opposite. So for its advantages will be the disadvantages of the split thickness graph. So basically it's secondary. Contracture is less so. When the wound heals, it doesn't shrink as much, unlike what happens with, um, the split thickness grafting. Um, you can use this on. You can use this on Villa's, you know. So areas of of the undergone injury that probably may have contractures you could, um, use it. They could give you a better, um, better. What's the word to use? Better output. A better response is, um, it resists trauma. Better is better cosmetic outcome. And because the dermis is intact, you still have hair growth at the recipient site on like its counterpart. Um, one of the disadvantages is that, uh, as I said, area only is your don't know your donor site. You can only you're limited to the size of the skin you can take because you also consider having to close it up. And then, um and it is Another disadvantage is that it's undergoes a lot of primary, um, contractual, which means when you do harvest the skin, you realize that, um, it's shrinks. So once you've taken out the the full thickness graft, you realize that it's it's not as big as what it was when you were taking it out in the first place. So this slide just shows, um, common donor sites for full thickness graphs and where the recipients the recipient sites are so for the face. Most times you take from the post auricular skin or you take from the supraclavicular area for if you're covering and I defect most times, you want to take skin from the opposite. I just so that in the end, there's like a balance on the looks When when you're done with the job, um, for hand surgeries, most times you take from the flexor areas of the skin and then for the palms of the hand. And so so the feet. You can take a skin from abdomen or from the thigh. So this is a picture that just shows like this patient has had, like, a lump exercise from here, and he had a full thickness graft. Sorry, full thickness graft used to repair the defect. So now what? What are the indications for full thickness grafting? There's something they call the reconstructive bladder. So basically, if you have a wound or an injury somewhere, you it's only most times you always think of what's the best way to cover this wound? You always want to go with less invasive ones, so let's say we get the wound healed by secondary intention, for example, and if that would doesn't hear what next. So there's a reconstructive bladder, but most times you don't go from one step to another. So this ladder has been edited and edited over time, so there are different variations, so you mustn't go from 1 to 2 to 3 to 4. But it just gives you an idea of the options. There are two, um, wound to treating wounds. Basically, so the skin grafting is one of the steps on this reconstructive bladder. So basically, you use it when you have an area of defects that would not be able to heal in the secondary intention or you've had the bonds patient and there's a massive skin loss, and you need to cover that wound, um, trauma patient that, for some reason, has had some skin loss or you've taken a patient came with, for example, necrotizing facilities, and you've had to take a huge chunk of skin away or part of your department and then people who have chronic oversize um, and then, for some procedures, you're doing sky excisions. You're doing a muscle flap. You need skin cover some some. In some of these cases, you need a skin graft. Yeah, So, like I said, the reconstructive bladder is not like you must go step by step. It just gives you an idea of the options. There are two skin cover, Um, contraindications. Why? Why should you not do a graft? Or put a graph that this particular site, if there's any sign of infection generally because the graft on Facebook most especially they would not They never want to graft a wound that has grown a strip, um, microorganisms on cultures. If there's active bleeding on the site, they would they would not want to graft there because, obviously, your your graft would not stick to the bed, and then you you won't. Graft over exposed bones or tendons or nerves that do not have the appropriate covering layer to provide blood supply to your graft is just going to fail. Um, if there's cancer at the site, you know, obviously that's going to fail. Some relative control medications could be fully controlled. Diabetes. Um, if the area has been, um, um, cuts on radiotherapy beams before, um, smoking immune suppressions. All these are relatively. You may end up winning the risks and benefits and decide what's best for your patients. Basically, uh, the what do you consider when you're seeing a patient and you think the patient needs a graft. So you'd consider how much skin would you need? Where would you get the skin from? Um, is that a relaxing of would you get adequate skin to meet your cover? Um, the color is something you consider if it's if you're considering putting skin on the face, you need to get from somewhere that the color is going to match on the face. If it's an area that has hair growth, for example, somewhere, let's see your you're taking something from around the eyebrows. Are you going to replace it with skin that is going to grow? And, oh, you're taking along from the chin in Harry in Men who have get, um, and you want to use that skin to replace skin somewhere where there's no hair growth so that hair is going to grow. So you need to put all these things into consideration. Um, grafting in elderly and Children, you know, obviously, Children heal better, so distance you should consider the skin. Um, the skin. The the thickness of the skin has been said to be, um, let's use what, the card and mail and females. So you also consider that when you're sitting, you're the depth or how thick your your dermatomes, which is what you used to address this split thickness grafting. How thick your going to set the the settings just so that you're getting a good, um, depth of skin and then you're going to consent the patient. So basically, you're letting the patient you know, everything there is about the skin grafting. Okay, why you're doing it. It's important and the complications. So you have to tell them, um, we are doing this to cover this place for if, for example, you are putting the politics in the graph, you're going to let them know it's not going to be. It's not going to look perfect. It's not going to look like the other side. The defect, the content defect to still be there. The color may not be the same. The sensation may not be there. Um, and then there's a chance that you can break down. There's a chance that I can feel you just need to let them know this thing so that they, whatever, whenever they're signing, they know that we were told. And then you need clear wound swaps, especially if they are chronic wounds because you don't want to graft a wound that has, for example, we stripped infection the intra operative consideration. So depending on where you're putting the grafts or depending on how much graft you have to take from the donor site, you might use general anesthetic, anesthesia, regional or local if it just involves taking a very small amount of skin. Most times you can use local for both the donor and the recipient sites. And then, um, you take into consideration where you're getting your skin from. That would determine how you position your patient cleaning, draping basically all these things you need to take into consideration because you need to have access to your donor site and also access to your recipient site. And then, um, once you've dripped the patient, you need to break. You do not your recipe inside. So if if it was not looking healthy, you need to divide it open to you when you see that the wound is actually bleeding, and you could you could see that it is free of any form of dead tissue, and then you move on to harvesting your craft. So, um, for the split thickness, grafting. I'll come the next time you get some pictures for the split thickness grafting you have been in other places or in in in. In past times, they've been using a free hand knife where you just there's a knife that just use on the skin, but that has its own disadvantages doesn't give you a unique, unique depth all through through some areas. Maybe Thich some areas, maybe thin, and it's not exactly consistent, and depending it's also dependent on the operator. But nowadays you have the use of dermatomes, which just gives you a consistent, um, a consistent size of the skin, or through depends on how you still apply it to the the skin and then for the full thickness grafting. You just basically need your scalp it because you're just going to mark around the area and then take out what you need. After harvesting these split thickness grafts, you usually would mesh it, and there is a graft measure, which is usually, Um, then when you're doing it, it's just one of the things you need in theater. Uh, it just helps you mesh. It has different ratios will come to that, Um you may or may not mesh the full thickness graft. It just depends most times. If you if you have two, mesh it. You just use your scalpel and you have to take out the subcutaneous fat. If you did, take those along along initially with your full thickness grafting and then once you've taken out your graft, you keep it aside. Just cover it with some saline soup bowls pending when you use it. And then you still have to consider your donor site the care of the one, because you've created another one just to cover something else. So we know for the full thickness graft donor site is going to be close primarily in very rare cases except where maybe you you did need a huge chunk of full thickness graft. Then you have to do a split thickness, have to cover the full thickness and use it for which was basically just like a chain. Yeah, but mostly if it's a small area, you just have to close it primarily. And then the split thickness grafting. You have to consider appropriate dressing for that area. One that's going to resist stress is going to be comfortable for the patient and a bit flexible or basically is going to still have enough tensile strength to allow adequate healing to occur at that site for the donor sites. Basically, um, So this slide just shows the, um, you have the Humvee knife or the Watson Night. This is just what has been used in the past. But nowadays we have we used the dermatome. So this the matter is very important, too, because it has different in the blade sizes comes in different inches. This picture, you see, they're measuring what they need with the size of the skin they needed also, just basically, you know that it matches, um, you can set this them at home to give you different depths of skin. It habits, and depending on the depth of the skin harvest, you have thin, medium and thick spiritedness graft. The thinner the graph, the better they take because it has less nutritional requirements. But there are some areas of the skin you might want to graph, and you know that you don't need something really thin, so that would affect how how we how thick your split thickness graft would be. Um, more than this address. I said most times we don't use the free hand anymore. Um, it would be also good to have a backup them at home in theater just so that in case because this is really electric power too. In case there is a problem with one, you don't have to send your patient back. Um, okay, so in this picture, So basically, once the patient is in theatre on the bed after you've done your checklist and spit and scrubbed and ready, you mark, you would you would have already marked out where you're taking out your skin graft from. So if you're looking at this picture you see in the first one up, you have to apply a bit of tension just so that whoever is holding the dermatome and really needs over the skin has a it taught and smooth plane to rule, and you don't get different depths of or you're harvesting. So basically, so you need help to hold the skin down to be tight and thought, and then you need to apply some lubricant so you can use saline. You can use some Vaseline, or you could use some mineral oil just so that the Democrats can glide smoothly over the area needed. And then when you uh you apply your graph, you apply the demands on to the skin at an angle in 6 to 45 degrees, and you need to apply a constant jen. It tends to constant downward pressure. So you you shouldn't press too hard. You shouldn't be too relaxed. Just need to get the right. Um, I don't know how you get it, but somehow I think we were doing the multiple times you get to learn. So maybe initially you do it, and it's just very jagged. But after a while, you get to get understand how it is. So, um, when you do that, you find out that the way you're harvesting is going to be folded up on the dermatome, it doesn't really matter. Someone could hold it up for you like it's being held up in this picture. Or you could just finish the process, and then you get to lay it out on the on the measure later, and then the last picture. You just have the bed of the donor sites and how it looks, and then you have the skin graft already split out on the measure, ready to be passed through the machine device. So So here you have the graft measure. Um, when you're laying the skin on this plastic, uh, what they call it a mesh graft collector. Whatever it is, you ensure you lay the so when you take when you take out the skin, you have the door side. When your your graft itself, you have the door side. You have the shiny side. When you're laying it on the measure on this mesh graft measure your lady shiny side because it's just easier. Because when you're laying it on when you're laying it on the on the recipient side, you're laying the shiny side down. So it's always easier if the shiny side is already up. So you don't have to start, um, struggling with setting it up again. Yeah, and then you pass. You passed the the measure, the graft collector through the measure, and then it gives you like a fine net net sits out basically. So this, um, measures that can be graded too. So you could mesh to a ratio of 1.5 to 1, which gives you almost 50% increase in the size of your graft. Or you could do 221 machine. 12121 machine. It all depends on what you want and how much graft you need to cover your donor site. Um, so basically, that's for this. How? How, how it works. Um, okay, So let's say you've you've taken taken the graft. Now you've placed it on the wound, right? You need to secure. And that's the Chinese side down. You need to think of how to secure your graft to the wound area. The wound bed. If you do a full thickness graft, you know, you just have to situated, please, both. For the split second paragraph, there are several options, so you could either put interrupted stitches around. Some use staples to just hold the graft to the edges of the graft to the edge of the the recipient site. And some would use skin glue just whatever they use in your trust, you just go with the flu. Um, and then once you've put the you've made the graft on. Once you played the graft on the bed, you need to then consider how to keep that graft pressed on the bed basically, because that's going to that's That's also something that's going to affect how well your graft takes or not. So we have, like, um, some goals dressings where you have a You put a non adherent, um, non adherent, ghostly. My trust. They use something like Maybe they'll just so that whatever you used to secure to apply pressure on top of the skin graph does not stick when you're taking it often spore or your good work. So you you've successfully at court your graft to the bed, and then you put a non adherent goes dressing, and then we also use called candle form. But some also use like moistening cutting balls, just basically something that is moist and still would not be sticking. So you put your phone, you measure the form to the size of the defect, put it over it. In this picture, you have them using a cutting goes. So whatever you have, you, um, put it on top of the non adherent dressings, and then you switch over it to the different ways of doing. Basically, if you see in this picture, they have they put in an individual interrupted, long stitches down. They put the, um, cutting ball in the middle, and then they stitched over it. Just ankle it in place, some. You could do that. Some other people. If if it's a larger area and you can't, it's not physically possible to do this. Some could use a factors. And just to ensure you keep that graph snug on the bed, Yeah. And then, as I said, for full thickness grafting, basically, you you just stick it in place. And, um, some might also do that, but not not every time. But basically, you need to do this to ensure that your graft is stuck on the bedside. And then after you've done this, after I'm pushed operatively your wound, you need to understand. Okay, Now you have to and your original site. You have your recipe inside for the split itiveness grafting. Usually we check the donor site the donor site within, um um, one week and then the Sorry. I think I mixed it up. In this case, you need to check your your graft site. Within that you do know your graphs it within one week and your donor site um, later on. So basically, when you're looking at the graphs, check your just checking If it has, um, taking who explained the what a graft take is have some steps explaining that, and then for your full thickness grafts, you check both the donor and the rest. You can check both sides in in one week. But as I said, the skin grafting you check the recipient sight in one week and you check the donor site. Um, later on, Um hum, yeah. So for the graft healing, there are setting, um, steps that are called in graft feeling. So once you've prepared the bed once you've lied before you even put the graft on the bed, you need to ensure that in most cases, because bleeding, which is one thing that would separate the graft from the bed and so would prevent the graph healing and promote graft failure. Um, so you need good homeostasis and plastic inhibition is just some is a stage that will cause within the first two days here. So once the graft is on the bed, it survived within those first two days by just diffusion of nutrients from the bed into the graft. So it becomes the matters because that's just how it fluid and nutrition with diffuse from the bed into the graph just to keep the graph alive and then within the next 2 to 3 days, uh, within the 2nd 2nd to the third day, slowly, some there'll be some vascular network vascular ization that will be occurring from the graft downwards and from the bed up words just so that, uh, the graft would be alive. And then later on, you have the renovation stage where, um, some sensation may come to the graft May or may not. Sometimes you get sensation. Sometimes you don't get sensations, so basically we have the anesthetic phase. You have the plastic in division, you have the escalation, and then you have the the innovation phases. So anything that disrupts this stage would contribute to your graphs not healing properly, or your graph not taken properly. Do what they use. Yeah, So what? What are the factors that would affect graft healing? So, like you said, graft factors think a graft may need more nutritional requirements, and if you put it at a site that doesn't have enough vascularity, it won't take your donor area needs to also be put into consideration. And then, um, delaying grafts want you to harvest a graph when you know you're ready to put it. So you prepare your wound bed first, Don't have ST a graph, and then go and start preparing your wounded. If not you, you take you waste a lot of time and then just reduce the chances of your graph surviving. Um, the area, the recipient area, Basically, how much pressure that area going to undergo is that area is going to be mobilized immediately because mobilizing immediately would, um even if you add hair or you keep your graft snug on debate. Early mobilization in that particular area may also cause some share stress to the graft, and we disrupt the earlier processes you mentioned, which would contribute to the graph not taken properly. And then you also also consider the graft bed factors. So you shouldn't be grafting over a bed and on bone or Catholic shouldn't be grafting the one that has, um, strep infection or an irradiated bed. For example, if if if it's too soon or anyone that has necrotic tissue, basically, Uh huh, So, um for the complications of skin grafts. Skin grafting In general, we've mentioned most of them as we're talking about different types. So just to put all of them in under one heading, we have the split thickness grafting, I said earlier on the good secondary contracture, which means, um, when the wound heals, it contracts more than full thickness. It's poorly resistant to trauma, and then you also have. Sometimes they do not site, even if it's meant to be a superficial wound you're creating. Sometimes it could get the passive, for example, gets infected. You could just get the person. You also have donor site mobility or something to consider, um, full thickness grafts. Also, they have. They have more primary contractures, so they shrink more wind. Wayne. Um, you harvest them, and then they have less secondary contracture. So on the long run, they don't shrink once the one that's healed. And this shrink is usually because the the full thickness graft shrinks because there's, um, because of the Pacific trail of of, um, um, last thing in the dermis. Because the epidermis had sorry, because the split graft has less of the DMSO, the shrinkage is less that's for the primary contracture. But because when you're taking the full thickness graft, you're taking both the epidermis and the demise. You have more of this contracture, and then the the you have movies Contractor, right? And then the second, the secondary contracture that the split technology graft undergoes is basically as a result of myofibroblast, which the full thickness graft because the demise is there, the DM is is able to resist most of the effect of this myofibroblast. So, um, the more or less balance out, you just have to wait and consider where you need your graft to be and what would be the best for you? Other things that could cause graft failure. As you said earlier, you have hematoma or seroma information under the graft infection. If they're sharing forces, say your graft, it's over. I joined, for example, and then you start moving joint immediately, so chances for those steps to to take place would be disrupted, especially if tiny blood vessels already being formed to need to feed the graph this would be disrupted. And it won't help malnutrition, um, technical error or say, for example, you place the door side of the graft down on the wound bed. So it obviously won't take because you switched it around, um, and then comorbidities patients on chemotherapy, steroids, smoking and all that. And then another complication, we said, was the sensitivity. Because for most statistically, it's crafting those areas will not be sense. Sense it. So as a way of conclusion understanding, skin grafts and flare ups quite critical for the Iraqi of patients. We need to know when it's needed. We need to know what type to use. And we had to use it and then let the patient know appropriately or adequately, what the options are and what complications this should be expecting so that it doesn't come as a surprise when this happen. And then we need to We need to know the basic principles to be followed to optimize success and minimize complications in are graphs. Thank you. So this is just watching the back. So yeah. Thank you. Okay, um, for such a wonderful presentation, Honestly, I really enjoyed the presentation. Does well detailed Well thought out fact. The presentation was we'll talk about and detailed presentation. Um, I'll give you a few minutes to allow for questions. from, um, those present while our next president presenter is getting ready. So our next presentation will be given by, uh, Juanita. She would be talking about ulcerative colitis. But please, please, please, um, do actual questions. Um, And also, um, please feel the feedback forms. I know that at the end of this teaching sessions, we're going to provide feedback forms for everything to run through the, um, whole program. However, I would appreciate if you can fill the feedback forms for the different presenters. Um, this would be highly appreciated. So once again, thank you again. Honestly, you you have done well. Thank you. So, the hard way on, just close my camera. All right? So questions, please. Questions, please. While the next presenter gets ready. Okay. If there are no questions, um, would have to, um, continue with the teaching session. Um, if you remember anything, or if you think about something else at some point and you want to ask, please drop between the, um, chatterbox. Um So, Juanita, over to you. Hi, guys. Good evening. I'm sorry. I'm just, um myself uploading. Can anyone here? Can everyone hear me? Yes. Okay. Okay. Thank you. Thank you. I'm sorry. The slides are still including, but just before, um, just while you're uploading, I'll introduce myself. My name is Juanita or Doctor. Uh, who was the case? May be, Um um especially take me in the whole university teaching hospital. NH estro so amount mouthful. Um, yeah. And I have a keen interest in surgery. Um, urology. Precisely today, I'll be giving a teaching on all street fighting. Um, for those of us that were here on Monday, um, it was supposed to be this teaching was supposed to be given a Monday, or at least it was partly giving on Monday, but there was a lot of connection problems. I'm hoping that that wouldn't be the case today. So, please, if you're having any problems hearing me, please let me know so that I would, um at least try to see what I can do. Thank you. Um, it's still the slides to uploading. If you just give me a couple minutes, then we can start. Come on. Come on. Right. Sorry. We're almost, like 70% gone. Okay, I think I'll just start with, uh, put it in because this is just the presented e d introduction. Um, and, you know, demographics and all of that stuff. So basic topic is, um, new development and ulcerative talking about the latest evidence of management treatment and maintenance. Um, so I think it's first. It's important to, um um, to note that authority colitis is, um, one of the is class under something we call inflammatory bowel disease. So usually, um, you, um some patients may present with the symptoms that maybe suggestive of what we call inflammatory bowel disease. But then it's could either be ulcerative colitis or this, um, by way of, um, by the way of, um, definition of crystallized is a chronic relapsing or remitting, not interest. Inflammatory disease of the gastrointestinal tract. Um, so basically, um, it's chronic. It's okay. My slide deck deck is ready. Present. Okay. Can ever see the slide. Yes. Yes. Okay, lovely. Thank you. Um, So I was saying that inflammatory bowel disease is, um, chronic relapsing inflammation of the bowel and the two major forms. Uh, Crohn's disease and ulcerative colitis. Crohn's disease, basically is, uh is the is the was the one that affects every aspect of the gastrointestinal tract. So from the mouth to the bomb. It's so they call it going to bomb. So from the mouth down into the rectum, any any part of it of the gastrointestinal tract can be affected in quantities. Authoritative colitis, on the other hand, just as the name suggests is, it just affects the colon. And I mean, I'm sure you would recognize that from the name Ulcerative talks about a lot of ulcers and then colitis talks about inflammation of the colonia. And so, like I said, by way of introduction, Ulcerative colitis is a chronic, relapsing remitting, non infectious inflammatory disease of the intestinal tract is usually characterized by diffuse, continuous, um, official inflammation of the large bowel that's of the colon. And it's usually limited to the intestinal mucosa. So it's the mucous membrane, or the the mucosa that is usually affected. That's where you find a lot of the ulcerations and all of that, and it does affect the rectum as well. Um, um, to a large extent, um, so in terms of the demographics, um, it's important to note that, um, that the age of onset is usually between 15 to 30 years old. Do, um, inflammatory bowel disease can present at any time, but usually 15 to 30 years is the peak age of um of presentation, whereby you find a lot of patients coming in and telling you this, giving you or telling you Symptoms are are suggestive of inflammatory bowel disease, usually between 15 to 30 years. There is always second peak within between 50 to 80 years, whereby you find senior patients coming in and and presenting symptoms suggestive of inflammatory bowel disease. Um, there is a slight female predominant in adult onset crone's disease, but males tend to, um, have more of ulcerative colli it ease, and then, in terms of race and ethnicity, um, it's quite common in the Jewish population as compared to non Jewish population. And since the baby lower in black people and Hispanic and black and Hispanic as compared to the white population. Okay, so, um, in terms of the etiology, um, it's important to note that the exact cause of the part of physiology is quite it's not. It's quite is unknown. So it's, um, but there have been so many theories. They have been so many things that has been linked to the development of of ulcerative colitis or basically of inflammatory bowel disease as a whole. Um, it's important to note that, um, the, um smoking, um, use of, um, overuse of NSAIDs. Like, you know, ibuprofen, like Rafinha, naproxen and all of that, um, has been linked to or or has some some effect on the developing on the development of, um, inflammatory power disease. Um, appendectomy. Um, some studies have, as have suggested, that, um, the weeks of queens disease is higher in, uh, higher after appendectomy. I do not know why, but like I said, some studies have suggested that, um in and then data suggests that appendectomy may actually lower the risk of developing ulcerative colitis. So that's something to know, I suppose, um, intestinal microbiota and the intestinal immune system. Um, in terms of pathophysiology, it's important to note that, um, uh, ulcerative colitis is thought to be an immune mediated mediated, um, condition and the results in impaired Epitol. You buy their function and chronic inflammation that is usually caused by some environmental triggers, as well as some of these other risk factors that I talked about and some all of these lifestyle factors. Um, so there are changes in the in the gut microbiome. But microbe. So entrepreneurs in the gut microbiome, um it can also affect, you know, the development of, um, authoritative collides These, um, other factors. Smoking is a risk factor for heart disease, like I said earlier. Um, but but not a risk factor for ulcerative colitis. Surprisingly, I'm not sure why they said is that you can. Actually, from from what I've studied it said the, um, smoking is set to actually have a role in reducing the effect or the in reducing the development of ulcerative colitis. Ask me why. I don't know why. Um, so yeah. Sorry. Now, in terms of the pathophysiology, these are the three things that that that, um that has been there has been, you know, um, found to be to to to cause the development of ulcerative colitis or to have a role to be there. The the things that have been found to, um to not quite sure the word to use. But you get what I'm trying to say. Um, so one is the disregulation at the epithelial barrier. So things like alterations in the intestinal mucous in the intestinal mucosa. High numbers of bacteria within the within the mucosa as well as increasing the snap permeability. They all cause this regulation in the cafeteria barrier and they could cause and obviously that also causes immune disregulation, which could affect the patient and thereby lead to a development of ulcerative colitis, another plateau physiology or and that thing that could that, um, another thing. Another. Another factor is this regulation in immune cells, so excessive immune cell recruitment and activation has been detected in multiple immune cell sublets. So there's an increase in there is increased cytokines in the lamina propria of, um, inflammatory bowel disease patients. So, um, when that all these has a role to play in the development. Um, the other factor is the regulation of secreted mediators. Um, abnormal levels of immunoregulatory and inflammatory site of kings correlate with active inflammatory bowel disease so that that's also very important to know. Uh, So, like I said earlier, ulcerative colitis is characterized by, um, recurring. We're calling episodes of inflammation limited to the mucosa layer of the colon. I stayed all this earlier, um, commonly involved the rectum and extending the proximal and continuous fashion to involve other parts of the colon. So it's mostly the colon that is affected. It's chronic. It's, um, is relaxing Remittance. It's non non infectious, Um, and it usually affects. It's usually, um, restricted to the intestinal mucosa. That's the part that is affected. It's never full thickness, um, and never and never involves the small bowel. So it's mostly the large bowel that's infected that is affected. Rather, um, so symptoms of ulcerative colitis is, um, abdominal pain, Bloody diarrhea. Rectal urgency 10 is, um, remember on Monday I was. I tried to explain that his mood is basically cramping rectal pain, so it gives you the feeling that you have a bowel movement, even though you've already had one. And then when someone has tennis moves, the patient may strain how that produce only a small amount to, um, bowel movements. So in terms of, um um, So when we see a patient, the patient presents with certain symptoms. A diagnosis of ulcerative colitis can be suspected in people who present with a history of bloody diarrhea for more than six weeks. For example, if a patient presents with rectal bleeding or fecal urgency and or incontinent, so sometimes they may come and tell you that they're they're physically incontinent, and then you take some of you take another. You take a, uh, an extensive history, do some examination, and you find that that this patient may actually have ulcerative colitis is, um, so another symptom could be nocturnal defecation? Um, Chinese? Most. Like I said earlier, abdominal pain. Abdominal pain tends to be very crampy. They will tell you that they've got crampy abdominal pain. Um, uh, that's also a telltale sign. Um, also, sometimes it tends to be lower abdominal pain. So when you ask them the location of the pain they tend to be it tends to be lower, usually below the umbilicus. Um, some patients may present with weight loss, um, or other non specific symptoms like general malaise, fatigue, um, anorexia and or fever. Um, okay. So, um, for a patient who's got all three difficult, it is if you're doing if you do, if you're trying to check the histology of the intestinal mucosa is affected. You find to see, um, you you tend to see a lot of pseudo polyps. Those are kind of those are the things that you can find. So there are certain things that you would see in, um, when you're doing like, uh, when you're looking at the colon of that patient on the microscope or you're doing like a histological preparation of the colon, you see so many things that can tell you. Okay, this is ulcerative. Colitis is pseudo polyps. You tend to see, um um, crypt abscess is you tend to see, like, pipes and all of that, but we'll just talk briefly about each of them. So for pseudo polyps, they are basically projecting masses of scar tissue that developed from the granulation tissue during the healing process. So there is, like, remember that I said at the beginning that from the name you can tell what usually happens in the colon. So I I already said it affects the large bowel and is restricted to the intestinal mucosa. That's where the bulk of the disease is from the name you can tell that there is inflammation and ulceration. So it's it's I remember that I also when I explained it, I said when I gave the definition, I had said it was a chronic We, um, relapsing and remitting sort of, you know, um, illness. So that lets that from that. You can just understand that there is, um, a circle of ulceration. So there is ulceration, and then it heals. And then there's another observation and heals. And so that produces a lot of granulation tissue. And then the granulation tissue then now has scar tissue, that project out of it. And that's what the pseudo polyps are. And then crypt abscess is, um so with if you if you look at the colonic mucosa of of a patient that has active, um, ulcerative colitis, um, it usually shows abscesses in the crypts of the I mean in the crypts. Um, and then it's they're basically just, um neutrophilic exudates that is found in the lumen of the crypt. Um, but like I said, it's always in patients that have active, active ulcerative colitis. Um, so if you're if you're looking at, I mean the colon. Um, but part of the things that causes us that, um, causes, um, um bowel sounds, you know, the the gosh. What's the name? Um, I can't remember. I can't remember Paris houses. Thank you. That's it. Part of the and and the. And the frustrations also has a role to play now in in ulcerative colitis. Thank you so much, Bernard, for that. Totally forgot. That would, um, in ulcerative colitis. Is, um, there is a complete loss of hospital markings. There are no ulcerations. That's, uh that's it's very, um um Pathognomic. I think that's what they use. Yeah, so it's very pathognomic. So if you're looking at the part of the direction of the colon on the part of the colon affected with medical ID is the organs appear smooth board and complete loss of frustration or just remarking, you know, basically like a pipe. Okay, um, so, um, important to know that even though the ulcerative colitis is kind of, um gosh okay, even the ulcerative colitis is is restricted to the Columbia extra intestinal manifestations. So we've got primary sclerosing cholangitis is in the in the biliary system. Goldstone's cholangiocarcinoma All of these, uh, things that you see that that if a patient comes down and you take an extensive history, you may find out that it's not just a primary, um, manifestation of disease. It is actually a an extra intestinal complication of, um, ulcerative colitis. A few of the very common ones are the primary sclerosing cholangitis in the liver, Um, erythema nodosa and pyoderma gangrenosum on the skin. Um, after the ulcers in the mouth, Um, And then, um, if you let's see And, um, on the light in the better job for you. Yeah. Respected. Okay. A shot for the government. So, um, looks like it's just basically painful source, Um, in the on the skin and your anxiety's, um um so one of the, um, Caucasians of ulcerative colitis is one of the things that could happen in a patient that has ulcerative colitis is is, um, what we call, um, toxic Mega colon, which is essentially little complication of inflammatory bowel disease is mostly ulcerative colitis. Chron's disease. Not so much mostly ulcerative colitis. Um, but just like it's written in reality, any inflammatory condition of the colon can cause toxic megacolon. Um, they could also be bowel obstruction. There could be anemia, malnutrition, goods, um, failure, colorectal cancer. It could be any number of things, to be honest, but one of the major complications is public mega colon, which is why it was worthy of slide. Um, there's also a cancer. So remember I had said, um in colorectal cancer is can also developed from both ulcerative qualities and Crohn's disease. Um, um um, what are the common type is obviously the adenocarcinoma, and obviously it depends on the disease. Um, duration? Um, yeah, it depends on on the duration of the disease. And there is always a few patients who have had, um, ulcerative colitis for quite a while. 10 years. Um, studies have shown that there is a 2% chance of developing, um, malignancy, uh, printing for patients who who has, um, who may develop malignancy or the screening for patients to check for any sort of malignancy is dependent on when, uh, when dependent on certain factors. Which I'll talk about shortly. Um, I think we talked about this already, so yeah, surveillance intervals. So, in a patient who has lower who who we consider a low risk or so basically low risk patients are patients that have no active endoscopic in histological, in remission or left sided colitis or colon societies. They are considered to be lower risks. And then, um, surveillance is done every five years. So remember that you have to do biopsies first. Before that's how you you know, that's how you um, decide which patient falls on that which, you know, surveillance group, you know. So for intermittent risk, surveillance is done every three years. Um, and these are patients that have extensive colitis with mild, with mildly active endoscopic or histological inflammation or post inflammatory polyps. Um, which is what we call pseudo polyps, Um, or if they have a family history of colorectal cancer in a first degree relative with that are 50 years old, they are considered to be intermediate tricks and is what's doing inter surveillance surveillance every three years. So you're surveilling for cancer. Um, and the higher risk surveillance is done every year. So in high risk patients and they've got extensive qualities with moderate or severely active and scopic or histological information, Or if they have stricture or dysplasia in the last five years, or if they've got primary sclerosing cholangitis these or a family history of colorectal cancer in the first degree relative, that is more than modified 50 years. Okay, so, um, for the patient, for the patients with higher risk, Um, and I remember one of the things. One of the things. One of the ways to know if they've got a higher risk is if they if they have any stricture or dysplasia in the last five years. So, um, for the dysplasia, for the dysplasia, um, you can manage depending on where they fall into. So there's endoscopic endoscopically, resectable polypoid dysplastic lesions. Um, what is recommended for them is annual surveillance colonoscopy. That's what is recommended rather than colectomy for the endoscopically receptible non polypoid dysplastic lesions. Um, after complete removal of that of those lesions, what is recommended or whether what is suggested for them is surveillance colonoscopy rather than collecting as well. Um, for patients with endoscopically invisible dysplasia, Um, usually it's confirmed by G I pathologists. Um, referral is suggested to and endoscopies with expertise in inflammatory bowel disease surveillance, Um, and then for this plastic if and then if the patient has got dysplastic lesions that cannot be resected completely due to extent due to the extent of the lesion or multiplicity, those patients are referred to MDT for discussion regarding definitive management, including surgical options. Okay, um, so the goals of treatment are basically induction of remission, so you have to try to get that to get the disease to go into remission. followed by maintenance of the remission in conjunction with the steroid free treatment in the long term management. So part of the criteria that is used is true love and with criteria and true love and with criteria is basically a, um is a validated endoscopic. Scoring to that helps to, you know, um, check the severity of ulcerative colitis, and it basically combines the frequency of bloody stools. So anything greater or equal to six stools per day with at least one marker of systemic toxicity. So we've got pulse rates greater than 90 90 BPM temperature greater than 37.8 more glow be and or, you know, es are or CRP um, the endoscopic mayor school. So these are just basically scoring system is to try to assess the severity of disease. So this is based on the mucosa, um, appearance at endoscopies. That would let you know how extensive the disease is. Um, this is another scoring system. Ulcerative colitis, endoscopic index of severity. Um, so for mouth moderate disease for the treatment of mild to moderate disease, um, we Usually we we give five amino Silas, five minutes a little solace. God, salicylates so so far as I mean, it's a mesalamine. Those medications they start at full strength does for induction of mission, and over time they can be reduced to a maintenance does. Um, it's It's important to consider, um, combining both or a rectal therapy because it's more effective for inducing remission. Remission? Um, it's And it's what? It's also important to know that routine use and is, uh, necessary to screen for interstitial nephritis while on mesalamine and then routine full blood count and liver function test should be checked. While so far as in, um so systemic corticosteroids are usually given first line for moderate to severe disease. Um, it's never importance. Never advised to give IV or oral steroids for long term therapy. Um, for maintenance of remission tile purines, anti anti TNF agents, anti integrations and and harness, um, Chinese inhibitors can be used. I'm sorry, I didn't think I didn't document all the medications for that. So examples of my parents are like, uh, God as, uh, she'll print it and just make make well. Six. MP, Um, these These are examples of our premiums that can be used in treatment of moderate to severe disease. There are very non. It's important to know that there are very non specific side effects. And there's also an increased risk of cancer of cancer. Um, these are examples of tiene of anti TNF agents, um, influence influencing mob. Darlene, you Bob, Um, it's important that you test. Um, you test this patient, you do. You do a lot of do basic basic screening, basic tests, or rather written blood tests before starting the therapy. Um, so cyclosporine is used as a rescue therapy with the new rules for long term therapy. These are all just medical treatment of ulcerative colitis. Um, thank you. So these are all just medical treatment? Um, um, let's talk about the surgical options. So usually, um, you could you could do either an elective or, um, emergency story. But more often than not, usually emergency surgeries may be due to some sort of, um, emergency or complication of arthritic variety. So we've got, uh, toxic megacolon. Like I said earlier, it is a very valid complication. Life, life threatening. The strength is not him already remember is that there's a lot of ulceration and then, um, acute for meningococcal I. It ease. That is not that is not responding to medical treatment. So, yeah, um, these are the four options for, um the for the for like for ulcerative colitis. They treat district middle management of ulcerative colitis. Those are the options. This, um this next slide gave a bit better. Um, yeah. So these are the surgical options for ulcerative diabetes. Um, so basically, we've got the books. Um, ileostomy. We've got the cox pouch. We've got Musica the little pouch in our anastomosis and the erectile anastomosis. So for the standard book or the standard of the ileostomy is the most common type that is used and usually the end end. Part of the ileum is pulled through the abdominal wall and stand back and switch out to the skin so it leaves the smooth rounded inside out the ileum as the as the stoma. So basically, the output would be obviously liquid or paced, like, you know, drainage. That and it's important to know that in this part in this kind of, um, ileostomy the all the drainage also contains digestive enzymes. So skin protection as management for this patient is very, very important. It's important to use an open ended pouch that can be emptied. So that's for the book is the standard, um, standard, um, a surgical, um management and is the most common. The next one is the continent Ileostomy, which is also known as the abdominal pouch or the cox pouch. Um, it's a different kind of standard ileostomy, and it's actually made by looking part of the ileum back on itself so that the so that a reservoir or a pocket is formed inside the belly. Um, so, um, usually the output that comes up from that is also like a liquid or a pace like sort of drainage. But there are no digestive enzymes in this case. So in terms of management, is just to drink off as often as trouble, um, with a small tube or like a catheter. And it's important, obviously, to use a stomach over cover. Um, the other one is the little pouch or the little pouch, and in our anastomosis or the in our reservoir, um, the output is usually soft forms to, um, and the management is basically natural. Our so so for this patient. Natural bowel movements take place, but you need to protect the skin around the, you know, obviously, because of the anastomosis. Um, so these are just more pictures that shows. Okay, that shows the the surgical management or the surgical. Um, um, aspects of, um, of the surgical treatment here of, um, ulcerative colitis. And that is it. Sorry. I think I was a bit fast, but, um okay, that's it. Thank you. Thank you. Thank you. Once again, I'm Juanita. I know in all fairness is a broad topic to cover within the time within the time. Uh, but we would look at maybe another avenue for you to do for that justice to this, um, every time. Present itself once again. Thank thank you all for, um, staying tune. Um, please. The floor is open for further questions. Um, well, the questions are, um, comment or we're trying to get our questions ready. Um, I will call on, um, Dan, um, he's already on stage than if he could a mute your mike and, um, done on your cameras so we can see you and try and get your things ready while we're waiting for questions. Um, monitor once again. Thank you for your presentation. Honestly, it was nice. It was a nice presentation. It's just sad that we have to wait until today. It would have been nice if we had it on Monday, but thank you. I honestly don't know what happened between Monday and today because it's the same. Internet is the same house. It's the same everything. I really don't know what changed. Honestly, Yeah. Maybe I was supposed to do it today instead of Monday? I think so. I think so. As well. So, Dan, thank you. Um, so the floor is yours. Your slides. Are you ready? I'm trying to upload the slides now. Um, so please feel free to drop any question you have on the chat box. I'm sure we'll be able to answer them. Um, and also, if you would want to um, yeah, if you would want to catch up on any of the topics so far, please feel free to, um, go to the page and the s t i g page, uh, and catch up with this with this topic so far, um dot Are you ready? Almost. Okay. Okay. Uploading my slide that. Yeah, to have done How is work? Uh huh. Work is fine. I guess I think I'm walking at home, then at my slightest. That is ready. Okay, good. So, over to you, then. Hello, everyone. If you can introduce yourself as well, that would be nice. Thanks. Yeah, thanks. Hello, everyone. My name is a canyon, and then I, uh, frustrate executed Department of Elderly Care Geriatric medicine with the Royal Family Hospital insurer here in Cornwall. It's one end of the UK Far Southwest, and I'll be doing the presentation on the general approach to management of acute abdomen. Is everyone hearing me loud and clear? Yes, I can hear you. Okay. And now we're seeing my slides. Yes. You can see your lungs as well. All right, so I tend to make this very brief. It's very broad topic. So I decided to go the other way, make it very narrow, and then talk about things more in the general sense. Because this thing, give me the luxury of, you know, a particular surgical topic to address. But it's something we can finish in one day, so we'll see how much we can do about this and how far we can go. I'm also going to share resources by using preparing where you can get more information if you want. Um, yeah, if you notice the background of the sliding screens. So my sincere had felt condolences to everyone up here over the loss of traffic queen who has served the United Kingdom almost all useful. Age 70 whole year's. Um it's quite sad she had to leave, but yeah, at some point, you need to exit the stage, and, uh, the back, uh, background is just communicate the fact that we have morning and clean. So acute abdomen. Yeah. Like I said, here it's a black hole of medicine, and, um, Black hole here is more like a metaphor for, you know, something that you get into and you don't really know where it's leading YouTube. And if you're not careful, you keep getting drawn and drawn and grown and probably lost in it. Or on the flip side, um, it can form very beautiful contrast where, like you have on this slide, you know, we have the black behind, and then you have the white writing come out clearly so you can form a very nice background to highlight very colorful and beautiful things. Uh, the definition of acute abdomen is really variable, but it generally presents a sudden onset of severe abdominal pain for which trauma is excluded. And that would usually need a surgical review and surgical assessment. Um, the timeline for the definition varies. Some people say 1 to 2 weeks. But in real life, patients usually present in a matter of us to maybe a few days Muslim, the E D. But then you could have your, you know, formally stable surgical patients in the world develop an acute abdomen or even a medical patient, so you won't rule it out completely. In a patient who has been stable has been an inpatient. Anything could have happened, making them presents with an acute abdomen. So the severe pain is the hallmark of acute abdomen. But can it be painless? Does anyone want to attend? Can acute abdomen be painless? Yes. Okay. Yes, we're here. We're here. Yeah. I was saying Okay. I think it means I should go ahead to answer the question. Yes, I think abdomen can be painless. Uh, it can be painless. In Children. It can be painless in diabetics, people who probably have, uh, you know, liver dysfunctions and they can't really translate pain or transmit pain. The etiology of acute abdomen. A whole lot of things can present an acute abdomen. I just decided to get this picture for patient info, and it shows you the different things that can present as acute abdomen. It shows us the picture of the abdomen divided into the four different quadrants. And then the various things that can happen in each quadrant of the abdomen that you know would present as a kid that can present as a kid to the abdominal pain for which you should consider acute abdomen, as, you know, a differential. So we've got here up in the epigastric area. It could have myocardial infraction. Tactical circular societies prioritize. So focused. And, uh, yeah, I'm sure we can all read these for ourselves, so I won't really waste time going through all of it. Um, the next thing would be the assessment of this patient that has, you know, been called Sorry. That presents you with an acute abdomen. Um, the assessment of this patient will just follow the same principles for the assessment of an on well, patient. Generally, most times these patients are seen in eating, and I refer to you as either the surgical shor effort. Okay, Know the surgical effort would take, uh, I will not take blips. So refer to the surgical S h o seen by an ent doctor of a severe acute abdominal pain. Now, the things I would always make them refer to the surgeons would be one. If there is very much standard nous of Puritanism say, Oh, we can't lay our hands on the abdomen. And for some of them, they will be diligent enough to do bloods. And once they have raised inflammatory markers like white Cell count, see are in the 200 or more, they'll be thinking it's something more surgical. Probably do a blood gas, and they come up with high lactate. Um, they'll be thinking of something surgical and they'll call you to come review. So when you call to see this patient, the first thing you should do is your eight to assessment of this patient. Um, this is not the patient. You go to sit down and you know you want to take a very detailed history because you could be taking history, and then the patient's dies right in front of you. So you start with your A B C d e. And that is not what we are going to address in this topic. We all know e you sort out the issues as you encounter them in doing your A B C d e. So, whatever you know, you find your a B C D. You should at that point correctly for moving ahead, and then you take your history. The focused history in this setting is what you you know, you go for and it goes side by side with the various interventions You you have to take to keep this patient that But nonetheless, you have to explore the securities of the pain because I think I have mentioned in the okay, now, this is the first time we mentioned the abdominal pain is the most prominent feature, but it could also be, Yeah, I did mention it earlier. So you should expect the securities of the pain because it will give you an idea to what kind of pain this patient is presenting to the three major types of abdominal pain you would have with the visceral parietal or referred pain and visual pain will be coming from whole obese cause caused by, you know, inflammation of the nerves within the hollow organs causing, uh, all kinds of pain, mostly colicky kind of pain. And you see, in this kind of patients, you see them wriggling around trying to get a comfortable position, and the other kind of pain is very little pain. And it's caused by irritation of the marital peritoneum. And it's what you have in puritanism. Probably you have some preparation somewhere, something irritating the para tile peritoneum and causing pain. And that pain will be referred according to the dermatomes of on the skin. So the area you're you're feeling the pain would give you an idea as to where this is coming from. Then referred pain is the other kind of pain Where, um, there is a pathology in a certain organ, and then the pain goes up somewhere else. Like you, probably you have a gallbladder issue. You you see, they have pain referred to the tip of the shoulder, so you should be able to explore those. The aim of your assessment of this patient is to determine if they need or gyn surgical intervention. So that's that's really your job as the junior doctor. Do they need or gyn surgical intervention? You cannot make all of that decision on your own. And that's why when we get to the management, I'll tell you why you need to, you know, call for for help earlier. Um, hum the examination. After you've taken your history, you want to examine your patients, and then you should go with your IPP. A can never go wrong with this for inspection like we're taught from medical school starts from the foot of the bed and then you go to the side of the patient. And what are you looking for for a patient that comes with pain? The first is the general physical exam, which you should have done in your age to be anyways, and then your in your abdominal exam. You'll be inspecting for any distention. Sorry. Um, it's an abdominal distention. Are you seeing visible striae or visible veins on your abdominal? You know your external abdomen Is that something that you can see physically wrong with the eyes and the next will be our patient, but you do your light and the palpitation you'll be feeling for tenderness for masses for hernias. Are there any swellings that things to be looking out for with your power patient and then, um, precaution, Of course where you can, you know, At least it sounds like you're shifting dullness to rule out fluid collection in the abdominal, you know, in the in the peritoneum and all. And then finally, your auscultation where you listen to start to school for, for bowel sounds, for a bruise. And, yeah, I think basically use attitude things to look out for on auscultation. Then, um, you have seen this patient. You've taken a brief history. You've done an examination to give you a rough idea of where the issue may be coming from. You don't think of the investigations you should do. And it's always safe to think of your investigations as bedside investigations, liberation and radiological investigations. But for the best side investigations first, few things you should do for the patient presented with acute abdomen would be when you should do an easy teen discount point in the direction of many things. These patients who is presenting as an active argument could actually be, and MRI and your e C D. Is going to help you pick that early enough. You do a urine dip really important to tell you if there is any, Probably your sepsis or something going on with the urinary tract, Your blood sugar, your blood sugar would answer a whole lot of questions. Um, especially in if these patients were to be a diabetic and then you're having very high blood blood glucose, then you'll be thinking in the area of could this be a peek A h s? And in that instance, you need to do you know your blood ketone to rule out a diabetic emergency. Blood gases are very, very important in, you know, assessing the patient that comes with this abdominal pain because it helps you make quicker decisions. For instance, uh, you do the blood gas and the patient comes back really acidotic. So it tells you that you have in your hands to do aggressive resuscitation for this patient. Let's say you have lasted as high as 9.0. You can give you an indication that probably this patient who has come with sudden onset, severe abdominal pain be having some bowel ischemia going on. It could be having some bowel obstruction if you know they came with obstructive type symptoms with the distention and all. So it gives you an indication as to how much anaerobic black OSIs is going on and the need for, you know, rapid resuscitation and intervention. You want to check your the saturation in laptops? I have always, I've already mentioned. And in today's world, you need to do cause of it so but at the bedside and seeing this patient, your blood test would be the full blood count the user is. You want to do the liver function test? I want to see what the CRP is doing because it's usually raised in inflammatory conditions and then blood cultures. Depending on the picture you're seeing, for instance, this patient is coming with the abdominal pain. Um, they have their free brow and you're thinking of cholangitis. You definitely would want to do blood cultures for this picture and then the radiological investigations. You always want to start with things that you can readily access, especially in eating. You're more likely to get something like the chest X ray done, and it would help you. Let's say you're having an elderly patients coming in with abdominal pain. All they could have could be probably a chest infection in pneumonia, and your chest X ray can help you rule that out. So if if you do that because there are times they they call you from eating with CRP of this, let's say 3, 15 and some tenderness in the right upper accordance. But the patients, all he he or she has it's just, you know, the right lower lobe pneumonia. So your chest X ray comes in really handy. I can help you make that impression and send them to the medics where they're supposed to be abdominal X ray really important for patients who come in with obstructive type type symptoms that come with abdominal distention and you are really tender. You're thinking of a perforation. You want to do an abdominal and erect abdominal x ray, which will show you, you know, uh, under the diaphragm. And it can also help you. If, uh, probably this patient is constipated, you'll be able to see that on your abdominal X ray. It can give a Q or include to, uh, obstruction, but for obstruction, you definitely need to have a C T a P done. The other investigation would be the ultrasound scan, which is important with biliary pathology. But you cannot always get, especially during the night time. You don't have the ultrasound all around the club. So you're CTAP really important and you know, readily available out of us, then MRI Is that which, you know most times has to be planned. The other investigations that can be done. But these are the ones that are, you know, readily done and helps you in making a quick decision. So your management of the patient that comes in as a case of acute abdomen, the first thing I put on the slide is to call for help. So as a junior doctor, you always have. You need to know that, um, you should always escalate things to your seniors, especially things that would be beyond your reach beyond your expertise as a junior doctor. So what I would do is even believe to the e. D. For a patient, I'm thinking would be an acute abdomen. I'll need to inform my registry so that he doesn't go out in that time to probably have a cigarette break. He knows he actually knows that. You know, there's something coming my way, and, you know, they're really handy to come in in case I need them. So I informed the seniors even before going to, uh, to assess this patient, because at times decision it's usually very, very urgent. And you know you can turn around. The other people will be mad at you. Where is your registry? So you need to inform them for going down and the general principles will be based or the principal. Whatever you do for the patient is going to be based on the presentation so that there are principles would include the fasting. And most important thing is resuscitation of this patient. And this is where you know we tend to lose patients if we don't adequately resuscitate them. So your patient comes in, you need to assess. Are they dehydrated? How much do I need to give them? And how rapidly do I need to give them this flu? What is the lactate level doing? How much fluid do I need to give them to, you know, correct this locket and they flew responsive. So if let's say, for instance, the patient comes with a packet of nine and you give one liter bottles of food. You need to recheck that lactate level in, say, and our spine if you check in one. Uh, and it's going up to 10 or 11, tells you that there's something going on that needs, you know, more aggressive resuscitation and quicker intervention, and you need to get that on on the ground now with the resuscitation, it's usually safe to get. Make it multidisciplinary. So if I have a patient that's accurately unwell in E team with high lactate highly acidotic, I would want to sleep outreach team and make them aware I've got such a patient and I need them to come with you for most times. Your your patients, uh, presenting with acute abdomen and they end up in theater. At times, you don't even get to the world. So it's from e d. Resuscitate and then take the theater directly. So you need to get those teams involved, you know, informed theater stuff, especially out of us. Inform your registry. So all hands on the bed and then you know that these patients can go either way. So the resuscitation part is, you know, really important for this patient. And it means you need to assess and reassess this patient for every intervention you're doing. If they are hypertensive, how much fluid do you have to give to them? You need to give them blood. Um, you need to give things like bicarbonate if they are being, you know, really acidotic. And you can't make all these decisions all by yourself. You need, you know, a multidisciplinary approach to dealing with this. Then the next thing will be analgesia. Pain is really prominent with acute abdomen. And it's really important for you to keep your patient, you know, comfortable before that worked out, you shouldn't really If you're patient, comes in a pen anxieties, you shouldn't give them pain killers because it's going to mask the symptoms. But that's that's not true. The pain and the analgesia keeps your patient's comfortable and, you know, helps you make a better assessment of these patients. But you still be able to elicit the signs like ferritin is, um, in these patients. Even after you've given them some analgesia to make them comfortable, the next one will be appropriate investigations. So what investigations are you asking for these patients and are they relevant at that time? And all of these decisions are the decisions that you can always make at the tip of your fingers, especially as a junior doctor. So that's why it is important to have you know your senior with you to help you. So let's say, for instance, your patient comes with bowels not opening for five days, two flat ooze or two feces, and they are distended, and they've been vomiting over time. Yeah, For patients like this, you'll be thinking this patient should have an intestinal obstruction. So in their resuscitation, you should do your whole sock and drip routine, putting an energy to give IV fluids. You know, you check their blood gases to see what they're doing because they've been vomiting loads of expecting some metabolic acidosis. So you want to be correcting that, then in your investigation for this patient, top of the list should be a CT, abdomen and pelvis, but you are able to do an abdominal X ray. If this patient does not look very bad and toxic, you can afford to, you know, waste that time to do an abdominal X ray. If they look really bad and toxic. You want to do a CT, abdomen and pelvis? This is my patients. You want to be requesting for an ultrasound scan for or say, for instance, the patient comes in with Sundays, has got believing of 19. Has CRP in the 100 l p l t. Raised their federal. They are hypertensive already thinking of cholangitis in these patients. And let's say eight PM in the night, you're not going to be able to get an ultrasound scan even when that would have been, You know, the best investigation for you. So for that patient, you want to go straight to having, you know, a CT of the abdomen and pelvis by so doing, you know, requesting for the appropriate investigations at the right time. You're helping to hasten the management of these patients. And there's no time lost in, you know, requesting the wrong investigations and then coming back to have a decision to say, Oh, probably, we should rather go for this. So it's really important that you're able to request for the appropriate investigations exact when you want to, and that patient with colon rises know when you'll be asking for an MRI C P at eight PM Because definitely you don't have anyone to do an MRI for you at that time of the night. Multi. See multidisciplinary team involvement, you know, maybe very necessary in management of the patients with, uh, acute abdomen. Because some of these patients don't come become other comorbidities. For example, your patients who comes with, uh, let's say it's chemical colitis or mesenteric ischemia. It's likely going to be 60 something. Some something year old who's got a probably has a background of heart failure, has had multiple heart attacks in the past. Some of them may be centered. Some of them may even have, you know, a pacemaker in in their hearts. So this patient is not just going to present to you with facts, um, abdominal issue, but they have other things complicating their story. So you may need the medical implants of the medical record. You may need an aesthetic team. This patient may need to go to I t U for resuscitation, so you need to factor in all of these for the patient. So, basically, your management of the patient with an acute abdomen it depends on what the presentation looks like so for a patient who comes to you looking really stable in new score of zero complaints of an abdominal pain and has some tenderness in the right iliac fossa, or is otherwise soft and nontender. And, let's say, has a CRP of 30 white cell count of 14 the current referral. They are not for meeting. At the moment, your approach to managing the patient is going to be different and probably let's say they are 30 years old. It's going to be different from your approach of managing. The patients who's got a history of atrial fibrillation has come in with sudden onset, um, severe abdominal pain, accompanied by about Oh, sorry, one big bowel movement at times with blood in it. And then, um, they are really tender in the abdomen. They got elected of nine. And yeah, they have other comorbidities like I already mentioned hypertension and your approach to managing these two patients, you know, at different You want to be more aggressive with the latter patients than you are with the first patient. Um, the commonest causes of acute abdomen in people above 50 would be biliary, you know, biliary pathology, then followed by a non specific abdominal pain. And then, uh, we'll follow closely would be, uh, the vascular issues, like your ischemic colitis and the rest. But for younger people, people less than 50 commonest causes will always be non specific abdominal pain. And that's you've done all the investigations, and then you're not able to find why we have presented with with an acute abdomen, then, uh, it's more from the things like appendicitis. These miliary pathology comes down down down the ladder for those younger people. So depending on the age of the patients, you should also be thinking in those lines. So your management of the patients active treatment is more or less management of the patients who comes accurately unwell, needing vigorous resuscitation. The only difference is that the decision has to be made if they need any surgical intervention at the time you're seeing them less than 30 minutes to one. Uh, that decision is a decision that would always be made by the seniors on the team and not necessarily by yourself as a junior doctor. But you should be able to sign post them to the fact that you're worried about this patient and you think you may need, you know, urgent surgical intervention, and then they'll come down to see the patient with you. So that is all we have on this presentation. And here I have some links to some of the resources I used and two more elaborate slide on acute abdomen that shows so much details. I didn't I didn't see the need to have all of those details here because we weren't speaking about, you know, in particular cause of acute abdomen, for which, you know, one could have explored everything from history management in that specific case. And one resource I couldn't put here. Yeah, its material I can share with everyone if we want. It's more like a revision book for surgery. And he teaches the basic basic surgical things are some cases that presents to you. And thank you very much for listening. Do we have any questions? Yeah. Once again, Done. I I think all the presenters today, uh, being brought the game of the game. You know, uh, everybody gave a very good presentation. I like the talk put into it. You could see that everyone has done a good amount of work to make sure that the presentation's well put together. And I truly do truly, truly appreciate that. Um, while we're waiting for questions, please drop any questions you have on the comment That on the chat box, Um, But while we're waiting for that, I think I will just draw some attention to a few things. The reason why we chose these topics were largely to start off with something broad. And as we go in the coming days, we narrow it down to bits and pieces and, uh, gets much more specific things. It's just, um it's, um this is the first session we're holding on this platform before. Now, we've had a few other sessions, not in this platform with other groups and things like that. But this is the first we're holding this platform. And, um, I think for me, I thought this was a better way to go. Um, while we're waiting for questions I would really appreciate if people can ask a few questions. Um, as as Well, so, um, my question would be, um, two. Um, Done. Um, just a quick one will be. Now, if, um what what are the You've mentioned the few telltale signs of, um, concerns. But what is the first thing if you go see a patient, um, that you are worried about the most Let's say you are called to see a patient with the query and an acute abdomen was the first thing that you're worried about the most with this patient. Hello? Don, are you there? Uh huh. Oh, yes, yes. Sorry. What's your question again? Sorry. What's the first thing you're worried about the most? Let's say, once you're called to see a patient with an acute abdomen, what's the first thing that you're worried about? Um, I really can't give an answer to that question because I'm wondering where that's coming from. It depends on you know what? The history, because you will always have a clue as to what is wrong with this patient. So it gives you an indication of what you should be worried about in that particular patient. But yeah, Do you Do you have any issues or anything towards know cues? It's just an open ended question. Basically no, que, no, no particular reasons why. Yeah, Okay, um thank you all. And I think Oh, my, my system is down. Good. Um, uh, just to let us know, I will be pasting the feedback link now to the training in the chat box. Please feel free to download that and feel that and, uh, automatically. By filling the feedback forms, a certificate will be sent to your emails as well for the presenters as well. Uh, I would ford you your certificates in the coming days. Uh, please feel free to suggest other topics you want to hear about. And we'll see how we can go about bringing that to light. Well, most Australia, I must thank everyone That has made out time to, um, be part of this presentation. Um, honestly, the time the efforts and everything you've put in has been well appreciated. And we've learned a lot honestly, from the from this exercise. Um, also, you'll be getting an email as well. At the end of this conference that has the feedback forms. It's, uh it's a link you could use. It's a one off link that you could use. Please feel free to leave honest feedback, because I think that will be all we need to improve going forward. Um, in the coming days, I would inform us about when we're going to have our next group of, um, lessons or sessions. It could be something spread out over a period. It could be something we do a massive, but it just depends on availability and all that. Um, once again, thank you very much. Thank you for the time. Thank you for the efforts. And thank you for the feedback. Some expected. So, um, going forward, I really looked working more with you guys and a bit more. Um, and other people as well. So thank you for your time. And I do have a wonderful night. Thank you.