PART-A

1)

1. Common clinical condition that is involved in the organ gall bladder is the gallstones or gall bladder stones or cholelithiasis.

• Gross anatomy of gall bladder:

The gallbladder is a piriform (pear-shaped) organ that straddles the undersurface of segments IVB and V of the liver. It has an inferior peritoneal surface and a superior hepatic surface that is closely applied to the gallbladder bed in the liver. The cystic plate is a condensation of fibro-areolar tissue that separates the gallbladder from the liver parenchyma. The cystic plate is well formed in the gallbladder body but gets thinner towards the gallbladder fundus. Small bile ducts may drain from liver parenchyma to the gallbladder through the cystic plate (ducts of Luschka). The part of the gallbladder projecting beyond the undersurface of the liver is called the fundus; fundus continues into the main body of the gallbladder, which lies in a fossa on the undersurface of the liver. The body of the gallbladder narrows into an infundibulum, which leads through the neck to the cystic duct.

The right and left hepatic ducts join outside the liver in its hilum (porta hepatis) to form the common hepatic duct (CHD). The cystic duct joins the CHD to form the bile duct (common bile duct or CBD), which travels downward in the HDL along with the proper hepatic artery to its left and the portal vein behind it.

• Microscopic and macroscopic gall bladder:

The gallbladder wall has the following components: mucosa composed of columnar epithelium that secretes mucus (not bile, which is produced in the liver and is only stored and concentrated in the gallbladder), tunica (lamina) propria, muscularis propria (crisscrossing muscles), subserosa (connective tissue), and serosa (on the inferior peritoneal surface only, not on the superior hepatic surface). The gallbladder has no submucosa. The inner mucosal surface of the gallbladder has multiple polygonal compartments, giving it a honeycomb appearance.

Rokitansky-Aschoff sinuses are mucosal outpouchings that go through the muscularis propria into the perimuscular/subserosal tissue. The cystic duct has spiral folds of mucosa (called valves of Heister). The bile duct (common bile duct or CBD) has a fibroelastic wall with no muscle layer except for the submucosal sphincter (of Boyden) around its lower end; it is lined with columnar epithelium, which secretes mucus.

• Blood supply:

The arterial supply to the gall bladder is through the cystic artery-a branch of right hepatic artery(which itself is derived from the common hepatic artery, one of the three major branches of the coelic trunk).

Venous drainage of the neck of the gall bladder is through the cystic veins, which drain blood directly into the portal vein. Venous drainage of the fundus and the body of the gall bladder flows into the hepatic sinusoids.

2 ) Gall stones is the common disorder that is seen in the gall bladder.

• Gall stones:

Gall stones are pieces of solid material that form in gall bladder, a small organ under liver. Bile also carries wastes like cholesterol and billirubim, which body makes when it breaks down red blood cells. These things can form gallstones. Gall stones can range from size of grain of sand to that of golf ball.

Symptoms:

Pain in upper belly, often on right just under the ribs, pain in right shoulder or back, upset stomach, vomiting, other digestive problems, including indigestion, heartburn and gas.

Cause of gallstones:

• Too much cholesterol in bile.
• Too much bilirubin in bile.
• Gallbladder doesn’t empty all the way.

Diagnostic methods:

• Blood tests , ultrasound, CT scan, MRCP(magnetic resonance cholangiopancreatography), cholescintigraphy (HIDA scan), endoscopic retrograde cholangiopancreatography(ERCP), endoscopic

Gallstones treatment methods:

Laproscopic cholecystectomy. This is the most common surgery for gallstones. Your doctor passes a narrow tube called a laparoscope into your belly through a small cut. It holds instruments, a light, and a camera. They take out your gallbladder through another small cut. You’ll usually go home the same day.

The surgeon makes a few small incisions on the right side of your abdomen (belly). The surgeon uses one incision to insert a laparoscope, a thin tube with a camera on the end. This shows your gallbladder on a screen. The gallbladder then gets removed through another small incision.

Open cholecystectomy. Your doctor makes bigger cuts in your belly to remove your gallbladder. You’ll stay in the hospital for a few days afterward. If gallstones are in your bile ducts, your doctor may use ERCP to find and remove them before or during surgery.

3) Medical management and treatment plan:

Laparoscopic cholecystectomy takes about an hour or two. A surgeon will make a few small incisions in your abdomen. The surgeon will insert thin, hollow tubes into those incisions. The surgical team will then place a laparoscope and other surgical tools into the tubes.

Your team may pump carbon dioxide into your abdomen. This step inflates the surgical area and makes it easier to see inside. Using the special tools, the surgeon will detach the gallbladder from the rest of the body and remove it. The team will then close the incisions with stitches, surgical clips or surgical glue.

If any complications occur during laparoscopic cholecystectomy, the surgeon may decide to use an open cholecystectomy instead. That procedure involves a larger incision.

After surgery, do the following to help recover:

• Avoid lifting heavy things.
• Drink plenty of water.
• Eat foods high in fiber to help your bowel movements (pooping).
• Follow your healthcare provider’s instructions about taking care of your wounds and taking medications.
• Slowly increase your activity.
• Walk a little bit every day to prevent blood clots.

4) Surgical management of the disorder:

• Anatomical basis of surgery and anatomical relation of organ:

The method of retraction during the laparoscopic procedure tends to distort the Calot's triangle by actually flattening it rather than opening it out. Also, the reluctance to (or difficulty in) performing a fundus first cholecystectomy during the laparoscopic procedure as opposed to the open procedure also contributes to the same lack of exposure of the Calot's triangle. Finally, the ‘posterior’ or ‘reverse’ dissection of the Calot's triangle, which is popular during an Laproscopic Cholecystectomy, again gives a different view of the area and since the gallbladder is flipped over during this method may lead to further anatomical distortion. The Rouviere's sulcus is a fissure on the liver between the right lobe and caudate process and is clearly seen during a LC during the posterior dissection in a majority of patients. It corresponds to the level of the porta hepatis where the right pedicle enters the liver. It has hence been recommended that all dissection be kept to a level above (or anterior) to this sulcus to avoid injury to the bile duct. Also, this being an ‘extrabiliary’ reference point it does not get affected by distortion due to pathology. Similarly, a clear delineation of the junction of the cystic duct with the gallbladder along with the demonstration of a space between the gallbladder and the liver clear of any other structure other than the cystic artery (safety window or critical view) is also recommended as an essential step to prevent bile duct injury.

• Instruments and equipments used:

To perform laparoscopic cholecystectomy we employ a high-resolution video endoscopy system, two high-resolution color monitors, a high-flow CO2 insufflator, a 300 W Xenon light source, electrocautery and/or lasers, and an endoscopic suction-irrigation system.

With these tools, appropriately designed for laparoscopic surgery, including a laparoscope, graspers, dissectors, cholangiography equipment, scissors, and clip appliers, the surgeon can remove the gallbladder without opening the abdomen. The procedure requires the induction of a CO2 pneumoperitoneum, insertion of four trocars, and placement of a grasping retractor to set the operative field. An additional retractor placed on Hartmann's pouch provides countertraction for dissection of the hilum. Careful dissection around the cystic duct and cystic artery with a combination of electrocautery and blunt dissection allows the surgeon to skeletonize the cystic duct and artery. After intraoperative cholangiography confirms the anatomy, the cystic artery and cystic duct are clipped and divided. Electrocautery or laser techniques can be used to perform retrograde dissection of the gallbladder from the liver bed and insure hemostasis. The gallbladder is detached and removed intact through the large trocars.

Laproscopic insufflators:

Xenon light source:

Irrigation system or drill:

• Equipments used to monitor the post operative care:

You will get pain medicine as needed. A nurse may give it to you. Or you may give it to yourself through a device connected to your IV (intravenous) line.

You may have a thin plastic tube that goes through your nose into your stomach. This is to remove air that you swallow. The tube will be taken out when your bowels are working normally. You won’t be able to eat or drink until the tube is removed.

You may have 1 or more drains in the incision if an open procedure was done. The drains will be removed in a day or so. You might be discharged with the drain still in and covered with a dressing. Follow your provider’s instructions for taking care of it.

5) Recent advances:

Laparoscopic cholecystectomy combined with endoscopic sphincterotomy and stone extraction or laparoscopic choledochoscopy and electrohydraulic lithotripsy for management of cholelithiasis with choledocholithiasis

Six hundred twenty-two laparoscopic cholecystectomies were performed at St. Vincent Hospital over a 14-month period. We reviewed the records of 366 of these patients who were referred to the authors. Thirty-six patients had suspected choledocholithiasis. The primary author (M.E.A.) performed 38 endoscopic retrograde cholangiopancreatography (ERCPs) on these patients for diagnosis and management. Seventeen of the 36 patients had common bile duct stones; 19 patients had negative studies. Of the 17 patients with choledocholithiasis, 15 had successful cannulation of the common bile duct, and, of these, 10 underwent laparoscopic cholecystectomy plus endoscopic sphincterotomy and extraction of the common duct stone(s). In one high-risk elderly patient, we extracted the stone from the common duct and left the gallbladder in situ. Two patients failed endoscopic cannulation and underwent open cholecystectomy with common bile duct exploration. Four additional patients, cannulated successfully, had unsuccessful endoscopic stone removal because the stones were too large or were impacted. Two of these patients underwent open cholecystectomy and common duct exploration. The two other patients underwent laparoscopic cholecystectomy and choledochoscopy through the cystic duct with the flexible choledochoscope. An electrohydraulic lithotripsy probe was then inserted through the choledochoscope to fragment the stones, and stone fragments were allowed to pass through the previously created sphincterotomy. We believe our data, supported by data in the literature, show that these alternative methods for treating choledocholithiasis are safe and effective and should be considered primary modalities for treating this condition now that laparoscopic cholecystectomy is the treatment of choice for cholelithiasis.

https://pubmed.ncbi.nlm.nih.gov/1344571/

1. The common respiratory system disorder is the cystic fibrosis:

• Gross anatomy of lungs:

The lungs are the major organs of the respiratory system and are divided into sections, or lobes. The right lung has three lobes and is slightly larger than the left lung, which has two lobes.

The lungs are separated by the mediastinum. This area contains heart, trachea, oesophagus and many lymph nodes. The lungs are covered by a protective membrane known as the pleura and are separated from the abdominal cavity by the muscular diaphragm.

With each inhalation, air is pulled through the windpipe (trachea) and the branching passageways of the lungs (the bronchi), filling thousands of tiny air sacs (alveoli) at the ends of the bronchi. These sacs, which resemble bunches of grapes, are surrounded by small blood vessels(capillaries). Oxygen passes through the thin membranes of the alveoli and into the bloodstream. The red blood cells pick up the oxygen and carry it to the body's organs and tissues. As the blood cells release the oxygen they pick up carbon dioxide, a waste product of metabolism. The carbon dioxide is then carried back to the lungs and released into the alveoli. With each exhalation, carbon dioxide is expelled from the bronchi out through the trachea.

• Microscopic and macroscopic structure of lungs:

The trachea has multiple layers (see the image below). The mucosa is composed of a ciliated pseudostratified columnar epithelium and numerous mucus-secreting goblet cells that rest on a basement membrane with a thin lamina propria (mainly collagenous). The submucosa contains seromucous glands. The adventitia contains cartilaginous rings interconnected by connective tissue. The hyaline cartilage rings have the form of the letter C and are opened posteriorly. The open ends are connected by fibroelastic tissue and a band of smooth muscle (the trachealis).

The epithelium of the bronchus is pseudostratified columnar ciliated epithelium, also with numerous goblet cells. This epithelium transitions first into a simple columnar ciliated epithelium and then into a cuboidal epithelium as it continues branching into smaller bronchioles. The cartilage support is eventually lost at the bronchiolar level (0.5-1.0 mm diameter). The muscle layer becomes the dominant structure and is composed of smooth muscle and elastic fibers (see the image below). At this level, the mucosa may be highly folded because of the loss of supporting structure

The terminal bronchioles are considered the respiratory zone of the lungs (ie, the area where gas exchange occurs). They divide into respiratory bronchioles, which continue downstream as alveolar ducts that are completely lined with alveoli and alveolar sacs (see the image below). Over 300 million alveoli exist in the human lung, all of them covered by an extensive network of capillaries (branches from the pulmonary arteries). The respiratory zone constitutes most of the lung (2.5-3 L).

• Blood supply to lungs:

https://www.kenhub.com/en/library/anatomy/the-lung

The lungs have dual, parallel blood supply referred to as pulmonary and systemic circuits. The pulmonary circuit arises from the heart and brings deoxygenated blood to the lung for gas exchange. This circuit also takes oxygenated blood back to the heart to be redistributed to the rest of the body. The systemic circuit takes oxygenated blood from the heart to the lung parenchyma that cannot be supplied by simple diffusion. The venous arm of this circuit also takes deoxygenated blood back to the heart to be processed.

Pulmonary supply:

Arterial supply:

2) one of the common disorder that is found in the respiratory system is the emphysema.

Emphysema is a lung condition that causes shortness of breath. In people with emphysema, the air sacs in the lungs (alveoli) are damaged. Over time, the inner walls of the air sacs weaken and rupture — creating larger air spaces instead of many small ones. This reduces the surface area of the lungs and, in turn, the amount of oxygen that reaches your bloodstream.

When you exhale, the damaged alveoli don't work properly and old air becomes trapped, leaving no room for fresh, oxygen-rich air to enter. Most people with emphysema also have chronic bronchitis. Chronic bronchitis is inflammation of the tubes that carry air to your lungs (bronchial tubes), which leads to a persistent cough.

Symptoms:

The main symptom of emphysema is shortness of breath, which usually begins gradually.

Causes:

The main cause of emphysema is long-term exposure to airborne irritants, including:

• Tobacco smoke
• Marijuana smoke
• Air pollution
• Chemical fumes and dust

Rarely, emphysema is caused by an inherited deficiency of a protein that protects the elastic structures in the lungs. It's called alpha-1-antitrypsin deficiency emphysema.

Risk factors:

Factors that increase your risk of developing emphysema include:

• Smoking
• Exposure to secondhand smoke
• Occupational exposure to fumes or dust.
• Exposure to indoor and outdoor pollution. .

Complications:

People who have emphysema are also more likely to develop:

• Collapsed lung (pneumothorax).A collapsed lung can be life-threatening in people who have severe emphysema, because the function of their lungs is already so compromised. This is uncommon but serious when it occurs.
• Heart problems.Emphysema can increase the pressure in the arteries that connect the heart and lungs. This can cause a condition called cor pulmonale, in which a section of the heart expands and weakens.
• Large holes in the lungs (bullae).Some people with emphysema develop empty spaces in the lungs called bullae. They can be as large as half the lung. In addition to reducing the amount of space available for the lung to expand, giant bullae can increase your risk of pneumothorax.

3) Medical management and treatment:

Diagnosis of emphysema

Chronic obstructive pulmonary disease, including emphysema, is diagnosed mainly using a lung function test called spirometry. Other tests that may help in diagnosis of emphysema include:

• other lung function (or breathing) tests
• chest x-rays
• CT scans.

Treatment for emphysema

There is no cure for emphysema, although it is treatable. Appropriate management can reduce symptoms, improve your quality of life and help you stay out of hospital.

Management includes:

• stopping smoking immediately and completely – this is the most effective treatment for COPD and emphysema
• avoiding other air pollutants
• respiratory (pulmonary) rehabilitation programs
• oxygen treatment, in advanced cases
• medications such as
• anti-inflammatory medications
• medicine to widen the airways (bronchodilators) and loosen the phlegm
• antibiotics
• stress management techniques
• gentle, regular exercise to improve overall fitness
• influenza vaccination and pneumococcal to protect against certain types of respiratory infection.

• SPIROMETRY:

Spirometry is a common office test used to assess how well your lungs work by measuring how much air you inhale, how much you exhale and how quickly you exhale.

Spirometry is used to diagnose asthma, chronic obstructive pulmonary disease (COPD) and other conditions that affect breathing. Spirometry may also be used periodically to monitor your lung condition and check whether a treatment for a chronic lung condition is helping you breathe better.

SPIROMETER:

https://en.wikipedia.org/wiki/Spirometer#:~:text=A%20spirometer%20is%20an%20apparatus,ventilation%20patterns%2C%20obstructive%20and%20restrictive.

A spirometer is an apparatus for measuring the volume of air inspired and expired by the lungs. A spirometer measures ventilation, the movement of air into and out of the lungs. The spirogram will identify two different types of abnormal ventilation patterns, obstructive and restrictive. There are various types of spirometers that use a number of different methods for measurement (pressure transducers, ultrasonic, water gauge).

Incentive spirometer:

Doctor, surgeon, or nurse will likely give you specific instructions on using your incentive spirometer. The following is the general protocol:

1. Sit up on the edge of your bed or chair.
2. Hold the incentive spirometer in an upright position.
3. Breathe out normally.
4. Place the spirometer mouthpiece in your mouth and close your lips tightly around it.
5. Breathe in through your mouth as slowly and deeply as you can, causing the piston or ball to rise toward the top of the chamber.
6. Hold your breath for 3–5 seconds or as long as possible.
• If the spirometer has a goal indicator, use this to guide your breathing. If the indicator goes above the marked areas, slow your breathing down.
7. Remove the mouthpiece from your mouth.
8. Breathe out normally. The piston or ball will return to the bottom of the chamber.
9. Rest for a few seconds, then repeat the steps 10 or more times.
• Go slowly. Take some normal breaths between deep breaths to prevent light-headedness.
• Do this every 1–2 hours when you’re awake.
10. After each set of 10 deep breaths, cough a few times to clear your lungs.

After each set of 10 breaths, it’s a good idea to cough to cleanse your lungs of any mucus buildup. You can also clear your lungs throughout the day with relaxed breathing exercises like the below:

1. Relax your face, shoulders, and neck, and put one hand on your stomach.
2. Exhale as slowly as possible through your mouth.
3. Breathe in slowly and deeply while keeping your shoulders relaxed.
4. Repeat four or five times per day.

If you’re having difficulty using the spirometer for any reason, including pain or frequency of use, talk with your healthcare professional. Get emergency help if you develop shortness of breath, cough up blood, or see fluid or blood coming from an incision site when you cough.

How are results measured?

The main column of your incentive spirometer has a grid with numbers. These numbers are usually expressed in millimeters and measure the total volume of your breath.

The piston in the main chamber of the spirometer rises upward along the grid as you breathe in. The deeper your breath, the higher the piston rises. Next to the main chamber is an indicator that your doctor can set as a target.

There’s a smaller chamber on your spirometer that measures the speed of your breath. This chamber contains a ball or piston that bobs up and down as the speed of your breath changes.

The ball will go to the top of the chamber if you’re breathing in too quickly and will go to the bottom if you’re breathing too slowly.

Many spirometers have a line on this chamber to indicate the optimal speed.

Incentive spirometer benefits

Research trusted source has found conflicting results on the effectiveness of using an incentive spirometer compared with other lung strengthening techniques.

Many of the studies looking at potential benefits were poorly designed and not well organized. But there’s at least some evidence it may help with:

• improving lung function
• reducing mucus buildup
• strengthening lungs during extended rest
• lowering the chance of developing lung infections

Pulmonary function test:

A spirometer is the main piece of equipment used for basic Pulmonary Function Tests (PFTs). Lung diseases such as asthma, bronchitis and emphysema may be ruled out from the tests. In addition, a spirometer often is used for finding the cause of shortness of breath, assessing the effect of contaminants on lung function, the effect of medication, and evaluating progress for disease treatment.

Types of spirometer:

Whole body plethysmograph

This type of spirometer gives a more accurate measurement for the components of lung volumes as compared to other conventional spirometers. A person is enclosed in a small space when the measurement is taken.

Pneumotachometer

This spirometer measures the flow rate of gases by detecting pressure differences across fine mesh. One advantage of this spirometer is that the subject can breathe fresh air during the experiment.^[27]

Fully electronic spirometer

Electronic spirometers have been developed that compute airflow rates in a channel without the need for fine meshes or moving parts. They operate by measuring the speed of the airflow with techniques such as ultrasonic transducers, or by measuring pressure difference in the channel. These spirometers have greater accuracy by eliminating the momentum and resistance errors associated with moving parts such as windmills or flow valves for flow measurement. They also allow improved hygiene by allowing fully disposable air flow channels.

Incentive spirometer

This spirometer is specially designed to encourage improvement of one's lung function.

Peak flow meter

This device is useful for measuring how well a person's lungs expel air.

Windmill-type spirometer

This type of spirometer is used especially for measuring forced vital capacity without using water; it has broad measurements ranging from 1000 ml to 7000 ml. It is more portable and lighter than traditional water-tank type spirometers. This spirometer should be held horizontally while taking measurements because of the presence of a rotating disc.

4) anatomy for the disorder:

Positions studied

1. Standing – unsupported active standing
2. Sitting – sitting on a chair or wheelchair with the backrest at 90° and all limbs supported
   3. Supine – lying flat on the back
   4. Right-side lying (RSL) – lying straight on the right side
   5. Left-side lying (LSL) – lying straight on the left side

Outcome measures and defined thresholds for clinical significance

1. FVC – forced vital capacity
   • Change of 200 ml or 12% from baseline values in FVC
2. FEV1– forced expiratory volume in 1 s
   • Change of 200 ml or 12% from baseline values in FEV1
3. FEV1/FVC – forced expiratory volume in 1 s divided by forced vital capacity
   • FEV1/FVC < 0.7 is defined as obstructive disease

4. VC – vital capacity
5. FRC – functional residual capacity

• Change > 10%

6.TLC – total lung capacity

• Change > 10%

7. RV – residual volume
8. Maximal expiratory pressure (PEmax)

• Change ≥24 cmH2O

9.Maximal inspiratory pressure (PImax)

• Change ≤ − 13 cmH2O

10.Peak expiratory flow (PEF)

• Change > 10% or 60 L/min

11.Diffusing capacity of the lungs for carbon monoxide (DLCO)

• Change ≥10% in DLCO

Pulmonary function tests (PFTs) provide objective, quantifiable measures of lung function. They are used to evaluate and monitor diseases that affect heart and lung function, to monitor the effects of environmental, occupational, and drug exposures, to assess risks of surgery, and to assist in evaluations performed before employment or for insurance purposes. Spirometric examination is the most common form of PFT. According to ATS/ERS guidelines, PFTs may be performed either in the sitting or standing position, and the position should be recorded on the report. Sitting is preferable for safety reasons to avoid falling due to syncope, and might also be more convenient because of the measurement devices and patient comfort. However, people who suffer from neuromuscular disease, morbid obesity, and other conditions may find it difficult to sit or stand during this test, which may influence their results.

One of the main goals of positioning, and specifically the use of upright positions, is to improve lung function in patients with respiratory disorders, heart failure, neuromuscular disease, spinal cord injury (SCI), and obesity, and in the past 20 years, various studies regarding the influence of body position on respiratory mechanics and/or function have been published. However, we did not find a systematic review that integrates findings from studies involving non-mechanically ventilated adults to derive clinical implications for respiratory care and pulmonary function test (PFT) execution.

5) Recent advances:

Spirometry, the most common lung function test, is used to evaluate individuals with respiratory complaints or known respiratory disease. However, its underutilization and the misinterpretation of its parameters are causes for concern. Areas covered: This review describes new spirometry-derived metrics, new reference equations, recent recommendations for presentation of results, recent spirometry-based prevalence studies, and technological advances in spirometry equipment. Expert opinion: The underutilization of spirometry can be overcome by increasing access to portable, hand-held, and user-friendly spirometers, together with strategies that increase awareness of the importance of spirometry. New metrics derived from spirometry, together with traditional spirometric criteria, can identify individuals with structural lung disease and respiratory morbidity. Some problems with the reference equations were solved by the Global Lung Function Initiative (GLI), which covers a wider age range and more ethnic groups and provides limits of normality using the z-score. Despite these advantages, the GLI equations lack data from large populations and greater representation of older people. Another disadvantage attributed to the GLI is the lack of predicted values for peak expiratory flow and other airflows, limiting the interpretation of the maximal expiratory flow-volume curve.

https://pubmed.ncbi.nlm.nih.gov/30977428/

3) Excretory system:

• Kidney:

The human excretory system organs include:

• A pair of kidneys
• A pair of ureters
• A urinary bladder
• A urethra

Kidneys are bean-shaped structures located on either side of the backbone and are protected by the ribs and muscles of the back. Each human adult kidney has a length of 10-12 cm, a width of 5-7 cm and weighs around 120-170g.

The kidneys have an inner concave structure. The blood vessels, ureter and nerves enter the kidneys through the hilum, which is a notch at the inner concave surface of the kidney. The renal pelvis, a large funnel-shaped space is present inner to the hilum, is has many projections known as calyces.

Excretion in humans:

Kidney has a structural filtration unit called nephron where the blood is filtered. Each kidney contains a million nephrons.

Capillaries of kidneys filter the blood and the essential substances like glucose, amino acids, salts, and the required amount of water get reabsorbed and the blood goes into circulation.

Excess water and nitrogenous waste in humans are converted to urine. Urine thus produced is passed to the urinary bladder via the ureters. The urinary bladder is under the control of the Central Nervous System. The brain signals the urinary bladder to contract and through the urinary opening called the urethra, we excrete the urine.

Mechanism of excretion:

The process of excretion in humans takes place in the following steps:

Urine Formation

The urine is formed in the nephrons and involves the following steps:

• Glomerular Filtration
• Tubular Reabsorption
• Secretion

Glomerular Filtration

It is the primary step in urine formation. In this process, the excess fluid and waste products from the kidney are filtered out of the blood into the urine collection tubules of the kidney and eliminated out of the body.

The amount of filtrate produced by the kidneys every minute is known as Glomerular Filtration Rate (GFR).

Tubular Reabsorption

It is the absorption of ions and molecules such as sodium ions, glucose, amino acids, water etc. Water involves passive absorption, while glucose and sodium ions are absorbed by an active process.

Secretion

Potassium ions, hydrogen ions, and ammonia are secreted out to maintain the equilibrium between the body fluids.

• Microscopic and macroscopic anatomy of kidney:

Each kidney consists of an outer renal cortex, an inner renal medulla, and a renal pelvis. Blood is filtered in the renal cortex. The renal medulla contains the renal pyramids, where urine formation takes place. Urine passes from the renal pyramids into the renal pelvis. This funnel-shaped structure occupies the central cavity of each kidney and then narrows as it extends out to join the ureter. Urine drains from the renal pelvis into the ureter.

Each kidney consists of an outer renal cortex, an inner renal medulla, and a renal pelvis. Blood is filtered in the renal cortex. The renal medulla contains the renal pyramids, where urine formation takes place. Urine passes from the renal pyramids into the renal pelvis. This funnel-shaped structure occupies the central cavity of each kidney and then narrows as it extends out to join the ureter. Urine drains from the renal pelvis into the ureter.

• Blood supply:

Blood enters the kidneys through renal arteries. These arteries branch into tiny capillaries that interact with urinary structures inside the kidneys (namely the nephrons). Here the blood is filtered. Waste is removed and vital substances are reabsorbed back into the bloodstream. The filtered blood leaves through the renal veins. All the blood in the body moves in and out of the kidneys hundreds of times each day—that’s about 200 quarts of liquid to be filtered every 24 hours.

2)uremia is one of the common disease found in the kidney failure person.

Uremia is a dangerous condition that occurs when waste products associated with decreased kidney function build up in your blood. Uremia means “urine in the blood” and refers to the effects of the waste product accumulation. It affects the entire body.

Uremia most often occurs due to chronic kidney disease that may lead to end stage kidney disease (ESKD), but can also occur quickly leading to acute kidney injury and failure that is potentially reversible. Uremia may cause serious health complications such as fluid accumulation, electrolyte, hormone and metabolic problems. Left untreated, uremia is usually fatal and was always so before dialysis and transplantation were available.

Risks:

• Diabetes mellitus
• High blood pressure
• Glomerulonephritis: damage to the filters in the kidneys.
• Polycystic kidney disease (caused by cysts, or fluid-filled sacs, in or around the kidneys).

Causes:

Kidneys help maintain normal levels of acids, electrolytes and hormones such as Vitamin D and erythropoietin (EPO). Damaged kidneys don’t work well, allowing multiple toxins to build up in your blood.

• Creatinine (waste product produced in muscle and in dietary protein).
• Urea (waste product formed in the liver as protein is broken down).

Symptoms:

• Cognitive dysfunction (problems with thinking and remembering).
• Fatigue.
• Shortness of breath from fluid accumulation.
• Loss of appetite.
• Muscle cramps.
• Nausea and vomiting.
• Itching.
• Unexplained weight loss
• In very severe instances, symptoms may include uremic fetor (a urine-like odor on the breath or metallic taste in the mouth) and uremic frost (yellow-white crystals on the skin due to urea in sweat).

Diagnosis:

• Creatinine and BUN blood tests help your provider confirm a diagnosis of uremia. These tests check your blood for high levels of waste products. They also used to estimate your glomerular filtration rate (eGFR). This rate measures your kidney function.

A kidney ultrasound checks the shape and size of your kidneys and looks for scarring. An ultrasound can also detect kidney blockages, such as kidney stones, or injuries. Additional tests may be needed in certain situations.

Treatment:

Dialysis (a procedure to clean the blood) is the most common treatment for uremia. There are two kinds of dialysis. Hemodialysis uses a machine to filter blood outside the body. Peritoneal dialysis uses the lining of your belly and a special fluid to filter blood.

You may need a kidney transplant if uremia is the result of end-stage renal (kidney) failure. A transplant replaces the failing kidney with a donor kidney from either a living or deceased donor.

3) dialysis:

Dialysis is a treatment for people whose kidneys are failing. When you have kidney failure kidneys don’t filter blood the way they should. As a result, wastes and toxins build up in your bloodstream. Dialysis does the work of your kidneys, removing waste products and excess fluid from the blood.

Injuries and conditions like high blood pressure, diabetes and lupus can damage kidneys, leading to kidney disease.

There are five stages of kidney disease. In stage 5 kidney disease, healthcare providers consider you to be in end-stage renal disease (ESRD) or kidney failure. At this point, kidneys are carrying out around 10% to 15% of their normal function. You may need dialysis or a kidney transplant to stay alive. Some people undergo dialysis while waiting for a transplant.

Procedure:

There are two ways to get dialysis:

• Hemodialysis.
• Peritoneal dialysis.

With hemodialysis, a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body. This 3- to 5-hour process may take place in a hospital or a dialysis center three times a week.

Before you start hemodialysis, you’ll undergo a minor surgical procedure to make it easier to access the bloodstream. You may have:

• Arteriovenous fistula (AV fistula): A surgeon connects an artery and vein in your arm.
• Arteriovenous graft (AV graft): If the artery and vein are too short to connect, your surgeon will use a graft (soft, hollow tube) to connect the artery and vein.

AV fistulas and grafts enlarge the connected artery and vein, which makes dialysis access easier. They also help blood flow in and out of your body faster.

If dialysis needs to happen quickly, your provider may place a catheter (thin tube) into a vein in your neck, chest or leg for temporary access.

During hemodialysis, the dialysis machine:

• Removes blood from a needle in your arm.
• Circulates the blood through the dialyzer filter, which moves waste into a dialysis solution. This cleansing liquid contains water, salt and other additives.
• Returns filtered blood to your body through a different needle in your arm.
• Monitors your blood pressure to adjust how fast blood flows in and out of your body.

With peritoneal dialysis, tiny blood vessels inside the abdominal lining (peritoneum) filter blood through the aid of a dialysis solution. This solution is a type of cleansing liquid that contains water, salt and other additives.

Peritoneal dialysis takes place at home. There are two ways to do this treatment:

• Automated peritoneal dialysis uses a machine called a cycler.
• Continuous ambulatory peritoneal dialysis (CAPD) takes place manually.

Procedure:

About three weeks before you start peritoneal dialysis, you’ll have a minor surgical procedure. A surgeon inserts a soft, thin tube (catheter) through your belly and into the peritoneum. This catheter stays in place permanently.

During peritoneal dialysis, you:

• Connect the catheter to one branch of a Y-shaped tube. This tube connects to a bag that has dialysis solution. The solution flows through the tube and catheter into the peritoneal cavity.
• Disconnect the tube and catheter after about 10 minutes, when the bag is empty.
• Cap off the catheter.
• Go about your usual activities while the dialysis solution inside the peritoneal cavity absorbs waste and extra fluids from the body. This process can take 60 to 90 minutes.
• Remove the cap from the catheter and use the other branch of the Y-shaped tube to drain the fluid into a clean, empty bag.
• Repeat these steps up to four times a day. You sleep with the solution in your stomach all night.

Some people prefer to do peritoneal dialysis at night. With automated peritoneal dialysis, a machine called a cycler pumps the fluid in and out of the body while you sleep.

4) anatomical positioning during dialysis process:

the patient is placed in the supine position. General anaesthesia is inducted and intravenous antibiotics are administered. It is preferable to create a pneumoperitoneum with an open procedure. A small subumbilical incision is made (2–3 cm) and the umbilical cord is grasped with forceps and lifted. Subsequently, the subcutaneous layer is transected. The anterior rectus sheath is opened and a suture is placed to lift the anterior sheath. The posterior sheath and subsequently the peritoneum are digitally opened. If adhesions are present close to the abdominal wall, they are transected. A 5 mm trocar or a screw trocar is inserted into the abdomen and insufflated with CO₂ gas to create a pneumoperitoneum of 12–14 mmHg. A Veres needle technique can also be adopted. Several methods have been described. One is to place the needle in the upper-left quadrant of the abdomen. Another way is to open the anterior sheath as explained in the open procedure, but the Veres needle is used for the last one or two steps (the posterior sheath or the peritoneum). After the needle is in place, its correct position is tested by the water drop test, which should disappear into the abdomen through the needle, and by insufflating and aspirating 10 ml saline. After creating a pneumoperitoneum, a 5 mm trocar is inserted in the subumbilical position. After the 5 mm trocar is in place, the patient is placed in a Trendelenburg position and a diagnostic laparoscopy is performed with a 5 mm 0° scoop. In case the Veres needle is placed in the left-upper quadrant of the abdomen, its position is checked and the needle removed. An extra 5 mm trocar is inserted under direct vision at the site of the planned exit-site position of the PD catheter (paraumbilical left or right 2– 3 cm below the umbilicus).

• The dialysis machine and the process is being explained according to the trivitron healthcare devices.
• Nikkiso DBB 27 Hemodialysis Machine
• Nikkiso DBB 27 Hemodialysis Machine is for Acetate/Bicarb dialysis/volume-controlled UF and conductivity profiling. The compact design of the machine offers comfort to the patient during treatment and offer a user-friendly interface that allows continuous monitoring of pumps and values during treatment and detection for air bubble and blood tubbing lines.
• It takes low disinfection consumption and less power consumption per dialysis. Offers continuous monitoring for discharge value of Duplex & UF Pump and for open-close of the solenoid valve. It also reminds for preventive maintenance kit replacement period.

Trivitron ‘T’ Dialyser Series

Trivitron ‘T’ Dialyser Series – Low Flux Polyethersulfone Hollow Fiber Dialysers. A dialyzer is an apparatus in which dialysis is carried out, and Trivitron Dialyzer are reliable and safe with advanced membrane design, higher clearance of uremic toxins, especially for a middle molecule.

They have excellent biocompatibility, a stronger ability to remove toxins, a high clearance rate of the molecules with small molecular weight, and better anticoagulant properties. Ultrasonic bonding of the cap, avoid blood and dialysate leakage. The D-Shape Ring improves the blood shear stress at the edge and prevents the blood residual effectively

Fistula needles:

The needles have flexible butterfly wings for better grip and this also allow easy insertion and minimize trauma to the patient

Bloodline

During the treatment process, the flow must be constant and at the right speed so that the exchange of solute is complete with the proper flow for successful dialysis.

The complete equipments used during the process are explained in detail with the following link.

https://www.trivitron.com/blog/equipment-and-devices-used-during-dialysis-process/

5) recent advances:

There are number of advances that are done in recent times where the dialysis processes are including that can be done in home and are user friendly with use of equipment also

The below link gives the latest study of the advances that are done in the dialysis process and their types.

https://www.intechopen.com/chapters/43105

PART-B

• The human skull is generally considered to consist of twenty-two bones—eight cranial bones and fourteen facial skeleton bones. In the neurocranium these are the occipital bone, two temporal bone, two parietal bones, the sphenoid, ethmoid and frontal bones.

The bones of the facial skeleton (14) are the vomer, two inferior nasal conchae, two nasal bones, two maxillae the mandible, two palatine bones, two zygomatic bones, and two lacrimal bones. Some sources count a paired bone as one, or the maxilla as having two bones (as its parts); some sources include the hyoid bone or the three osscicles of the middle ear but the overall general consensus of the number of bones in the human skull is the stated twenty-two.

Some of these bones—the occipital, parietal, frontal, in the neurocranium, and the nasal, lacrimal, and vomer, in the facial skeleton are flat bone.

• Flat bonesare bones whose principal function is either extensive protection or the provision of broad surfaces for muscular attachment. These bones are expanded into broad, flat plates as in the cranium (skull), the ilium (pelvis), sternum and the rib cage. The flat bones are: the osscipital, parietal, frontal, nasal, lacrimal, vomer, hip bone (coxal bone), sternum, ribs, and scapulae.

These bones are composed of two thin layers of compact bone enclosing between them a variable quantity of cancellous bone which is the location of red bone marrow. In an adult, most red blood cells are formed in flat bones. In the cranial bones the layers of compact tissue are familiarly known as the tables of the skull; the outer one is thick and tough; the inner is thin, dense, and brittle, and hence is termed the vitreous (glass-like) table.

• Blood supply:

Blood is supplied by three separate systems: a nutrient artery, periosteal vessels, and epiphyseal vessels. The diaphysis and metaphysis are nourished primarily by the nutrient artery, which passes through the cortex into the medullary cavity and then ramifies outward through haversian and Volkmann canal to supply the cortex. extensive vessels in the periostium, the membrane surrounding the bone, supply the superficial layers of the cortex and connect with the nutrient-artery system. In the event of obstruction of the nutrient artery, periosteal vessels are capable of meeting the needs of both systems. The epiphysis are supplied by a separate system that consists of a ring of arteries entering the bone along a circular band between the growth plate and the joint capsule. In the adult these vessels become connected to the other two systems at the metaphyseal-epiphyseal junction, but while the growth plate is open there is no such connection, and the epiphyseal vessels are the sole source of nutrition for the growing cartilage; therefore they are essential for skeletal growth.

Drainage of blood is by a system of veins that runs parallel with the arterial supply and by veins leaving the cortical periosteum through muscle insertions. Muscle contraction milks blood outward, giving rise to a centrifugal pattern of flow from the axial nutrient artery through the cortex and out through muscle attachments.

• Bone remodeling and new bone formation:

Whereas renewal in tissues such as muscle occurs largely at a molecular level, renewal of bone occurs at a tissue level and is similar to the remodeling of buildings in that local removal (resorption) of old bone must precede new bone deposition. Remodeling is most vigorous during the years of active growth, when deposition predominates over resorption. Thereafter remodeling gradually declines, in humans until about age 35, after which its rate remains unchanged or increases slightly. From the fourth decade on, resorption exceeds formation, resulting in an approximate 10 percent loss in bone mass per decade, equivalent to a daily loss of 15 to 30 mg of calcium.

Except for the addition of the osscification mechanisms within cartilage growth and development involve exactly the same type of remodeling as that in the adult skeleton Both require continuous, probably irreversible differentiation of osteoclasts and osteoblasts, the former from circulating monocytes in the blood and the latter from the undifferentiated bone mesenchyme. The life span of osteoclasts is from a few hours to at most a few days, while that of osteoblasts is a few days to at most a few weeks.

• Anatomical basis of bone implant:

https://www.cureus.com/articles/31561-immersive-surgical-anatomy-of-the-craniometric-points

external fixation is used to stabilize a bone or joint by orthopedic surgoens during reconstruction, with pins or wires placed percutaneously. Compared to internal fixation, external fixation offers minimal soft tissue damage and invasiveness, which can be especially beneficial for instances of acute trauma, and the placement of external fixators can easily be adjusted after fixation whereas the same cannot be done with internal fixators. However, external fixators have limitations to their use, such as a restriction in limb movement. Additionally, external fixation treatments of fractures results in higher rates of malunions and nonunions and comparatively poorer outcomes than internal fixation.

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5461575/